Surgical complications in the first and second semesters of the general surgery medical residence. A study of 14063 cases.

OBJECTIVE: To evaluate whether the rate of surgical complications is higher during the first semester of the General Surgery residency in the largest hospital complex in Latin America. During this period, students are expected to have less experience in carrying out procedures. METHODS: During a period of two years, all General Surgery resident doctors at the Hospital das Clínicas of the Faculty of Medicine of the University of São Paulo, made a notification of all the procedures they performed (n = 14.063), containing information such as name of the procedure, date, who participated, complications, among others. These data were analyzed with the purpose of evaluating the variation in the rate of complications throughout the year. RESULTS: There was a 52 % increase in the rate of complications in the first academic semester when compared to the second semester. This phenomenon was observed in resident doctors in the first and second years of residency. Furthermore, it was observed that second-year residents remain with high rates of complications, in some procedures, for a longer time than first-year residents. Furthermore, the first three months (March, April and May) seem to have the highest complication rates of the entire year. CONCLUSION: The impact of these complications can affect several health services and the increase in surgical complications in the first half of the year must be monitored by institutions, in order to control this phenomenon.

Percepções de estudantes de Medicina sobre o estresse acadêmico e a mentoria no seu enfrentamento: um estudo qualitativo / Medical students' perceptions of academic stress and mentoring for coping: a qualitative study / Percepciones de estudiantes de medicina sobre el estrés académico y la tutoría en su enfrentamiento: un estudio cualitativo

A formação médica é considerada estressante devido a fatores como: extensa carga horária, atividades práticas complexas, muito conteúdo e alta exigência de dedicação. Programas de mentoria podem amenizar esse estresse acadêmico. Com o objetivo de investigar a percepção dos estudantes de um programa de mentoria sobre o estresse da formação médica e a mentoria como recurso de enfrentamento, desenhou-se um estudo do tipo transversal com metodologia qualitativa. Selecionaram-se 12 alunos e realizaram-se sessões de grupo focal. Os dados produzidos foram submetidos à análise temática, resultando em duas categorias de estressores - 1. ser estudante e 2. ambiente acadêmico - e em duas categorias de elementos protetores - 1. autocuidado e 2. mentoria. A mentoria foi considerada recurso de enfrentamento por ser um espaço de reflexão e desenvolvimento de habilidades e comportamentos que aumentam competências relacionais, além de propiciar acolhimento, alívio psicológico, pertencimento e efeito tranquilizador.(AU)

Medical training is considered stressful due to factors such as heavy course load, complex practical activities, the large volume of content and high expectations in terms of dedication. Mentoring programs can alleviate academic stress. The aim of this qualitative cross-sectional study was to investigate medical students' perceptions of a mentoring program designed to reduce stress and mentoring as a tool for coping. We selected 12 students and held focus group sessions. We performed a thematic analysis, which resulted in the identification of two categories of stressors and protectors: being a student and the academic environment and self-care and mentoring, respectively. Mentoring was considered a coping resource because it provided a space for reflection and helped students develop skills and behavior that enhance relational skills, in addition to providing a welcoming environment, psychological relief, a feeling of belonging and a tranquilizing effect.(AU)

La formación médica se considera estresante debido a factores tales como: extensa carga horaria, actividades prácticas complejas, mucho contenido, alta exigencia de dedicación. Programas de tutoría pueden amenizar ese estrés académico. Con el objetivo de investigar la percepción de los estudiantes de un programa de tutoría sobre el estrés de la formación médica y la tutoría como recursos de enfrentamiento, se diseñó un estudio del tipo transversal con metodología cualitativa. Se seleccionaron 12 alumnos y se realizaron sesiones de grupo focal. Los datos producidos se sometieron a análisis temático, resultando en dos categorías de factores de estrés: 1. ser estudiante, y 2. ambiente académico; y dos categorías de elementos protectores: 1. autocuidado, y 2. tutoría. La tutoría se consideró recurso de enfrentamiento por ser espacio de reflexión y desarrollo de habilidades y comportamientos que aumentan competencias relacionales además de propiciar amparo, alivio psicológico, pertenencia y efecto tranquilizador.(AU)

Use and misuse of biomarkers and the role of D-dimer and C-reactive protein in the management of COVID-19: A post-hoc analysis of a prospective cohort study.

OBJECTIVE: Coronavirus disease 2019 (COVID-19) is associated with high mortality among hospitalized patients and incurs high costs. Severe acute respiratory syndrome coronavirus 2 infection can trigger both inflammatory and thrombotic processes, and these complications can lead to a poorer prognosis. This study aimed to evaluate the association and temporal trends of D-dimer and C-reactive protein (CRP) levels with the incidence of venous thromboembolism (VTE), hospital mortality, and costs among inpatients with COVID-19. METHODS: Data were extracted from electronic patient records and laboratory databases. Crude and adjusted associations for age, sex, number of comorbidities, Sequential Organ Failure Assessment score at admission, and D-dimer or CRP logistic regression models were used to evaluate associations. RESULTS: Between March and June 2020, COVID-19 was documented in 3,254 inpatients. The D-dimer level ≥4,000 ng/mL fibrinogen equivalent unit (FEU) mortality odds ratio (OR) was 4.48 (adjusted OR: 1.97). The CRP level ≥220 mg/dL OR for death was 7.73 (adjusted OR: 3.93). The D-dimer level ≥4,000 ng/mL FEU VTE OR was 3.96 (adjusted OR: 3.26). The CRP level ≥220 mg/dL OR for VTE was 2.71 (adjusted OR: 1.92). All these analyses were statistically significant (p<0.001). Stratified hospital costs demonstrated a dose-response pattern. Adjusted D-dimer and CRP levels were associated with higher mortality and doubled hospital costs. In the first week, elevated D-dimer levels predicted VTE occurrence and systemic inflammatory harm, while CRP was a hospital mortality predictor. CONCLUSION: D-dimer and CRP levels were associated with higher hospital mortality and a higher incidence of VTE. D-dimer was more strongly associated with VTE, although its discriminative ability was poor, while CRP was a stronger predictor of hospital mortality. Their use outside the usual indications should not be modified and should be discouraged.

COMVC-19: A Program to protect healthcare workers' mental health during the COVID-19 Pandemic. What we have learned.

OBJECTIVE: In 2020, the COVID-19 pandemic brought a work and stress overload to healthcare workers, increasing their vulnerability to mental health impairments. In response, the authors created the COMVC-19 program. The program offered preventive actions and mental health treatment for the 22,000 workers of The Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP). This paper aims to describe its implementation and share what we have learned from this experience. METHODS: Workers were able to easily access the program through a 24/7 hotline. Additionally, a mobile phone app that screened for signs and symptoms of emotional distress and offered psychoeducation and/or referral to treatment was made available. Data from both these sources as well as any subsequent psychiatric evaluations were collected. RESULTS: The first 20 weeks of our project revealed that most participants were female, and part of the nursing staff working directly with COVID-19 patients. The most frequently reported symptoms were: anxiety, depression and sleep disturbances. The most common diagnoses were Adjustment, Anxiety, and Mood disorders. CONCLUSIONS: Implementing a mental health program in a multimodal intervention was feasible in a major quaternary public hospital. Our data also suggests that preventive actions should primarily be aimed at anxiety and depression symptoms, with a particular focus on the nursing staff.

Humanistic training in Medicine through dancing in the hospital: students' perceptions / Formação humanística em medicina por meio da dança em hospital: percepções de alunos

Abstract: Introduction: The humanization of assistance is associated to empathy, embracing, and effective communication, being part of the medical training. According to its nature, humanization requires methods that involve affections and stimulates critical thinking. Objective: Extensive literature shows the benefits of the arts in medical education; however, there are still few studies on dancing, the subject of this study, which was carried out by medical students and whose aim was to investigate hospital dancing in the teaching of humanization, from the perspective of medical students. Method: A qualitative action research study was designed, in which medical students performed choreographies for patients, companions and employees in three different wards of the teaching hospital. The action consisted of continuous cycles in the planning of interventions, performance, observing, reflection, and re-planning of subsequent actions, in a systematic manner and controlled by the researchers. Data production took place by direct observation, narratives and focal group. The data were analyzed using the content and thematic analysis methods. Results: For three months, 17 female and 7 male students between 18 and 24 years of age performed the action, producing data that was subsequently classified into 3 thematic categories: 1. Dimension of affection: contents of the student's emotional character; 2. Care dimension: contents about caring for the patient; 3. Dance dimension: contents on dance in the humanistic training in Medicine. In the triangulation of the techniques, it was observed that joy, anxiety, and the perception of dance as an instrument of bonding were significant. The experience of changing socially-marked places for the student and the patient made the student face and overcome different feelings. The dance allowed the refinement of the look and the capacity to understand the other, taking into account perspectives that converge to or diverge from their own convictions. On the other hand, the students experienced the anxiety and joy of an encounter with themselves, perceiving dance as a pleasurable and humanizing activity. Conclusion: The dance in the hospital lead to experiences and reflections that stimulated the students' self-knowledge, favored the student-patient relationship, and brought elements to understand the use of dancing in medicine, mainly for the teaching of empathy and humanized care.

Resumo: Introdução: a humanização está relacionada à empatia, acolhimento, e comunicação efetiva, fazendo parte da formação médica. Pela sua natureza, a humanização requer métodos que mobilizem afetos e estimulem pensamento crítico, justificando o uso das artes como ferramenta de ensino. Vasta literatura mostra os benefícios das artes no ensino médico, entretanto ainda há poucos estudos sobre a dança, objeto deste artigo, em que apresentamos uma pesquisa conduzida por estudantes de medicina, cujo objetivo foi investigar a dança em hospital no ensino de humanização, na perspectiva dos estudantes. Método: desenhou-se uma pesquisa qualitativa do tipo pesquisa-ação, na qual alunos de medicina executaram coreografias para pacientes, acompanhantes e funcionários em três diferentes enfermarias do hospital-escola. A ação consistiu em ciclos contínuos de planejamento das intervenções, realização, observação, reflexão e replanejamento das ações subsequentes, de forma sistematizada e controlada pelas pesquisadoras. A produção de dados se deu por observação direta, narrativas e grupo focal. Os dados foram analisados pelos métodos de análise de conteúdo e temática. Resultados: durante três meses, 17 alunas e 7 alunos entre 18 e 24 anos de idade realizaram a ação, produzindo dados posteriormente classificados em 3 categorias temáticas: 1. Dimensão do afeto: conteúdos de caráter emocional do aluno; 2. Dimensão do cuidado: conteúdos sobre cuidar do paciente; 3. Dimensão da dança: conteúdos sobre dança na formação humanista em medicina. Na triangulação das técnicas, verificou-se que alegria, ansiedade, e percepção da dança como instrumento de criação de vínculo foram expressivas. A vivência da mudança dos lugares socialmente marcados para o estudante e o paciente fez com que o aluno enfrentasse e superasse sentimentos diversos. A dança permitiu o refinamento do olhar e da capacidade de compreender o outro, levando em conta perspectivas convergentes ou divergentes às suas próprias convicções. Por outro lado, os alunos vivenciaram ansiedade e alegria de um encontro consigo mesmo, percebendo a dança como atividade prazerosa e promotora da humanização. Conclusão: A dança no hospital provocou vivências e reflexões que estimularam o autoconhecimento, favoreceram a relação estudante-paciente, trouxeram elementos para entender o uso da dança em medicina, especialmente para o ensino da empatia e do cuidado humanizado.

Virtual mentoring for medical students in the Covid-19 times / Mentoria virtual para estudantes de medicina em tempos de covid-19

Abstract: Introduction: Throughout the SARS-COV-2 pandemic, schools had to adopt social distancing and remote learning, which, according to recent studies suggest an increase in depression, anxiety and behavioral disorders among university students. Medical training, which has a heavy load of psychological issues had to face this aggravating factor, reinforcing the need for support actions for students, such as mentoring programs. Mentoring programs offer empathetic and developmental support that encourages self-care, well-being and resilience. Experience report: A group of teacher-mentors from a medical school adapted the mentoring activities to a remote model, offering them to upper-level students who had already participated in mentoring, and, separately, to students who were newly enrolled in the medical course. In the remote format, the mentoring proposal was maintained as a "place of conversation", but on a digital platform. The technical follow-up was carried out by remote meetings of the group of teacher-mentors, and consultation with students through a self-administered online questionnaire. The data obtained were submitted to content analysis. Discussion: From March to December, 109 virtual mentoring meetings were held. The students considered the meetings satisfactory in terms of the quality of discussions, the mentors' attitudes and the emotional environment. The interactive development varied among groups, but it was observed to be easier in the groups of upper-level students. Among the newly-enrolled students, the recurring topic was the fear of poor performance in the tests, losing the semester, or not learning. Upper-level students highlighted the difficulties of adapting to remote learning and organizing their activities, and the decrease in practical activities. All groups reported fear of the pandemic, of death, of the worsening of parents' financial situation, and sadness about the loss of relatives to COVID-19. It drew the attention of the mentors the fact that the students, even in a welcoming space, kept the cameras turned off. Conclusion: For mentors and students, virtual mentoring worked as an important student support system. Upper-level students and first-year ones reported feeling cared for, supported and grateful, suggesting that the meetings allowed a good interaction and produced beneficial effects. A limitation of this study was the duration of the experiment. Therefore, it is recommended that the research be maintained.

Resumo: Introdução: Durante a pandemia de Sars-CoV-2, as escolas adotaram distanciamento social e atividades a distância que, segundo estudos recentes, sugerem o aumento de depressão, ansiedade e distúrbios de comportamento entre estudantes universitários. A formação médica que é marcada por forte estresse psicológico contou com esse agravante, reforçando a necessidade de ações de cuidado destinadas aos alunos, como os programas de mentoria. A mentoria de alunos oferece suporte empático e desenvolvimental que estimula autocuidado, bem-estar e resiliência. Relato de experiência: Um grupo de professores-mentores de uma escola médica adaptou atividades de mentoria para um modelo remoto dirigido aos alunos veteranos que já participavam da mentoria e separadamente aos estudantes recém-ingressos no curso médico. No formato remoto, manteve-se a proposta de mentoria como "lugar de conversa", mas em plataforma digital. O acompanhamento técnico da proposta se deu por meio de encontros remotos do grupo de mentores e de consulta aos alunos por meio de questionário autoaplicado on-line. Os dados obtidos foram submetidos à análise de conteúdo. Discussão: De março a dezembro de 2020, realizaram-se 109 encontros de mentoria virtual. Os alunos consideraram satisfatórios os encontros remotos em termos de qualidade das discussões, atuação do mentor e ambiente emocional. A desenvoltura interativa variou entre grupos, mas foi facilitada nos grupos de veteranos. Entre os alunos ingressantes, o tema recorrente esteve atrelado ao sentimento de medo: de ter mau desempenho nas provas, de perder o semestre e de não aprender. Entre os veteranos, destacaram-se as dificuldades de adaptação ao ensino a distância e de organização diante do excesso de atividades, e a diminuição das atividades práticas. Todos os grupos relataram medo da pandemia, da morte e de a situação financeira dos pais piorar, além de tristeza em razão de perda de parentes pela Covid-19. Chamou a atenção dos mentores o fato de os alunos, mesmo em um espaço acolhedor, manterem fechadas as câmeras. Conclusão: Para os mentores e discentes, a mentoria virtual funcionou como importante suporte ao aluno. Veteranos e calouros relataram que se sentiam cuidados, fortalecidos e gratos, sugerindo que os encontros permitiram uma boa interação das pessoas e a produção de efeitos benéficos perceptíveis. Um limite deste estudo foi o tempo de experiência. Assim sendo, recomenda-se manter tal investigação.

Mentoria de acolhimento para alunos ingressantes no curso de Medicina / Welcome mentoring for new medicine students

Resumo: Introdução: As mudanças de vida do estudante quando ingressa na Faculdade de Medicina tornam os primeiros anos os mais vulneráveis para desenvolver estresse psicológico e suas consequências. Em 2020, essa condição se agravou devido à pandemia de Sars-CoV-2. Para dar suporte aos alunos, várias escolas médicas desenvolvem programas de mentoria, entretanto a adesão deles costuma ser baixa. Objetivo: Este estudo teve como objetivos criar um modelo de mentoria - denominada "Mentoria de Acolhimento" - como suporte psicossocial e pedagógico aos alunos ingressantes, e estudar seu processo de implementação e os resultados para maior adesão e efetividade. Método: Com um desenho metodológico do campo da ciência da implementação, utilizaram-se técnicas e instrumentos de pesquisas qualitativas e quantitativas para compor um estudo de métodos mistos. Obtiveram-se os dados qualitativos em reuniões com os mentores e os dados quantitativos em questionários eletrônicos anônimos para os alunos. Os encontros dos grupos de mentoria foram previstos na grade curricular obrigatória, em horários predeterminados nos quatro meses do primeiro semestre da graduação. Analisaram-se os dados qualitativos por meio da técnica de análise temática, e os dados quantitativos foram examinados de modo descritivo. Resultado: Participaram da Mentoria de Acolhimento 147 alunos (77% dos ingressantes). Identificaram-se os seguintes facilitadores de implementação: inclusão automática de todos os alunos nos grupos, inserção na grade, qualidade do mentor e disposição dos discentes para a mentoria. Observaram-se as seguintes barreiras: falhas na comunicação com os alunos, não realização de encontros por mentores, atividades extracurriculares no horário previsto para a mentoria e o modo presencial remoto. A experiência foi avaliada como positiva por alunos e mentores, verificando-se ganhos de desempenho acadêmico, em conhecer o cotidiano escolar e lidar com aspectos emocionais e relacionais da vida de estudante. Conclusão: A Mentoria de Acolhimento ajudou a integração do aluno ingressante na faculdade. Mostrou-se adequada em termos de modelo e resultados, mas requer aprofundamento dos estudos de impacto na formação médica.

Abstract: Introduction: Upon entering medical school the student undergoes life changes that make the first years the most crucial in terms of vulnerability to developing psychological stress and the associated consequences. In 2020, this condition was aggravated due to the SARS-COV-2 pandemic. To offer students more support, many medical schools have encouraged them to participate in mentoring programs, however student adherence is typically low. Objective: To create a mentoring model - called "Welcome Mentoring" - as a psychosocial and pedagogical support for incoming students, and study its implementation process and results, with the aim of achieving greater adherence and effectiveness. Methodology: Using a methodological design from the field of implementation science, qualitative and quantitative research techniques and instruments were combined to form a mixed-methods study. Qualitative data were obtained in meetings with mentors, and quantitative data through anonymous electronic questionnaires for students. The meetings of the mentoring groups were foreseen in the mandatory curricular schedule, at predetermined times during the four months of the first semester of the undergraduate course. Qualitative data were analyzed with thematic analysis technique, and quantitative data were analyzed descriptively. Results: 147 students participated in the Welcome Mentoring (77% participation). The factors that facilitated the implementation were: the automatic inclusion of all students in the groups, insertion in the curriculum, quality of the mentor, and students' availability for mentoring. The following barriers were observed: communication failures with students, no meetings with mentors, extracurricular activities during mentoring hours, and the remote mode for meetings. The experience was evaluated as positive by students and mentors, with gains in academic performance, in learning about daily school life, and in dealing with the emotional and relational aspects of student life. Conclusion: Welcome Mentoring helped integrate incoming student into university life. It proved adequate in terms of the model and results, but requires further studies on its impact on medical education.

COMVC-19: A Program to protect healthcare workers' mental health during the COVID-19 Pandemic. What we have learned

OBJECTIVE: In 2020, the COVID-19 pandemic brought a work and stress overload to healthcare workers, increasing their vulnerability to mental health impairments. In response, the authors created the COMVC-19 program. The program offered preventive actions and mental health treatment for the 22,000 workers of The Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP). This paper aims to describe its implementation and share what we have learned from this experience. METHODS: Workers were able to easily access the program through a 24/7 hotline. Additionally, a mobile phone app that screened for signs and symptoms of emotional distress and offered psychoeducation and/or referral to treatment was made available. Data from both these sources as well as any subsequent psychiatric evaluations were collected. RESULTS: The first 20 weeks of our project revealed that most participants were female, and part of the nursing staff working directly with COVID-19 patients. The most frequently reported symptoms were: anxiety, depression and sleep disturbances. The most common diagnoses were Adjustment, Anxiety, and Mood disorders. CONCLUSIONS: Implementing a mental health program in a multimodal intervention was feasible in a major quaternary public hospital. Our data also suggests that preventive actions should primarily be aimed at anxiety and depression symptoms, with a particular focus on the nursing staff.

Use and misuse of biomarkers and the role of D-dimer and C-reactive protein in the management of COVID-19: A post-hoc analysis of a prospective cohort study

OBJECTIVE: Coronavirus disease 2019 (COVID-19) is associated with high mortality among hospitalized patients and incurs high costs. Severe acute respiratory syndrome coronavirus 2 infection can trigger both inflammatory and thrombotic processes, and these complications can lead to a poorer prognosis. This study aimed to evaluate the association and temporal trends of D-dimer and C-reactive protein (CRP) levels with the incidence of venous thromboembolism (VTE), hospital mortality, and costs among inpatients with COVID-19. METHODS: Data were extracted from electronic patient records and laboratory databases. Crude and adjusted associations for age, sex, number of comorbidities, Sequential Organ Failure Assessment score at admission, and D-dimer or CRP logistic regression models were used to evaluate associations. RESULTS: Between March and June 2020, COVID-19 was documented in 3,254 inpatients. The D-dimer level ≥4,000 ng/mL fibrinogen equivalent unit (FEU) mortality odds ratio (OR) was 4.48 (adjusted OR: 1.97). The CRP level ≥220 mg/dL OR for death was 7.73 (adjusted OR: 3.93). The D-dimer level ≥4,000 ng/mL FEU VTE OR was 3.96 (adjusted OR: 3.26). The CRP level ≥220 mg/dL OR for VTE was 2.71 (adjusted OR: 1.92). All these analyses were statistically significant (p<0.001). Stratified hospital costs demonstrated a dose-response pattern. Adjusted D-dimer and CRP levels were associated with higher mortality and doubled hospital costs. In the first week, elevated D-dimer levels predicted VTE occurrence and systemic inflammatory harm, while CRP was a hospital mortality predictor. CONCLUSION: D-dimer and CRP levels were associated with higher hospital mortality and a higher incidence of VTE. D-dimer was more strongly associated with VTE, although its discriminative ability was poor, while CRP was a stronger predictor of hospital mortality. Their use outside the usual indications should not be modified and should be discouraged.

Family Medicine from the First to the Sixth Year of Undergraduate Medical Training: Considerations on an Educational Proposal for School-Service Curricular Integration / Medicina de Família do Primeiro ao Sexto Ano da Graduação Médica: Considerações sobre uma Proposta Educacional de Integração Curricular Escola-Serviço

ABSTRACT Medical training is current topic of discussion both on the national and international stage due to changes in contemporary society and the consequent health demands. In Brazil, insertion into the workplace of the Primary Health Care (PHC) student is recommended throughout the medical course. However, such insertion is hampered by inadequate practical scenarios, the lack of preceptors, insufficient training of general practitioners to receive students, teachers without adequate training in teaching in the area and resistance by teachers of traditional disciplines. This article describes and analyzes a model for insertion into PHC and Family and Community Medicine (FCM) of students from a medical course in São Paulo, the challenges of teaching-management integration and the actions that help to address these issues. The proposal is based on educational objectives aimed at developing competences (knowledge, skills and attitudes) so that the student can offer comprehensive care, understanding the individual in the context of family, social and environmental life. The program contents were developed to provide learning in an increasing degree of complexity, connecting previous knowledge to new knowledge. From this starting point, the development of the educational project has as innovative brand involving a combination of planning and educational management that adopts the following measures to improve the quality of the teaching-learning process: (1) insertion of students into Basic Health Units (BHU) from the first year to internship; (2) hiring family doctors as faculty staff; (3) integration of the contents of the Family Medicine and PHC modules with the contents of other disciplines, such as Epidemiology, Health Policies and Evidence-Based Medicine; (4) critically questioning teaching methodologies regarding their suitability for the topic addressed and the student and teacher profiles; (5) formative assessments; (6) pedagogical improvement for teachers and preceptors for the exercise of teaching in health; (7) practices that encourage students to work in interprofessional teams; (8) encouragement of national and international exchange programs for undergraduate and residency students in FCM; (9) promotion of the publication of books, articles and research in PHC. Among the facilitating factors for the good progress of this teaching proposal, it is highlighted that FCM and PHC are the axial foundations of the political-pedagogical project of the medical course and are developed in an institution that has a long history of assistance and teaching in the health area, contributing significantly to service-school integration. Dialogue is required for the execution of didactic activities in the practical settings, due to the proximity between local management, preceptors and teacher-managers. Another factor which strengthens the proposal is the investment in the preceptor team through training, participation in the construction and integration of content proposed in the FCM modules and a human resources policy that values them. Thus, it is considered that the presentation of this initiative could contribute to the debate on educational models for curricular insertion into FCM and PHC, and the related challenges and possibilities in contemporary medical education.

RESUMO Em contexto nacional e internacional, discute-se a formação médica devido às mudanças na sociedade contemporânea e suas demandas de saúde. No Brasil, preconiza-se a inserção do aluno na Atenção Primária à Saúde (APS) durante todo o curso médico. Tal inserção é dificultada pelos cenários práticos inadequados, pela falta de preceptores, pela formação insuficiente dos médicos generalistas para receber estudantes, pelos docentes sem capacitação adequada para o ensino na área e pela resistência de docentes de disciplinas tradicionais. Este artigo descreve e analisa um modelo de inserção da APS e Medicina de Família e Comunidade (MFC) em um curso médico no município de São Paulo, os desafios da articulação ensino-gestão e as ações que ajudam a enfrentá-los. A proposta parte de objetivos educacionais que visam desenvolver competências (conhecimentos, habilidades e atitudes) para que o aluno possa oferecer cuidado integral, compreendendo o indivíduo no contexto de vida familiar, social e ambiental. Os conteúdos programáticos foram desenvolvidos para propiciar aprendizagem em grau crescente de complexidade, articulando saberes prévios com novos saberes. Deste ponto de partida, o desenvolvimento do projeto educacional tem como marca inovadora a combinação de planejamento e gestão educacional que adota as seguintes medidas para aprimorar a qualidade do processo ensino-aprendizagem: (1) inserção dos alunos em Unidades Básicas de Saúde (UBS) do primeiro ano ao internato; (2) contratação de médicos de família como docentes da faculdade; (3) integração dos conteúdos dos módulos de Medicina de Família e APS com os conteúdos de outras disciplinas, como Epidemiologia, Políticas de Saúde e Medicina Baseada em Evidências; (4) metodologias de ensino problematizadoras adequadas à temática abordada e ao perfil do estudante e do docente; (5) avaliações formativas; (6) aprimoramento pedagógico para docentes e preceptores para o exercício do ensino em saúde; (7) práticas que estimulem o aluno a trabalhar em equipes interprofissionais; (8) incentivo a programas de intercâmbio nacionais e internacionais para alunos de graduação e de residência em MFC; (9) fomento à publicação de livros, artigos e pesquisa em APS. Entre os fatores facilitadores para o bom andamento dessa proposta de ensino, ressalta-se o fato de que MFC e APS são fundamentos axiais do projeto político-pedagógico do curso médico e se desenvolvem em uma instituição que tem longa história de assistência e ensino na área da saúde, contribuindo fortemente para a integração serviço-escola. A interlocução necessária às atividades didáticas nos cenários de prática se dá pela proximidade entre gestão local, preceptores e gestores-docentes. Outro fator de fortalecimento da proposta é o investimento na equipe de preceptores por meio de capacitação, participação na construção e na integração de conteúdos propostos nos módulos de MFC e a política de recursos humanos que os valoriza. Assim, considera-se que a apresentação desta iniciativa poda contribuir para o debate de modelos educacionais para inserção curricular da MFC e APS, seus desafios e possibilidades na educação médica contemporânea.

Qual Guia de Comunicação na Consulta Médica É o Mais Adequado para o Ensino de Habilidades Comunicacionais na Atenção Primária à Saúde Brasileira? / Which Communication Guide for Medical Visits is the Most Appropriate for Teaching Communication Skills in Primary Health Care in Brazil?

RESUMO Introdução O uso de habilidades de comunicação está associado a desfechos positivos na consulta médica e no cuidado à saúde, como melhora da adesão aos tratamentos, da satisfação de médicos e pacientes, e da relação entre eles. Isto é ainda mais significativo na Atenção Primária à Saúde (APS), que é um espaço de cuidado integral de saúde. Uma comunicação efetiva é aquela em que todos os participantes interagem de modo a trocar informações e em que, ao final, todas as partes tenham o mesmo entendimento sobre o problema, acordem sobre as medidas a tomar e se sintam entendidas em suas necessidades. Para que este tipo de comunicação aconteça, o ensino dessas habilidades deve ocorrer de forma adequada e contínua, durante toda a formação médica. Até o momento, não existe um instrumento brasileiro que cumpra esta finalidade. No Brasil, têm-se utilizado guias internacionais para este ensino. No entanto, dos guias mais usados internacionalmente e mais citados na literatura da área, nenhum é completamente adequado à realidade da APS brasileira. Objetivo Comparar quatro instrumentos de habilidades de comunicação frequentemente utilizados, tendo em vista os aspectos que caracterizam a APS nacional. Metodologia Os guias foram descritos, analisados qualitativamente e comparados quanto às seguintes categorias: estrutura do guia, criação do guia, etapas importantes da consulta e foco no médico. Análise: Os instrumentos diferem quanto a facilidade de uso, foco no ensino de APS, discussão de etapas importantes da consulta e foco no médico; todos discutem a construção de planos compartilhados e nenhum tem uma tradução validada para português do Brasil. Conclusão Dos quatro guias estudados, "A Consulta em 7 em Passos" tem o melhor perfil de uso para a APS nacional. No entanto, recomenda-se a criação de um guia brasileiro para estruturar, homogeneizar e facilitar o ensino das habilidades de comunicação nas escolas médicas do País.

ABSTRACT Introduction the use of communication skills is associated with positive outcomes in medical visits and health care, such as better adherence to treatments, satisfaction of doctors and patients and the relationship between them. This is even more significant in Primary Health Care, which is a space of comprehensive health care. An effective communication happens whenever all participants interact to exchange information and, in the end, everyone has the same understanding about the problem, everyone agrees about the actions to be taken and everyone feels they are being understood in their needs. In order for this kind of communication to happen, these skills must be taught appropriately e continually, during the whole medical training. Up until now, there is no Brazilian instrument that fulfills this purpose. In Brazil, international guides are being used to achieve that. However, amongst the most internationally used guides and those most cited in specific literature, none is completely suitable to Brazil's reality. Objective To compare four frequently used communications skills instruments, under the perspective of Brazilian Primary Care characteristics. Methodology The guides were described, qualitatively analyzed and compared according to the following categories: guide structure, guide creation, important steps of the visit and focus on the doctor. Analysis: The instruments differ in easiness of use, focus in Primary Care teaching, discussion of important steps of the visit and focus on the doctor. They all discuss the construction of shared plans and none has a validated translation to Brazilian Portuguese. Conclusion "A Consulta em 7 Passos" has the most suitable profile for Brazil's Primary Care, among the studied guides. However, the creation of a Brazilian guide is recommended to help structure, homogenize and facilitate the teaching of communication skills in Brazil's medical schools.

Medicina de Família do Primeiro ao Sexto Ano da Graduação Médica: Considerações sobre uma Proposta Educacional de Integração Curricular Escola-Serviço / Family Medicine from the First to the Final Year of Undergraduate Medical Training: Considerations about an Educational Proposal to Integrate Service-Learning into the Curriculum

RESUMO Em contexto nacional e internacional, discute-se a formação médica devido às mudanças na sociedade contemporânea e suas demandas de saúde. No Brasil, preconiza-se a inserção do aluno na Atenção Primária à Saúde (APS) durante todo o curso médico. Tal inserção é dificultada pelos cenários práticos inadequados, pela falta de preceptores, pela formação insuficiente dos médicos generalistas para receber estudantes, pelos docentes sem capacitação adequada para o ensino na área e pela resistência de docentes de disciplinas tradicionais. Este artigo descreve e analisa um modelo de inserção da APS e Medicina de Família e Comunidade (MFC) em um curso médico no município de São Paulo, os desafios da articulação ensino-gestão e as ações que ajudam a enfrentá-los. A proposta parte de objetivos educacionais que visam desenvolver competências (conhecimentos, habilidades e atitudes) para que o aluno possa oferecer cuidado integral, compreendendo o indivíduo no contexto de vida familiar, social e ambiental. Os conteúdos programáticos foram desenvolvidos para propiciar aprendizagem em grau crescente de complexidade, articulando saberes prévios com novos saberes. Deste ponto de partida, o desenvolvimento do projeto educacional tem como marca inovadora a combinação de planejamento e gestão educacional que adota as seguintes medidas para aprimorar a qualidade do processo ensino-aprendizagem: (1) inserção dos alunos em Unidades Básicas de Saúde (UBS) do primeiro ano ao internato; (2) contratação de médicos de família como docentes da faculdade; (3) integração dos conteúdos dos módulos de Medicina de Família e APS com os conteúdos de outras disciplinas, como Epidemiologia, Políticas de Saúde e Medicina Baseada em Evidências; (4) metodologias de ensino problematizadoras adequadas à temática abordada e ao perfil do estudante e do docente; (5) avaliações formativas; (6) aprimoramento pedagógico para docentes e preceptores para o exercício do ensino em saúde; (7) práticas que estimulem o aluno a trabalhar em equipes interprofissionais; (8) incentivo a programas de intercâmbio nacionais e internacionais para alunos de graduação e de residência em MFC; (9) fomento à publicação de livros, artigos e pesquisa em APS. Entre os fatores facilitadores para o bom andamento dessa proposta de ensino, ressalta-se o fato de que MFC e APS são fundamentos axiais do projeto político-pedagógico do curso médico e se desenvolvem em uma instituição que tem longa história de assistência e ensino na área da saúde, contribuindo fortemente para a integração serviço-escola. A interlocução necessária às atividades didáticas nos cenários de prática se dá pela proximidade entre gestão local, preceptores e gestores-docentes. Outro fator de fortalecimento da proposta é o investimento na equipe de preceptores por meio de capacitação, participação na construção e na integração de conteúdos propostos nos módulos de MFC e a política de recursos humanos que os valoriza. Assim, considera-se que a apresentação desta iniciativa poda contribuir para o debate de modelos educacionais para inserção curricular da MFC e APS, seus desafios e possibilidades na educação médica contemporânea.

ABSTRACT Medical education has been heavily debated in both national and international contexts due to changes in society and public health demands. In Brazil, it is postulated that learning in Primary Health Care (PHC) should occur throughout the entire medical course. Learning in PHC has faced some barriers such as inadequate environment for medical practice, including a lack of supervisors and general practitioners with insufficient training to assist students, lack of lecturers with expertise in the area, and resistance from traditional faculties to include PHC in the curriculum. This paper addresses an educational model to include PHC and family medicine in a medical school curriculum in the city of São Paulo, Brazil. Furthermore, we describe the challenges of tying in educational and managerial objectives in the context of primary care services, and how to overcome such challenges. Our proposal is based on using educational objectives to develop student competencies (knowledge, skills and attitudes) so they can provide comprehensive care as regards the individual's background (social, family and environmental). Students are exposed to increasingly complex educational content that requires connecting new knowledge to previous knowledge. The innovative aspect of this educational project is its integration of planning and educational management, involving the following strategies to achieve a better quality learning process: (1) Students in primary care services from the first to the last semester of the course; (2) Hiring family doctors as faculty members; (3) Integrating PHC and family medicine with the contents of other subjects such as epidemiology, public health policies and evidenced-based medicine; (4) Using problem-solving methodologies suitable both to the studied theme and to student and lecturer profiles; (5) Formative evaluations; (6) Improving teaching skills for lecturers and field supervisors; (7) Implementing practices to encourage students to work in multi-professional teams; (8) Motivating students to take part in interchange programs with national and international institutions; and (9) Encouraging the publications of books, scientific papers and research into PHC and family medicine. Several factors facilitate the success of this educational proposal, including: PHC and family medicine being underlying matters in the political-pedagogical faculty project; the educational setting being that of an institution with a long history of health education, public care provision and contributions to service-learning integration; the close relationship between health service managers, lecturers and supervisors, which facilitates coordination between the theoretical content and practice in PHC; the investments made to develop supervisor teaching skills, to support their participation in the debate about relevant family medicine content, and in the discussion about integrating theory with practice; and finally the human resource policies that raise the value of family doctors who are also supervisors. We hope this experience contributes to enhancing the debate about PHC and family medicine educational models in medical courses, and the related challenges and possibilities within medical training.

Using the Manchester triage system for refusing nonurgent patients in the emergency department: A 30-day outcome study.

OBJECTIVE: To evaluate the long-term outcomes and satisfaction of nonurgent patients who seek care in the emergency department (ED) and are diverted to primary health services (PHS). METHODS: Data were collected from 264 nonurgent patients diverted from the ED of a tertiary public university hospital in São Paulo, Brazil. The nonurgent patient definition was performed by Manchester triage system version II (MTS-II) associated to medical interview in the triage service. Satisfaction levels were evaluated by telephone interviews. The outcomes were assessed within 30 days after the ED visit. RESULTS: Based on the MTS-II, 56.4 percent of the diverted patients were classified as green, 34.3 percent as blue, and 9.3 percent as white. Only one patient required a hospital admission and no deaths were registered within 30 days after ED diversion. After diversion, the majority of patients searched for PHS (62.7 percent), 14.4 percent sought out other EDs, and 22.9 percent did not seek out any other health services. Regarding patient satisfaction, 61.9 percent evaluated the triage team as fair, good, or very good. CONCLUSIONS: Our study suggests that diverting nonurgent patients from the ED to PHS may be carried out in a hierarchic system like the Brazilian public healthcare system. The MTS-II can be a useful triage system to support physician in the diverting process. In addition, patient satisfaction with the refusing was reasonable. Future studies should be designed to evaluate patient safety outcomes in a larger sample and in different healthcare systems.

Humanidades Médicas como Campo de Conhecimento em Medicina / Medical Humanities as a Field of Knowledge in Medicine

RESUMO Este ensaio aborda as humanidades médicas como campo de conhecimento e sua constituição em corpo teórico e metodológico de caráter próprio, particularmente na educação médica. Historicamente, as humanidades médicas surgiram paralelamente ao desenvolvimento do campo das ciências humanas e sociais em saúde, tendo com elas vários pontos de contato. Pelo estudo da literatura, delimitamos os dois campos quanto a objeto de estudo, interesses e interação com a realidade. Na educação médica, ainda que não haja consenso sobre as disciplinas/saberes que compõem as humanidades médicas, a tarefa é desenvolver nos alunos competência ético-relacional para a boa prática médica. Entre as várias dificuldades, destaca-se o distanciamento das experiências de ensino de temas humanísticos com a prática médica. O ensaio finaliza com a ideia de que a formação humanística deve emergir da práxis médica. Falta medicina nas humanidades médicas, principalmente porque faltam professores capazes de realizar a interdisciplinaridade constitutiva de seu campo.

ABSTRACT This essay addresses the medical humanities as a field of knowledge and its establishment as a theoretical and methodological body in its own right, especially in medical education. Historically speaking, medical humanities emerged alongside the development of the field of social sciences in health, with several crossover points between the two. Through study of the literature we delimited the two fields of knowledge in relation to study scope, interests and interaction. In medical education although there is no consensus on which subjects compose the area of medical humanities, the task is to develop ethical and relational competence in students for good medical practice. Of the many difficulties, we highlight the distancing between experiences of teaching humanistic themes and medical practice. The essay concludes with the idea that humanistic education should emerge from medical practice. There is a lack of medicine in the medical humanities, mainly due to a shortage of teachers capable of achieving the interdisciplinary quality that constitutes the field.