How to Progress from Discourse to Practice? A New Agenda for Change in Medical Schools into the Next Decade

doi:10.4236/ce.2012.34087

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Creative Education

2012. Vol.3, No.4, 595-599

Published Online August 2012 in SciRes (http://www.SciRP.org/journal/ce) http://dx.doi.org/10.4236/ce.2012.34087

How to Progress from Discourse to Practice? A New Agenda for

Change in Medical Schools into the Next Decade

José Lúcio Martins Machado1,2, Valéria Menezes P. Machado2, Joaquim Edson Vieira3

1Faculdade de Medicina de Botucatu, Universidade Estadual Paulista (UNESP), Botucatu, Brasil

2Universidade Cidade de São Paul o Medical School, São Pa ulo, Brasil

3Faculdade de Medicina, Center for Development of Medical Educa tion (CEDEM), Universidade de São Paulo,

São Paulo, Brasil

Email: [email protected]

Received June 22nd, 2012; revised July 26th, 2012; ac c e p t ed August 5th, 2012

In the context of medical school instruction, the segmented approach of a focus on specialties and exces-

sive use of technology seem to hamper the development of the professional-patient relationship and an

understanding of the ethics of this relationship. The real world presents complexities that require multiple

approaches. Engagement in the community where health competence is developed allows extending the

usefulness of what is learned. Health services are spaces where the relationship between theory and prac-

tice in health care are real and where the social role of the university can be revealed. Yet some compe-

tencies are still lacking and may require an explicit agenda to enact. Ten topics are presented for focus

here: environmental awareness, involvement of students in medical school, social networks, interprofes-

sional learning, new technologies for the management of care, virtual reality, working with errors, train-

ing in management for results, concept of leadership, and internationalization of schools. Potential barri-

ers to this agenda are an underinvestment in ambulatory care infrastructure and community-based health

care facilities, as well as in information technology offered at these facilities; an inflexible departmental

culture; and an environment centered on a discipline-based medical curriculum.

Keywords: Guidelines; Education, Medical, Undergraduate; Problem-Based Learning; Professional

Competence

Introduction

Modern scientific and technological developments have

brought about deep changes in health practices that have mobi-

lized large financial resources in different professional fields

with train ing foc used on sp ecializ ation. Howev er, th e segmente d

approach of a focus on specialties and excessive use of tech-

nology seem to hamper the development of the professional-

patient relationship and an understanding of the ethics of this

relationship. In parallel, medical schools take the same approach

and promote a curriculum focused on targeting practices in

hospitals of high complexity and multiple specialties. Resisting

this view, int ernation al conferen ces such as the Alma Ata (1978)

and others that followed hav e called for health practi ces that ma y

support primary health care (PHC) inst ead , i nflu enc ing tre nds in

the training of health professionals (World Health Organization,

1978).

Issues like technology-driven medical care and hospital- and

specialty-centered medical education are general in scope, likely

affecting societies worldwide. Indeed, if the primary goal of

undergraduate medical education is to produce students skilled

in core medical competencies, then pati e nt-centeredness ne e d s a

focus in parallel with learner-centeredness, and health care

quality should be considered in parallel with educational quality

as metrics of any medical education system (Hirsh et al., 2007).

How do we learn in the workplace? Learning by doing and

reflecting on the work: “… competence consists in attributes

displayed in the context of a carefully chosen set of realistic

occupational tasks, which are of an appropriate level of gener-

ality” (Hager and Gonczi, 1996). The real world presents com-

plexities that require multiple approaches. Engagement in the

community where health competence is developed allows ex-

tending the usefulness of what is learned. A wide range of skills

associated with flexibility allows professionals to develop be-

yond “capability” (Fraser & Greenhalg, 2001).

Knowing how to work as part of a t eam is essential at al l levels

of care, which involves fundamental concepts of interdiscipli-

nary and multidisciplinary interaction. Health promotion and

disease prevention have always been considered of low com-

plexity, but the critical success factors are the combination of

traditional approaches and the complexity of events, especially

regarding their promotion (Feuerwerker, 2003).

The need to train professionals willing to take on the respon-

sibility of caring for a diversity of needs and to use resources

available in communities is imperative. Health services are

privileged places for this purpose wh ere the relat ionship between

theory and practice in health comes to life and may confirm the

social role of the university. The experience of the Brazilian

health system and its reception of medical education present an

interesting opportunity to monitor and learn from the develop-

ment of learning with the practice of health care.

Although the literature in medical education emphasizes the

primary health care and the focus during undergraduate directed

towards patient and quality of care while performing as a team

member, the com plexities of “real wo rl d” health care challeng es

these prescriptions.

The objective of this hypothetic study was to propose an

J. L. M. MACHADO ET AL.

agenda in the field of medical education from experiences re-

ported and related to the Brazilian experience with a national

health system as well as with the implementation of an educa-

tional guideline for health education.

Methods

An Agenda for the Decade

A review of literature in the field of undergraduate medical

education and the evaluation of educational experiences applied

to Brazilian medical schools after the offering of a National

Curriculum Guidelines in that country was applied. The litera-

ture search related to national experiences from those Guide-

lines included Brazilian journals in the field of medical educa-

tion, from 2000 to 2012, and the national health system was

considered as a base for the development of such guidelines.

In Brazil, two associated movements have resulted ultimately

in efforts directed to both patient-centeredness and learner-

centeredness: the organization of the health system and imple-

mentation of a national guideline for medical education. The

first, related to health communitarian movements, is the Na-

tional Health System—the SUS (for the Portuguese “Sistema

Único de Saúde”), which relies on worker and user committee

opinions in addition to those from technicians (Cornwall &

Shankland, 2008). Weaknesses and strengths have emerged in

the process of implementing this system, alternating moments

of significant advances with times of significant setback that

have led to reassessment of its principles (Barnes & Coelho,

2009).

The creation of the SUS and the representation of Brazilian

society within it helped to boost the relationship between theory

and practice, i.e., between health care and health education. In

this environment, both governmental and associative initiatives

led to the proposal of the National Curriculum Guidelines—

DCN (Portuguese for “Diretrizes Curriculares Nacionais”) in

the year 2000, with important advances to promote community-

oriented curricula and address community health needs (Re-

solução CNE/CES, 2001). The DCN allowed other methods of

teaching and learning to be used for better incorporation across

the accumulated knowledge. In this environment, new curricu-

lum designs were outlined with active methods: Problem-based

Learning, Projects-based Learning, and Learning Teams, each

with its purposes.

Considering the advances in Brazilian medical schools in the

last 10 years, as guided and encouraged by the DCN, an agenda

for change in medical training for the second decade of the 21st

century can be presented. This agenda prompts a progression

from discourse to practice that could be embraced by under-

graduate medical education institut i o n s .

Results

1) Environmental Awareness. Combines policies of sustain-

ability and preservation of life on the planet with the incorpora-

tion of new habits and health practices, including considera-

tions of waste management, rational use of energy, and carbon

deficits associated with health services and their impact on the

health of the population (Pereira, 2007). Medical schools could

embrace programs like the WHO city health profiles. Experi-

ences already indicate that such programs provide an evidence

base to inform health planning for a city, even though appropri-

ate analyses for identifying inequalities within the city are still

lacking. In these matters of identifying and mapping inequali-

ties, engaged students could make the difference (Webster &

Lipp, 2009).

2) Student Involvement in Medical School: Medical educa-

tors around the world have linked three specific aspects to the

recognition of excellence in education: evaluation (Assessment),

student engagement (Engagement), and social responsibility

and “accountability” to society (Accountability). The current

schedule indicates a global medical education committed to

social development, opening up spaces for the promotion of

talents that unite expertise, training, a critical, reflective, and

humanistic outlook, scientific curiosity, willingness, and the

attitude of a lifelong learner (ASPIRE, 2011). In fact, some

experiences set the stage for medical training, including the

importance of understanding the philosophy of service learning

and time for reflection (Elam et al., 2002).

3) Social Networks produce significant sites of learning,

whether formal school spaces or informal learning experiences.

The “Canadian Council of Learning” defines the multiplicity of

spaces and situations such as mixtures of “unlimited dimen-

sions of learning” and points out the need to register these

situations and access evidence evaluation with qualitative and

quantitative research. The popularity of social networks high-

lights the need to incorporate them as a teaching medium and to

research their educational potential (Marti, 2010). Although

these networks are relatively new, some investigations already

suggest the potential that social networks have for disseminat-

ing innovations in health service delivery and organization

(Jippes et al., 2010).

4) Interprofessional Learning requires integration of experi-

ences among medicine and other professions, right from the

beginning. The “Network towards Unity for Health”

(http://www.the-networktufh.org/home/index.asp) is a network

that has contributed to this view, using the concept that inter-

professional education occurs when “one or more professions

learn with, for, and about each one, to improve collaboration

and quality of care.” Versatile and flexible curricula are based

on the experience of Bologna’s interdisciplinary bachelor's

process, the medical schools of Canada, and the formation of

the American “College” (Almeida Filho, 2008). However, in-

terprofessional learning is not an easy task, considering the

suggested three levels of action that must be incorporated: indi-

vidual, group (faculty), and institution, all to influence health

and educational practices (Ho et al., 2008).

5) New Technologies for the Management of Care. Devel-

oping technologies for the management of care that include

expanded clinical aspects (patient accountability), construction

of lines of care (organization of work for the integral and hu-

manized assistance—continuity of care, acceptance, commit-

ment, accountability, and problem solving), matrices (enabling

interconnection among care services in primary, secondary, and

tertiary health care), and shared construction of individual

therapeutic projects (a therapeutic single subject or individual’s

involvement in the community as a result of interaction with an

interdisciplinary health team) (Campos et al., 2006).

6) Virtual Reality, Robotics, Artificial Intelligence in tele-

medicine and graduate training in health as a replacement for

the set of practices that may go into disuse. Some examples are

the teaching of anatomy, pathology, and surgical skills in un-

dergraduate medical education, with difficulties that arise from

cadaver availability and the pressure from animal defense and

protection movements (Machado, 2010). These two items are

596

J. L. M. MACHADO ET AL.

directly or indirectly related to simulation, and there seems to

be no question of whether medical simulation is a critical com-

ponent of training and certification (Gordon, 2012).

7) Working with Reflection and Error in the evaluations of

medical students by using the tools that encourage reflection on

daily practice. Portfolio narratives from human and personal

experiences during medical education are good examples. The

systematization of recording practical aims makes possible

knowledge assessment, questioning of conflicts, and generation

of reflections. The reflection on errors involves values of ethics,

transparency, autonomy, and responsibility. The school must

provide a “sheltered environment” where error is observed, and

the simulations, of either high or low-fidelity mannequin, have

been gaining ground among the most successful environments

in this field (Aranaz et al., 2008).

8) Training in Management for Results. Regardless of the

chosen specialty, actions must be proactive and direct to resolve

collective as well as individual care. It should include health

promotion, prevention of risks and diseases, and rehabilitation

of patients and the communities. In contrast to the apparent

broad spectrum of competence and performance, it should fo-

cus on primary care and emergency care of low and medium

complexity. Performance evaluations should be promoted not

only for purposes of certification and recertification training but

also to promote institutional self-knowledge and its graduates

(Vecina Neto & Malik, 2011).

9) Developing the Concept of Leadership as a competence

required for a medical professional. Issues include globalization,

climate change, digital literacy, the balance of individualism

and team actions, and finally the ability to manage student di-

versity and the approach of teachers who encounter various

habits, cultures, and languages (Morin, 2000). Even though

leadership is not a task simply related to identifying high-po-

tential individuals, their strengths, and the provision of didactic

and experiential learning (Wolf et al., 2005), it seems that im-

mersion in the community would provide a rich and complex

experience.

10) The Internationalization of Schools and Medical Educa-

tion aims at universal characteristics: quality, equity, relevance,

innovation, and appropriate use of resources should be im-

proved at schools and during the practice of medical training. In

this context, the increasing mobility of health professionals and

patients from different countries may present a need for new

training profiles and curricula that provide mobility for students

to experience different environments and contexts. International

certification and accreditation takes on new meaning for social

engagement (AAMC—Association of American Medical Col-

leges, 2011; Biggs, 2010; Snadden et al., 2011; Boelen &

Woollard, 2011). Perhaps even more challenging would be to

consider this engagement as an effort to set up collaboration

between a number of schools in different countries, bringing a

global context rather than the context of a single country to the

medical education teaching and learning environment (Harden,

2006).

Discussion

The health human resources community in Br azil has a h istory

of a partnership between Pan-American Health Organization

(PAHO) and the Ministry of Health that has allowed the devel-

opment of projects such as Teaching Care Integration (IDA, for

Portuguese “Integração Docente-Assistencial”). Its premise was

to develop medical training and health care in the same field,

combining theory and practice. Individual and institutional

resistance within universities and a short maturity period of the

SUS as a field of practice limited these projects (Marsiglia,

1995); however, the IDA paved the way for a new program

supported by the Kellogg Foundation, the “UNI Program—A

New Initiative in the Education of Health Professionals, Union

with the Community” (1991-1997), focused on improving the

training of health professionals. A key differentiator for both

projects was involving the community with leadership training

and participation within its own management (Machado et al.,

1997).

In the decade after the DCN was established, medical schools

followed and adapted to the DCN, exposing themselves, in-

structors, and students to the external environments of the real

health s yst em. It seemed they could inde e d engage i n real-world

experience as a way to explore the advancements in science and

technology wit h the intention to achiev e excell ence. But wh at, in

fact, is excellence?

The answer t o th i s que stion li es i n th e “ Agenda de Salud para

las Américas” 2008-2017 from PAHO/World Health Organiza-

tion (WHO), which focuses on promoting the progress of

medical education. This agenda, involving countries of the

Americas and the Caribbean, aims to improve health indicators

by 15% by 2015. The basis for this action is the sharing of new

teaching practices aimed at PHC and the development of col-

laboration and documentation (O rganización Pana mericana de la

Salud, 2007).

All of these efforts indicate the need to train professionals

willing to take on the responsibility of caring for a diversity of

needs and to use resources available in communities. Health

services are privileged places for this purpose where the rela-

tionship between theory and practice in health comes to life and

may confirm the soc ial role of the university. The experience of

the Brazilian health system and its reception of medical educa-

tion present an interesting opportunity to monito r and learn from

the development of learning with the practice of health care.

How to “recognize health as a right, and act to ensure com-

prehensive he alth care” is a responsibili ty th at deman ds complex

educational resources, located beyond the classroom. In the SUS,

the Family Health Teams create fertile ground for the develop-

ment of comprehensive care and for Continuing Education in

Health. To look critically at the contextual situation and be able

to plan health actions are also flagged by the DCN. The profes-

sionalization of teaching is a powerful strategy used by some

schools as well as the continuing education program in place for

health professionals (Machado et al., 2011).

In addition, the objective “to know the principles of scientific

methodology” indicates that the student must be a builder of

critical knowledge of relevant information. The application of

the DCN implies changes in the structure and organization of th e

Brazilian university in its own environment, which asks for the

listening and reflection of qualified peers, institutional partners,

and students (Feuerwerker & Sena, 2002; Bowe et al., 2003).

The Brazilian DCN su ggests th e necessar y ski lls as follows: 1 )

Health care at differe nt levels b ecause these levels are not readily

identified in the work processes; 2) Decision-making because

competence requires prof essional s who hav e skills and work out

systematization and evidence; 3) Communication skills that

involve multidisciplinary knowledge and interactions based on

codes that should be understood and recognized as familiar and

invite participation; 4) Leadership, the commitment to and re-

J. L. M. MACHADO ET AL.

sponsibility for the skills already described; 5) Administration

and management because they are not equitable for all health

professions; and 6) Continuing education, or the ability to learn

how to learn, which can be achieved through specific teaching

strategies.

The DCN also established specific skills for scientific and

technical issues: proficiency in medical history, physical ex-

amination, interpretation of laboratory tests, clinical reasoning,

and therapeutics. There are difficulties, however, such as when

to consider the epidemiological criteria for the topics covered in

the training curriculum (Machado et al., 2012).

Some competencies are lacking, and may need the estab-

lishment of a environment where to develop them: the compe-

tence of working in primary care because most medical profes-

sionals/teachers were trained in a hospital-centered model

school; the competence of acting as an agent of social change

because there is limited experience in exercising politics in the

sense of citizenship; and the promotion of a healthy lifestyle,

although it is a skill not so distant from the practice of health

education courses and services, considering that the actions

related to health promotion are more accepted by the health

services as something th at does n ot disturb their routine (Cotta et

al., 2007).

We believe the majority of potential barriers to this agenda

could be related to those of any new educational approach in

general (Hirsh et al., 2007). The two most important barriers

related to health care are probably underinvestment in 1) am-

bulatory care infrastructure as well as in community-based

health care facilities directed to promote a learning environment

and 2) in information technology offered at these facilities

(ambulatory and community). In addition, the almost inflexible

departmental culture, mostly related to an environment where

the medical curriculum is discipline based, could impair pro-

gress toward an improved understanding and compromise for a

patient-centered education process. A simple strategy, like vis-

iting families in underserved areas, has helped medical under-

graduate students to acquire capacities in identifying social and

local health realities and understanding the Family Health Pro-

gram, the PHC structure, and the national health system (Vieira

et al., 2007).

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