Specialization courses offered in the scope of the More Doctors Program: documentary analysis from the perspective of Interprofessional Education.
The dynamic and complex character of people's reality of life and health has been increasingly revealing the need to reorient the production model of the health services and, consequently, health professionals' education. The current model, characterized by a strong division of labor, is centered on the health professional's technical knowledge; thus, health professionals' education focuses exceedingly on specific competencies, developing a professional profile that is incapable of facing this context. This negatively affects quality and the attention given to these complex health needs (1,2).
This debate is related to the historical movement of construction and consolidation of Brazilian National Health System (SUS). The SUS assumes the amplified concept of health and views comprehensive care as fundamental to the construction of a strong health system, capable of providing the most adequate responses to health needs and problems. As an essential principle of the SUS, comprehensive care (re)situates these needs on a central position in the production process of the health services (3).
In spite of this principle and notwithstanding the amplified conception of health, there has been a dispute between the traditional model of education and work in the area of health, which is centered on diagnoses and therapeutic procedures, and a recent model that understands health as a citizenship right. This imposes the need to propose, in a joint and articulated way, reforms in health teaching and work (4).
This situation justifies many global recommendations that have been encouraging countries to bet on the development of competencies for effective teamwork, performed through collaboration, having the improvement in the quality of care as the horizon of these changes. It is with this purpose that international agencies have recognized the importance of Interprofessional Education and collaborative practice as the structuring basis of an effective healthcare provision model (5,6).
Interprofessional Education is defined as the occasion in which actors from different health professions learn together, in an interactive way, with the explicit purpose of strengthening collaboration and improving the quality of the provided services (7). Collaborative practice, in turn, is defined as integration of professional practices focusing on the offer of comprehensive care, recognizing the centrality of users, families and communities in the organization of the work dynamics and in the level of interaction among professional practices (8).
Despite these recommendations, one of the challenges that teamwork and education for comprehensive care face is the unequal distribution and education of health professionals, a problem shared by different contexts around the world (2).
It is not different in Brazil, mainly when we analyze the education and distribution of doctors. There is a clear concentration of educational institutions in large urban centers, which produces a strong insertion of doctors in these spaces. Consequently, remote areas of Brazil and needy regions of large cities face shortage or a complete absence of doctors (9,10).
To face this historical problem, PMM was created in 2013 (11), resulting from the action of social forces and from the increased closeness between the interests of the State and of society, making it become a priority theme in the government's agenda. As an ideological basis to the formulation of PMM as a component of a public health policy, the re-emergent attempt to solve the insufficiency of doctors in the sphere of the SUS is an important artifice to strengthen Primary Care, as it operates by means of multiprofessional teams in which the doctor is indispensable (12-14).
Besides providing doctors for areas that lack these professionals, PMM also aims to stimulate teaching-service integration and permanent education as principles to change the logic of work and education in the area of health. In this sense, a different aspect of this program is the obligatory incorporation of doctors in complementary education activities, with methodological proposals targeted at themes that improve the practice of Family and Community Medicine and aim to qualify the professional in the perspective of the Brazilian health model and policies (11,15). In this policy, Primary Care emerges as a strategic scenario for the reorientation of health professionals' education because it promotes their contact with socially and historically determined health needs, configuring their complexities. In addition to these aspects, it provides subjects with more possibilities of developing their autonomy while choosing health actions that are coherent with those needs.
The pedagogical structure of the PMM's educational actions is organized in two cycles. The first is formed by a specialization course in Family Health conducted by a higher education institution that is part of SUS Open University (UNASUS), and activities performed by supervisors in the territory. The second cycle aims to deepen the participant doctor's knowledge about relevant themes related to Primary Care. Educational activities are performed in the level of improvement an extension (15).
The PMM doctors' action in the territories aims to strengthen and expand their capacity to intervene and solve problems in an integrated way with the other professionals who form the Primary Care teams. Therefore, the educational activities are an opportunity to strengthen the capacity to develop the necessary competencies to change the healthcare model--among them, those related to the education of subjects who are fit for collaborative teamwork. The reason is that it is possible to perceive, in the daily routine of health work, that the working process is still fragmented according to disciplines, which derives, mainly, from a uniprofessional academic education that is not in tune with the principle of comprehensive care defended by the SUS (16).
The Curricular Guidelines for Undergraduate Medicine Courses (17), whose review, performed in 2014, was triggered by the PMM, recommend that the courses must favor educational approaches that emphasize interprofessionality (18). Therefore, it is concluded that Interprofessional Education is the most adequate strategy to overcome a fragmented education and health model, as it promotes integrated and collaborative teamwork among professionals from different areas, focusing on the health needs of the user population (5).
Considering these aspects of PMM, the research was guided by the following question: What aspects of PMM's educational offers are possibilities to the adoption of the presuppositions of Interprofessional Education, revealed as promising possibilities to the promotion of changes in the logic of health work in the perspective of comprehensive and effective care?
In light of this, this article aims to analyze the political-pedagogical projects (PPP) of the specialization courses in Family Health offered in the sphere of PMM, as a possibility to the adoption of the theoretical and methodological presuppositions of Interprofessional Education.
This is a documentary and exploratory research that used a qualitative approach and was carried out in 2017. The decision to conduct a qualitative research is coherent in view of the study's object, as this approach values the researchers' perceptions, reflections and impressions as part of the process of interpretation of reality (19). The study's exploratory nature, in turn, is adequate because it enables to investigate aspects of the PPPs that are still unknown, related to the possibilities they present for the adoption of Interprofessional Education. The exploratory research reveals important issues, like potential difficulties, sensitivities and areas of resistance against the theme under study (20).
The choice of the PPPs as the object of this study is justified by the understanding that they represent the instrument that guides the educational process, delimiting its intentions. Although exploring pedagogical proposals presents limitations, as it does not allow to investigate the daily routine of the schools, it represents a recognition of their role in the processes of change or continuity of health education.
The research corpus was constituted of nine PPPs of specialization courses in Family Health offered in the sphere of PMM. The proposing institutions are: Universidade Federal de Ciencias da Saude de Porto Alegre--UFCSPA; Universidade Federal de Minas Gerais--UFMG; Universidade Federal do Maranhao--UFMA; Universidade Federal do Ceara--UFC; Universidade do Estado do Rio de Janeiro --UERJ; Universidade Federal do Mato Grosso do Sul--UFMS; Universidade Federal de Pernambuco --UFPE; Universidade Federal de Santa Catarina--UFSC; and Universidade Federal de Sao Paulo UNIFESP To avoid identification of the institutions in the presentation of fragments of the PPPs, we used only PPP--Course--numeral.
The documentary investigation was guided by the stages proposed by Bardin (21). Initially, all the documents were read for the researchers to be acquainted with the content and organize the analytical corpus. Then, relevant textual fragments were extracted and grouped according to their frequency, enabling the construction of units of meaning and ensuring the subsequent creation of empirical categories based on the elements that emerged in the investigation of the corpus.
The analysis of the documents enabled to identify the elements that configure the educational contexts and reveal their potential for the adoption of the theoretical-conceptual and methodological presuppositions of Interprofessional Education.
As we investigated offered courses whose PPPs are available at public domains, we did not submit the study to the Ethics Committee for Research with Human Beings.
The in-depth reading of the nine PPPs enabled the creation of thematic categories of analysis, presented below.
Reflective methodological approaches
Although the presuppositions of Interprofessional Education were not explicitly mentioned, the methodological approaches are coherent with the development of collaborative competencies, as they value professionals' reflection and life experiences at their workplaces. The curricular structure and the use of the teaching and learning methods that were adopted can potentialize interprofessionality through the utilization of mechanisms that favor collaborative and integrated learning, based on the development of transversal themes, stimulating knowledge exchanges and shared learning.
Methods like mixed-mode learning (e-learning integrated to a traditional learning method), Problem-Based Learning, problematization and complex case resolution emerge in a clear way in seven PPPs. These methods present important elements for reflections on complex health problems and needs through shared learning and evidence-based practice.
The pedagogical conception that guides the course is grounded on a critical and problematizing pedagogy. The didactic and pedagogical design of the course was developed with the objective of challenging students to participate actively in the entire course, articulating theory and practice. The center of the teaching process is the student. They will be stimulated to read, to analyze critically and to perform activities related to problem situations, presented through complex cases. (PPP--Course 1)
Considering that the courses in the sphere of PMM are offered only to doctors, they do not necessarily have a multiprofessional character, which, in principle, can discourage Interprofessional Education. On the other hand, shared learning and the encouragement to reflection and to education through work are important interaction and collaboration devices that need the participation of other professions, but this depends on the intention present in the PPPs and also on its fulfilment.
As for the theoretical framework, three courses develop the principles of education through work and significant learning, adopting problematization as the pedagogical method based on the integration between educational activities and the health services' scenarios--aspects that show a clear similarity with the concepts of Interprofessional Education.
For the development of the course, we decided to use the problematizing pedagogy and education at the workplace, as we believe that, in many situations of the daily routine of health work, professionals are concerned fundamentally about technical parameters and, due to this, they run the risk of working mechanically, without thinking about the situation in a contextualized way and in the individual with their own characteristics. (PPP--Course 8)
Although the PPP of Course 9 does not explicitly mention the adopted educational theory, its pedagogical model is governed by the paradigms that guide interactive educational practice and complex case learning, characteristics that are related to Social Psychology and the Complexity Theory.
The course is organized in a new version that fosters the interlocution between the theoretical framework and complex cases, organized in learning modules that deal with aspects related to family approach, construction of therapeutic projects and the importance of teamwork. It believes that these tools are necessary for the discussion of other complex cases until the end of the course. (PPP--Course 9)
Development of specific, common and collaborative competencies
Although the majority of educational offers is targeted at the doctors of the PMM, it was possible to identify elements for the development of specific, common and collaborative competencies. The latter are clearly delimited by the need to improve teamwork capacities in the Family Health Strategy (ESF).
Three projects have potential for competency-based education, as they value the integration of disciplines in axes or nuclei. In fact, content integration alone does not develop competencies, but reveals the belief that education fragmented in disciplines, which grounds the uniprofessional perspective, must be overcome. The transversal contents, present in two PPP are related to research methodology directed at the development of the course completion essay.
Although the curriculum organization potentially favors the integration of knowledge and practices --interdisciplinarity and interprofessionality -, the information available in the PPPs of the nine courses do not explain the articulation between disciplines and modules. Six pedagogical projects present evidences that the course aims to develop competencies for shared professional action, assuming that the exchange of experiences among different actors involved in the educational process is an opportunity to reflect on practice.
Developing the course according to the principles of education at the workplace, stimulating the exchange of experiences among students, teachers, tutors and in-service professionals, allowing reflection on practice and the creation of interaction spaces [...]. (PPP--Course 7)
The other five PPPs present proposals related to the theoretical and methodological bases of Interprofessional Education, emphasizing that the courses should promote education to improve course participants' capacity for teamwork, by means of teaching-service integration, aiming to increase the efficiency of the health system.
It is important to highlight that two PPPs focus on the participation of more than one professional category (doctors, nurses and dentists), as the course is offered also to the professionals of Qualification Program for Primary Care Professionals (PROVAB). This aspect shows the potential for multi- and interprofessional educational practices, although it is not possible to state, based on what the programs contain, that these categories learn together. There was also reference to the development of the specific competencies of each professional who participates in the course.
The PPPs contain the expressions multiprofessional and interdisciplinarity, the singularities of the health work, and aspects related to dialog and development of skills that need the integration of different health professionals. Thus, it is possible to state that the context of debate of the Brazilian healthcare reform allows to recognize the need to establish a dialog with this modality of education, which can bring positive results to the professional practice of doctors and to the improvement in the quality of healthcare.
Assessment to strengthen the teaching and learning process
The assessment models of the courses are very similar. They mention the adoption of the diagnostic, formative and summative perspectives, without detailing them further. Undoubtedly, the assessment of the teaching and learning process was the weakest aspect in the pedagogical projects. There is little information about the precepts that guide this stage of the education process.
The assessment models are greatly relevant to the adoption of the presuppositions of Interprofessional Education, as this modality of education recognizes the importance of a systematic and continuous assessment of the results of the education process, based on shared learning and on the acquisition of collaborative skills, which involve capacities for a joint professional action.
The projects show tendencies towards the understanding of assessment as a process aligned with competency-based education in the different scenarios of reality where the participant's professional practice is taught.
The course's assessment will be a summative and continuous process that will happen throughout the development of the course. The tutor will monitor knowledge construction processes and the acquisition of the expected competencies, in consonance with the course's theoretical framework. (PPP--Course 1)
The course's assessment must be a process developed during the entire course. It can be diagnostic, when it helps to identify strong and weak points (...); formative, when it is a process that takes place during the whole qualification period; and summative, when it is the final "measurement" of the participant's performance, delivered by means of grades. (PPP--Course 2)
The PPPs lack information about the program's assessment and, consequently, about the pedagogical methods used to meet the learning objectives. In addition, there is no information about the dissemination of the results of this type of assessment. Nevertheless, in view of the fact that the specialization courses are linked to PMM through an agreement with the Ministry of Health, situational reports about the courses can incorporate assessment aspects of the pedagogical proposal not limited to a quantitative description of data, in order to disseminate educational experiences that serve as examples for new proposals.
Interprofessional Education is a relatively recent theme of discussion in Brazil, although the literature presented the first movements of this debate in the 1960s (22). In spite of this, Brazil presents a historical accumulation in the field of the healthcare reform, in which health work is viewed as collective, marked by a strong relational character, guided by communicative action (23) and interdisciplinarity as principles to strengthen comprehensive care (24)--aspects that strongly interact with the presuppositions of Interprofessional Education.
With the world crisis that has affected the workforce in the area of health, characterized especially by the difficulty in having health professionals working at less developed places, remarkably the doctor, the principles of Interprofessional Education and collaborative practice have gained strength and have been assumed as an important strategy to optimize healthcare outcomes (7,14).
Interprofessional Education is a powerful means of health education to overcome inequities among the different professions that compose the field of health; furthermore, it can overcome the biomedical model of healthcare, still in force, whose main agent is the doctor. The perspective is that this approach can overcome the logic that separates fields of practice, which delimit professional tribes, and focus on the user as the center of health acts (1,25).
The qualification of doctors in the scope of the PMM, which uses the primary care services as a pedagogical resource for education, is an opportunity to adopt the methodological bases of Interprofessional Education, subsidizing the development of competencies targeted at collaborative practices in the daily routine of the health work. The reason is that the principles of this educational approach combine with the principles that guide the SUS; in addition, there is a relationship of mutual influence between healthcare and health education (26).
Adopting diversified pedagogical methods as strategies to develop professional competencies is an advance, as it shows the intention of overcoming the traditional health education model, which presents limitations in the formation of a professional profile aligned with social demands. The use of active methodologies, namely problem-based learning and the discussion of complex clinical cases, which have been viewed as strategies to develop critical thought, is an important movement of recognition of the complex and dynamic character of health needs. This has been increasingly justifying the relevance of interprofessional practices to the resolution of problems by means of collaborative work (27,28).
Active methodologies have been increasingly employed in the sphere of postgraduate health courses, as other studies have shown (29,30). These methodologies are strongly indicated for educational processes based on Interprofessional Education (31), as they stimulate students' active interaction with the content, their leading role, and their autonomy in the knowledge construction process (32).
As we are dealing with specialization courses in which the major part of the number of hours is allocated to online lessons, the use of active methods to approach Interprofessional Education can improve the PMM doctors' learning, especially regarding the understanding of other health professionals' roles. In addition, it can overcome geographical and logistic issues inherent in the delivery of this educational approach (33,34).
However, the methodologies must be grounded on a robust theoretical basis whose pedagogical constructs stimulate significant learning. About this issue, the research corpus does not provide evidences that the courses' design was guided by intentionally chosen educational theories. However, it is possible to identify that the reflective practice is strongly valued, as it defends education through work and the precepts of Social Psychology and of the Complexity Theory, which, according to the literature, guide the development and implementation of Interprofessional Education (35,36).
Education through work assumes that the interrelation between health and education based on work results in significant learning and in development of new knowledge, shortening the distance that exists between the educational and the working process; consequently, it weakens the logic of banking education (36). Therefore, the education of health professionals based on education through work is a theory capable of boosting teaching-service integration and transforming pedagogical and labor practices in the area of health (37), strongly related to the perspective of reflective practice.
The Theory of Reflective Practice strengthens the relations between knowledge construction and experience and between theory and practice, understanding that reflection happens in action, while it is being performed and, subsequently, on action, in a process that evaluates practice (38).
Social Psychology and the Complexity Theory explain the influence of dynamism and of the interaction between cognitive and environmental factors on learning, that is, they investigate the interaction among individuals and their contexts and life experiences (35). To them, knowledge is socially created through interactions with other professionals and the work environment, and involves collaborative attitudes and skills. Thus, interprofessionally, students must involve themselves actively with the roles of other professionals by means of collaborative learning, in order to outline and reach shared goals (39).
It is important to mention the presence of elements from other theories that ground the creation of pedagogical strategies that can be related to approaches that favor interprofessional learning and the development of collaborative competencies, such as Andragogy (40). Andragogy is the science that studies the best practices to guide adults in the construction of knowledge, valuing students' experiences and personal needs to motivate them to learn (41).
It is necessary to bear in mind that Interprofessional Education expresses the adoption of new contents, the recognition of new knowledge, and the use of new teaching and learning approaches. Thus, theories related to professionalism, to the development of professional competencies, to critical-reflective and transformative learning, seem to be central to Interprofessional Education and guide specific educational interventions that can favor its presuppositions (35).
It is possible to state that the PPPs do not provide details about the central elements of the educational process, especially concerning assessment methods. Although they reveal the intention of performing a process-based assessment, they do not provide details about the forms used to analyze whether the learning objectives have been reached.
However, the recognition of assessment as a process is relevant in the perspective of Interprofessional Education, as it allows to explore the strong points and weaknesses of the course's participants in the process of development of competencies. Thus, it is possible to change or enhance the teaching strategies, depending on the educational needs of each individual or group. Similarly, institutional assessment must be incorporated as an incentive to experience exchange and pedagogical flexibility, in favor of the improvement in the results through a re-planning of the educational contexts (30).
As the PMM is an important strategy of provision linked to professional training that, in terms of its reach, is unprecedented in the Americas, the analytical and assessment processes of the lines that constitute the program are fundamental to its success and, consequently, to improve access to and the quality of Primary Care.
Studying pedagogical projects in the context of PMM by focusing on the presuppositions of Interprofessional Education assumes a singular relevance, as it allows to identify the intention that permeates this strategy of health provision and education, revealing the project of health and society that we intend to construct.
Despite the absence of elements that identify the intention to defend the principles of interprofessionality as a referential basis, the PPPs, to a higher or lower degree, present possibilities of strengthening the principles of Interprofessional Education, especially regarding the recognition of the complex and dynamic character of health needs, which demands, in turn, greater interaction among different professional practices.
The research brings two important considerations that are intrinsically related: The need to think of more systematized pedagogical proposals in which the theoretical-conceptual and methodological principles are clearly established, and, in spite of this, the courses' potential for adopting the principles of Interprofessional Education. In this scenario, we highlight that the PPP as an institutional instrument that expresses values, objectives and pedagogical methods, needs to be consistent and reveal, in an explicit way, the elements that conduct the educational process.
Furthermore, it is not possible to state that what is present in documents is, in fact, operationalized; it would be necessary to complement this research with other studies that can investigate the dynamics of educational processes based on the realities and subjects involved.
Moreover, although the interprofessionality approach can be hindered by the absence of other professional categories in the scope of the specialization course, well-employed pedagogical methods can favor the development of the theoretical-methodological elements of Interprofessional Education, which requires systematized proposals and the engagement of this policy in the education process of other health professionals. Finally, it is necessary to call the reader's attention to the importance of teacher development in transformative educational proposals.
The format of the studied projects is a limitation of the study, as it does not provide sufficient elements to reveal the horizon of this educational process. Generally speaking, the PPPs cannot represent only a conditionality to the existence of the course. They must explain the theoretical-conceptual and methodological bases capable of contributing to the construction of a new project of health and society.
This finding may have important implications to the policy itself because it shows proposals that lack theoretical-conceptual and methodological solidness, fundamental to an education model that has, in its genesis, the commitment to transform the logic of health education and work.
Therefore, the program needs deeper analyses of its educational aspects, which can be complex, structuring and long lasting.
Jose Rodrigues Freire Filho participated in all the stages of the development of the manuscript; Carinne Magnago and Marcelo Viana da Costa participated in the discussion of the results and in the writing, review and approval of the manuscript's final version; Aldaisa Cassanho Forster participated in the conception of the research, critical review of the content, discussion of the results and approval of the manuscript's final version.
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Translator: Carolina Siqueira Muniz Ventura
Submitted on 11/09/17. Approved on 07/25/18.
Jose Rodrigues Freire Filho (a)
Carinne Magnago (b)
Marcelo Viana da Costa (c)
Aldaisa Cassanho Forster (d)
(a d) Departamento de Medicina Social, Faculdade de Medicina de Ribeirao Preto, Universidade de Sao Paulo (FMUSP-Ribeirao Preto). Av. Bandeirantes, 3900, Monte Alegre. Ribeirao Preto, SP, Brasil. 14049-900. firstname.lastname@example.org
(b) Curso de Medicina, Escola de Saude, Faculdade Meridional (Imed). Passo Fundo, RS, Brasil. email@example.com
(c) Escola Multicampi de Ciencias Medicas, Universidade Federal do Rio Grande do Norte. Caico, RN, Brasil. firstname.lastname@example.org
Chart 1. Thematic categories, subcategories and units of meaning that emerged from the documentary investigation of the Political-Pedagogical Projects of the Specialization Courses in Family Health offered in the sphere of the More Doctors Program Brazil, 2017 Categories Subcategories Units of meaning Reflective 1--Use of reflective * Mixed-mode learning methodological methodologies * Distance teaching approaches * Problem-based learning 2--Focus on teaching * Problem situations through work in * Problematization; health services * Competency-based education; 3--Teaching-service- * Education at the workplace; community integration * Exchange of knowledge; Development of 1--Formation of * Respect for the specific, professional nuclei professions' specificities; common and * Action in the family health collaborative 2--Common themes to team; competencies the health worker * Alignment with complex health problems; * Interdisciplinarity; * Comprehensive care; * Public policies; * Shared responsibility; 3--Teamwork education * Multiprofessional actions; * Collaborative work; Assessment to 1--Process assessment * Diagnostic assessment; strengthen the * Formative assessment; teaching and * Summative assessment. learning process Source: Created by the authors.