Expression of the governmentality process in Health Care Residencies

Daniela Dallegrave Ricardo Burg Ceccim About the authors

Abstract

The paper presents an essay on the concept of governmentality according to Michel Foucault and some of its expressions in the everyday life of the Health Care Residency programs. The process of building the learning images in the programs showing how this concept appears, was developed based on a PhD research concluded in 2013.

Health care residency; Governmentality; Public Health


Introduction

This essay presents some results of the doctoral dissertation entitledEncontros de aprendizagem e governamentalidade no trabalho em saúde: As Residências no País das Maravilhas (Learning and governmentality encounters in healthcare: Residencies in Wonderland), submitted to the Postgraduate Program in Education of Universidade Federal do Rio Grande do Sul (Federal University of Rio Grande do Sul) in December 2013. The essay discusses Michel Foucault’s concept of governmentality and its expressions in the institutionalization of Healthcare Residencies in Brazil, especially the Residencies in a Healthcare Professional Area.

The original research collected material from conversations held with people involved in Healthcare Residencies who were present at the following events: I Rio Grande do Sul Meeting, II National Meeting of Healthcare Residencies, and X Brazilian Collective Health Congress. These events were held in 2012 in the city of Porto Alegre, State of Rio Grande do Sul (Southern Brazil). In addition, the legislation on Healthcare Residencies was analyzed. Overall, 18 documents were examined: 11 concerning Medical Residency and 7 related to Multiprofessional Residencies. The research collected free manifestations through a pamphlet that asked, “How would you express a learning experience in Healthcare Residency (image, audio, narrative, poem…)?” The answers were received by e-mail. The empirical material was organized based on emerging issues and explored in the perspective of Michel Foucault’s discourse analysis11. Foucault M. A ordem do discurso. São Paulo: Loyola; 2006..

The methodological proposal had characteristics of cartographic studies. However, connections were weaved with Alice’s walk across Wonderland: meetings with the pink-eyed White Rabbit were reported, research curiosity was awakened, and coherence nodes were offered when we stumbled across unusual situations. As the process was reported based on Alice’s walk, we decided not to present the discourses of Wonderland’s inhabitants (the study’s participants and information producers), for this Land was gradually constructed from what Alice felt and from the way in which she was touched by what she found while she walked.

The constitution of the dissertation’s question, related to delimiting the concept of governmentalization, derived from the empirical perception experienced in the roles of resident, preceptor and coordinator in the daily routine of Healthcare Residency programs, and from a series of propositions that aimed to organize and regulate in-service learning processes, especially discussions about curriculum formulation. From this perception, the following questionings emerged: Is it necessary to standardize teaching in the Residencies? What would be the limits of curricularized education? In what way was this governmentalization concerned about potentializing theensi-g-namentos of in-service healthcare teaching?Ensi-g-nar, a term constituted from Deleuze22. Deleuze G. Proust e os signos. 2a ed. Rio de Janeiro: Forense Universitária; 2010.’ ideas, is the possibility of learning through signs.

These issues formed the original interest of this research, but they were also questions circumscribed to a political agenda, an agenda that was public and that interested the researchers and participants in the itineraries that composed the Residency.

Thus, the article is structured in the following sections: Governmentality in Michel Foucault , which presents the central concept; The governmentalization process of Healthcare Residencies , in which the reader is invited to imagine a situation that enables the construction of thought around the issue that guides the writing of the text;Governmentalization in Wonderland , which presents the results of the dissertation’s research into the concept of governmentality and its expressions in the governmentalization process of Healthcare Residencies; and, finally, the Final remarks , in which the elements of the theoretical formulation that contribute to a reflection on the current education policy in Healthcare Residencies are revisited, and their unquestionable role of educating workers for the SUS (Brazil’s National Healthcare System) is strengthened.

Governmentality in Michel Foucault

Governmentality encompasses the studies conducted by Michel Foucault from 1978 onwards, in the shift operated in the axis of disciplinary power, passing by biopower and arriving at governmentality. These three concepts are different power technologies that have coexisted in the complex arrangements of the Western society after the 16th century33. Maia AC. Sobre a analítica do poder de Foucault. Tempo Soc. 1995; 7(1/2):83-103..

To arrive at governmentality, Foucault discussed a disciplinary power materialized in the panopticon, in which disciplinary relations and the orthopedics of the body were the main objectives, that is, a technology that regulated action over bodies and their acts. The author also approached biopower, whose objective was the body and life, but viewed as belonging to a species, a set, a multiplicity known as population, on which regularities and laws are imposed. In this sense, governmentality marks a transition: it is important to govern the others in articulation with the government of the self, with practices and exams that are put into operation so that each individual governs himself33. Maia AC. Sobre a analítica do poder de Foucault. Tempo Soc. 1995; 7(1/2):83-103.. According to the philosopher, governmentality is the “contact between the technologies of domination of others and those of the self” 44. Foucault M. As técnicas de si [Internet]. 1982 [acesso 2014 Set 7]. Disponível em: http://cognitiveenhancement.weebly.com/uploads/1/8/5/1/18518906/as_tcnicas_do_si-_michel_foucault.pdf
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(p. 2).

Foucault55. Foucault M. Segurança, território, população. Curso no Collège de France (1977-1978). São Paulo: Martins Fontes; 2008. registers his understanding of the word “governmentality” based on: 1) the grouping composed of institutions, procedures, analyses and reflections, calculations and tactics that enable the exercise of this power, which aims to reach the population using the knowledge of political economy and, as an instrument, security devices; 2) the tendency towards this power called government of others, which carries with it a specific governing apparatus and develops different types of knowledge; 3) the verification that the state is governmentalizing itself. Concerning the specific issue of the governing of individuals, Foucault66. Foucault M. Do governo dos vivos. Curso no Collège de France (1979-1980). São Paulo: Centro de Cultura Social; 2010.mentions that it is necessary to know each individual and each behavior in order to govern.

In the first part of the text “Omnes et singulatim”: Towards a Criticism of Political Reason, the theme of governmentalization is seen as the development of “power techniques oriented towards individuals and intended to rule them in a continuous and permanent way” 77. Foucault M. Omnes et singulatim: uma crítica da razão política. In: Motta MB, organizador. Estratégia, poder-saber. 2a ed. Rio de Janeiro: Forense Universitária; 2010. p. 355-85. (p. 357), showing traces of a pastoral power that serves everyone and each one. This highlights the importance given to this theme by Christian thought and institutions. God and the king played the same role in the care provide for their flock, which was the people. The association between these two figures happened naturally77. Foucault M. Omnes et singulatim: uma crítica da razão política. In: Motta MB, organizador. Estratégia, poder-saber. 2a ed. Rio de Janeiro: Forense Universitária; 2010. p. 355-85..

Four characteristics of the pastoral power integrate the art of governing, which is constituted based on it: 1) The shepherd wields power over a flock rather than over a land; 2) the shepherd gathers together, guides, and leads his flock; 3) the shepherd’s role is to ensure the salvation of his flock; 4) wielding power is a duty. Everything the shepherd does is for the sake of his flock. To meet these characteristics, the shepherd must know his flock as a whole, and in detail77. Foucault M. Omnes et singulatim: uma crítica da razão política. In: Motta MB, organizador. Estratégia, poder-saber. 2a ed. Rio de Janeiro: Forense Universitária; 2010. p. 355-85.. The specificity of the pastoral power is the relationship of obedience among individuals, that is, one that directs and the other that is directed.

Based on the analysis of what a shepherd does, at certain times, it was possible to say if the king was or was not a kind of shepherd77. Foucault M. Omnes et singulatim: uma crítica da razão política. In: Motta MB, organizador. Estratégia, poder-saber. 2a ed. Rio de Janeiro: Forense Universitária; 2010. p. 355-85.. The difference between them is that the shepherd is responsible, by himself, for providing care, feeding, organizing the reproduction, treating people when they become ill, gathering them together, etc. The king shares these functions with other people, like the baker, the healthcare professional, the guard, the pedagogue, etc. According to Foucault77. Foucault M. Omnes et singulatim: uma crítica da razão política. In: Motta MB, organizador. Estratégia, poder-saber. 2a ed. Rio de Janeiro: Forense Universitária; 2010. p. 355-85. (p. 365), with Plato, the idea that “the men who hold political power are not to be shepherds” became effective, together with the notion that the politician’s role would be to assure the city’s unity.

In the second lecture of “Omnes et singulatim”: Towards a Criticism of Political Reason, Foucault77. Foucault M. Omnes et singulatim: uma crítica da razão política. In: Motta MB, organizador. Estratégia, poder-saber. 2a ed. Rio de Janeiro: Forense Universitária; 2010. p. 355-85. showed how this pastorship happened to combine with its opposite: the state. The philosopher77. Foucault M. Omnes et singulatim: uma crítica da razão política. In: Motta MB, organizador. Estratégia, poder-saber. 2a ed. Rio de Janeiro: Forense Universitária; 2010. p. 355-85. (p. 373) argues that “The doctrine of reason of state attempted to define how the principles and methods of state government differed, say, from the way God governed the world, the father his family, or a superior his community.” Therefore, the reason of state is an art of governing that functions as a technique that is molded according to certain rules.

That is why government is only possible if the strength of the state is known: it can thus be sustained. In short, the reason of state is government in accordance with the state’s strength whose aim is to maintain and increase this strength77. Foucault M. Omnes et singulatim: uma crítica da razão política. In: Motta MB, organizador. Estratégia, poder-saber. 2a ed. Rio de Janeiro: Forense Universitária; 2010. p. 355-85.. The increase in the state’s strength, at that time, depended on the action of the police, who also had to keep people happy. In the 18thcentury, the police’s role encompassed watching over religion, morals, health and public safety, supplies, roads, highways and town buildings, the arts and factories, trade, manservants and laborers, and the poor. The government’s objective, through the reason of state, was “to develop those elements constitutive of individuals’ lives in such a way that their development also fosters that of the strength of the state” 77. Foucault M. Omnes et singulatim: uma crítica da razão política. In: Motta MB, organizador. Estratégia, poder-saber. 2a ed. Rio de Janeiro: Forense Universitária; 2010. p. 355-85. (p. 383).

When Foucault55. Foucault M. Segurança, território, população. Curso no Collège de France (1977-1978). São Paulo: Martins Fontes; 2008. approaches Machiavelli’s The Prince in the course “Security, Territory, Population”, the philosopher argues that there was the intention of underlining the discontinuity between the Prince’s power and any other form of power. Furthermore, he highlights upward continuity, which refers to one’s capacity of governing oneself, one’s family and one’s domains, in order to reach the state government; and downward continuity, which could be seen when a state was governed well, when fathers governed their goods and property well, and when individuals conducted themselves properly. Thus, upward continuity was guaranteed by the Prince, and downward continuity, by the police.

Based on this notion of continuity, it can be noted that the act of governing belongs to many, as it was mentioned above: “the father of a family, the superior in a convent, the teacher, the master in relation to the child or disciple” 55. Foucault M. Segurança, território, população. Curso no Collège de France (1977-1978). São Paulo: Martins Fontes; 2008. (p. 124). There is also the Prince’s government. Based on these figures that govern, three types of government operate: the government of oneself, which falls under morality; the art of properly governing a family, which is part of economy; and finally, the government of the state, which belongs to politics.

In the governing practices, what is questioned is the exercise of power and the manifestation of truth, that is, a truth manifestation ritual, through verbal or non-verbal procedures, sustained by the exercise of power. Government or governmentalization would be, according to Foucault66. Foucault M. Do governo dos vivos. Curso no Collège de France (1979-1980). São Paulo: Centro de Cultura Social; 2010. (p. 43), “mechanisms and procedures intended to conduct men, to direct their conduct, to conduct their conduct”. Diverse governing mechanisms function in laws, directives, guidelines, resolutions and pedagogic projects related to Integrated Healthcare Residencies/Multiprofessional Healthcare Residencies and operate in the governmentalization of the practices performed at in-service learning encounters.

This ongoing form of process called governmentalization acts in a capillary and insidious way. The question that triggered the reflection on this issue was: how is governmentalization configured in the conduction and direction of what to learn and how to learn it in work-based education?

The research proposal of the doctoral dissertation was to listen to the actors – residents, preceptors, coordinators and whoever was interested – in conversations during and about learning encounters, articulating this with the instruments generated by Comissão Nacional de Residência Multiprofissional em Saúde (CNRMS – National Committee for Multiprofessional Healthcare Residencies), seen here as the Government’s apparatus that performs governmentalization. The committee is composed of managers of the Ministry of Education, representations of teaching institutions (education management), teaching associations (management of teaching-learning relations), professional councils and unions (management of professions and work), and federal, state and municipal healthcare system managers (government/public administration). Last but not least, the representation of residents and coordinators of the Programs of Integrated Healthcare Residencies/Multiprofessional Healthcare Residencies.

The proposition of teaching guidelines or even of a curriculum also participates in the ways of unveiling governing elements that will be together with the signs, present in the encounters, producingensi-g-namentos.

In Healthcare Residencies, two movements coexist: the inventive movement, which is born and emerges from actors in problematic hearing, and a process of regulation and rule-making, in reactive emergence. In Residency education, the educational work is accompanied by a curricularization of in-service education. Curricularization, one of the tactics of the governmentalization process, requires a Settled curriculum88. Corazza SM. Noologia do currículo: vagamundo, o problemático e assentado, o resolvido. Educ Real. 2002; 27(2):131-42. that undoes and solves all the problems invented by the Problematic curriculum. The learning encounters require a Problematic curriculum. They intermediate sensitivity, accumulations and thought to the “questioning and problematizing power of the signs”, sacrificing the “facility of recognitions” (p. 136).

A Settled curriculum and a Wandering curriculum or Problematic curriculum do not exist in isolation, nor do they defeat one another in each didactic-pedagogic proposal. However, they can signal the intention of the proposers of rules, regulations and monitoring. What do these proposers want?

The governmentalization process of Healthcare Residencies

To allow the reader to have a practical visualization of the research problem, we present, below, an invented image. This image offers an invitation to a tour round the thoughts. Where will this tour be conducted? The answer is: you choose it! The options are: one Unidade de Saúde da Família (USF - Family Health Unit), one Centro de Atenção Psicossocial (Caps – Psychosocial Care Center), one hospital emergency unit, one intensive care unit, one street clinic, one delivery room, or one cancer treatment unit. It may be any place where a healthcare practice is provided, especially in the SUS, as the Residencies are characterized as a strategy to form professionals to work in this system.

After choosing the place, we propose that you observe the people who are working at it and their routine. In a typical scenario, there are professionals with well-defined roles: the secretary, who answers the phone calls, welcomes users or relatives, and refers each issue to its flow; the nursing assistant, who is there to execute his/her care functions, attested by his/her professional board; the nurse, who receives tasks when he/she is on duty or provides assistance and performs his/her private functions; the nutritionist, the doctor, the social worker, and so on. Each one performs the functions for which they graduated.

Now, let’s imagine that this team receives a new professional. He/she may have any profession. Some professionals will help their new colleague upon his/her arrival; some due to affinity, others because of empathy, and others out of responsibility (for example, if the professional comes from the same category). However, none of them will have a formal commitment, unless the manager designates him/her to welcome the new professional.

In our tour, we propose to think about how this team – called fixed team – would receive another team, composed of three or four residents. Reflecting on their professions is not important here, too. Before receiving them, however, the team would have participated in conversations about the Residency program and, although they did not have a clear idea of what it was, they were open to this encounter. They had to make some decisions, or received news about decisions that had already been made. Decisions that already interfered in the roles played by each one in the team. Perhaps one or two of them had become preceptors. All of them, although many times this is not formally declared, had become educators. Therefore, it is possible that a formalization of pedagogic practices that already existed in that place had been performed.

Although they did not know what would change in their work with the arrival of the Residency program, they talked about this new element that was opened in the working process. One of the team members worked at another institution that had a Residency program, and commented on some discourses referring to preceptors he knew about, through observations made at this other place: a) the professional model, based on the existence of a series of practices intermediated to constitute this professional figure to be followed – production of mental imagery, desire of future, the preceptor “as an example”; b) the constitution of a teaching function – “becoming a teacher, master, tutor, preceptor, supervisor, mentor”: intermediations that are intertwined in the social construction of this position of specialist knowledge; c) the evaluator of professional practices: residents have professional qualification but depend on the preceptor as a guarantor – “the preceptor as the one who certifies the assertiveness of the conducts” –, whose task is to “evaluate” and disapprove certain actions.

Thus, we believe that there is a double condition of in-service learning in the Residency programs: that of a professional who is a resident and that of a professional who is a preceptor. Based on the practice of these discourses, without any declared intentionality, the entire team begins to position themselves in a different way. If the preceptor is designated by someone outside the team, the other team members may overvalue this professional. This may also happen if he is chosen by the group. There is something that is insinuated and occurs in the conduction of the conducts of every and each individual.

Here comes the day when the team of residents arrives. Some professionals of the fixed team are on holidays, as the Residency programs begin between January and March. The new team arrives slowly. They do not know the place, they do not know the people, these are other territories. When people are introduced, the qualifications are heard: this is the nurse, this is the nutritionist, that is the doctor, and that one is the PRECEPTOR. He is …, and an identification with the preceptor happens immediately due to his explicit bond with the Residency. With the other professionals, perhaps… Although all the professionals participate in the residents’ education, the preceptor holds the formal responsibility of being a reference to the residents in the performance of the practical activities experienced in the daily routine of health care and management99. Ministério da Educação. Perguntas e respostas sobre Residência Multiprofissional e em Área Profissional da Saúde [Internet]. Brasília (DF); 2013 [acesso 2014 Set 7]. Disponível em: http://portal.mec.gov.br/index.php?option=com_content&view=article&id=18168&Itemid=813
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. In practice, some instituted operations and techniques are organized to legitimate, endorse and make this place function. There is a positioning of this professional due to the circumstances that put him in the place of evaluator, as it was mentioned above.

When things run smoothly, all the individuals adjust themselves. The team becomes one, including fixed and itinerant members. They share assistances and learn mutually. If the teaching-learning practices did not have an important space in the first team, now their value is duly recognized. Everything happens as in any other team, with institutional crossings that are typical of the work, constituting ways of being there.

At any moment, the practices of that place can be reconfigured by something that is external to them, as that Residency program is part of a national policy of education of workers to the SUS. In this team, unlike in others, it is not only the institutional crossings and those typical of the work that reconfigure the practices. Moves of the CNRMS, which occur very distantly from the places where the programs are, interfere insidiously in the daily work, in the possible learning encounters that occur in the programs - the existence of something that Foucault called Governing (as described in Foucault55. Foucault M. Segurança, território, população. Curso no Collège de France (1977-1978). São Paulo: Martins Fontes; 2008.

6. Foucault M. Do governo dos vivos. Curso no Collège de France (1979-1980). São Paulo: Centro de Cultura Social; 2010.

7. Foucault M. Omnes et singulatim: uma crítica da razão política. In: Motta MB, organizador. Estratégia, poder-saber. 2a ed. Rio de Janeiro: Forense Universitária; 2010. p. 355-85.

8. Corazza SM. Noologia do currículo: vagamundo, o problemático e assentado, o resolvido. Educ Real. 2002; 27(2):131-42.

9. Ministério da Educação. Perguntas e respostas sobre Residência Multiprofissional e em Área Profissional da Saúde [Internet]. Brasília (DF); 2013 [acesso 2014 Set 7]. Disponível em: http://portal.mec.gov.br/index.php?option=com_content&view=article&id=18168&Itemid=813
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-1010. Foucault M. O governo de si e dos outros. Curso no Collège de France (1982-1983). São Paulo: Martins Fontes; 2010.).

Governmentalization in Wonderland

“I don’t think they play at all fairly,” Alice began, in rather a complaining tone, “and they all quarrel so dreadfully one can’t hear oneself speak — and they don’t seem to have any rules in particular; at least, if there are, nobody attends to them — and you’ve no idea how confusing it is all the things being alive”.1111. Carroll L. Aventuras de Alice no país das maravilhas: através do espelho e o que Alice encontrou por lá. Rio de Janeiro: Zahar; 2009. (p. 100).

Governmentality in the Residencies is viewed here as the existence of many governments, in many modalities, such as those of CNRMS and Coremu (a collegiate sphere that exists in each Residency program, responsible for deliberating about local issues), as well as the government of pedagogic projects, of preceptors and of residents. It is important to consider that these governments (and, maybe, others) happen at the same time, with multiple forms of governing and with emerging governing practices.

When we consider that the curriculum is a governing practice that emerges from each one of these governments, it is possible to think of it as a paradox. Curriculum is the “action of traveling a certain course”1212. Veiga-Neto A. O currículo e seus três adversários: os funcionários da verdade, os técnicos do desejo, o fascismo. In: Rago M, Veiga-Neto A, organizadores. Para uma vida não-fascista. Belo Horizonte: Autêntica; 2009. p. 13-26. (p.17). Thus, with the capture of the curriculum, the “curricularization” of the practices occurs, being introduced as a composition for the educational machinery that organizes the disciplinary logic.

The coexistence of the Wandering curriculum with the imposed Settled curriculum will produce an “extraordinary” curriculum. Two modes that inhabit the same places and the same people, simply because it is not possible to delete the “interstice”, the “intermezzo”, the “in-between”, the Wonderland. To teach and ensi-g-nar, each one over their triggers. It is like in the analysis that Deleuze1313. Deleuze G. Lógica do sentido. 5a ed. São Paulo: Perspectiva; 2011. (p.36) provides about Alice’s work: “it is neither at the same time nor relatively to the same thing that I am younger and older, but it is at the same time that I become one and another and through the same relation”. These multiple components, these “types” of curriculum, fight over different learnings. Some students will learn A, others B because the ordinary and the extraordinary will be asserting themselves.

The curriculum and the so-called minimum conditions of the places that receive the Residency program are continually evaluated by residents. The possibility of qualification of their actions through learnings in the world of work is not an issue to them. It is not an issue because they are sure that it happens independently of any curriculum – independently, even, of a settled curriculum or of the (non) existence of minimum conditions. And it is because of this recognition that they justify their search for the modality of learning in Residencies, the incontestable qualification for them to enter into and continue in the SUS, the inclusion, in their life choices, of the passage through a Residency program, the experience in their curriculum-education. Even so, this segment states that they need a curriculum along the lines recognized by the educational systems, by the educational machinery, as we observed in our walks for the constitution of this Wonderland of Residencies.

If the health services teams had permanent education in their working processes, they might be more permeable to the Residency proposal, in the way it was defined by some of the study’s participants: an opportunity to reflect on issues that emerge in the daily routine of the healthcare work. The arrival of a resident would be nothing more than the arrival of any new member in a team, with the difference that the resident’s stay would have a previously defined beginning and end (or not even that, if we were to think about other ways in which education in the Residencies might occur). It would be like welcoming any new fellow worker. It would be like including him in an ongoing process.

The Residency is the possibility of experiencing certain states. It is a type of learning that is felt in the body. Knowledge of the body. Knowledge to care for the body. For one’s own body and for the other’s body. It is an intense and borderline experience. To some extent, it can be violent.

There is a regularity in the rules of the Residency program: a kind of acceleration of the subjects. Acceleration of the resident: the intensive use of life hours transformed into working hours, the multiplication of the assistance activities offered by the units where the residents are allocated, the acceleration of the time of learning – the “recovery” of what was not learned in the undergraduate course, acceleration of production, that is, of the presentation of the health product.

It is also the permission to stop, but this permission is regulated, either by the time of the clock or by the time of the calendar. The time of the clock regulates the daily rest. The time of the calendar regulates the weekly rest and the holidays. The time to stop is defined in advance, not by the rhythms of the bodies and by the decisions of the people involved in the process: “it is possible to say that, to the neoliberals, the time invested in work is merely a detail”1414. Veiga-Neto A. Currículo: um desvio à direita ou delírios avaliatórios [Internet]. 2012 [acesso 2014 Set 7]; 17. Disponível em: http://www.fe.unicamp.br/TEMPORARIOS/veiga-neto-curriculos-delirios-avaliatorios.pdf
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(p.13).

In addition, it is an acceleration of the preceptor. Acceleration of production, that is, of presentation of the health product and the resident product. It is an acceleration of the multiplication of their working time, which used to be assistance time and now, with the Residency, it is the time of assistance, of supervision, of pedagogic management – it is presence time1515. Fajardo AP. Os tempos da docência nas Residências em Área Profissional da Saúde: ensinar, atender e (re)construir as instituições-escola na saúde [tese]. Porto Alegre (RS): Universidade Federal do Rio Grande do Sul; 2011..

When the legislation determines the amount of hours (almost all of them dedicated to work) that a Residency occupies in the life of many people, it is proposing to control the way of producing “good health professionals”, preventing residents from having time except from that of exclusive dedication to their training. Thus, it prevents them from studying and attending the Residency; it prevents them from working and attending the Residency; it prevents them from being on duty at places other than those proposed by the Residency – practices that are common among resident doctors.

Governmentalization also happens through an acceleration of the program’s coordinator, which is similar to the acceleration of the resident and of the preceptor. As if it were to maintain a downward continuity of the art of governing well, which goes from CNRMS to the program coordination, from the coordination to the preceptor and from him to the resident. At all points, there is the production of reports, evaluations, indicators, all of them viewed as emerging government practices in the service of feeding governmentalization in the Residencies.

In these procedures to register and control working activities, it is possible to see the three types of government, as described by Foucault1616. Foucault M. A governamentalidade (1978). In: Motta MB, organizador. Estratégia, poder-saber. 2a ed. Rio de Janeiro: Forense Universitária; 2010. p. 281-305.:

1) the government of oneself, in which resident, preceptor and coordinator perform practices of themselves engendered by the norms that establish who is each one of these actors, what they must do in the scenario of practice and how they must behave;

2) the art of properly governing a family. In this case, the family is replaced by the Residency program, in which government is exercised by the crossing of the norms that rule the work and the educational machinery, producing other ways of being there;

Questions and answers – Multiprofessional Residency: 5) Can the Residency program function without the existence of preceptors? No. As the Residency program is an in-service training, the resident must be continuously supervised. Furthermore, the Residency program is a specialization; therefore, it must supervise its students properly99. Ministério da Educação. Perguntas e respostas sobre Residência Multiprofissional e em Área Profissional da Saúde [Internet]. Brasília (DF); 2013 [acesso 2014 Set 7]. Disponível em: http://portal.mec.gov.br/index.php?option=com_content&view=article&id=18168&Itemid=813
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.

3) the science of governing the state; in this case, the policy for the education of health workers by means of Multiprofessional Residencies, which has always been grounded on the science of governing the education of specialist doctors by means of Medical Residencies. In other words, when the Multiprofessional Residency looks at itself through the mirror, it sees the Medical Residency reflected, in many aspects. However, we draw your attention emphatically to the education of specialists. It is also important to emphasize the focus of the Multiprofessional Residencies, which is on education targeted at the SUS.

To the exercise of governmentality, as described by Foucault77. Foucault M. Omnes et singulatim: uma crítica da razão política. In: Motta MB, organizador. Estratégia, poder-saber. 2a ed. Rio de Janeiro: Forense Universitária; 2010. p. 355-85., a relation of obedience is necessary. It seems that this relation emerges from rules or instructions that are established and follow the downward line that originates in the CNRMS, goes to the coordination of the Residency programs, then to the preceptor and, finally, to the resident (does the contrary also happen?). In this relation, one directs and the other is directed.

Based on conversations with the inhabitants of the Wonderland of Residencies, it is possible to consider that both the acceleration and the regulated stop (approached above) respond to this relation of obedience, an obedience that does not seem to be oriented only by hierarchy. Based on the Latin origin of the word oboedire, which means “listening attentively”, it is possible to say that such relation is also oriented by listening to and respecting the sphere that issues the orientations that must be followed, although, sometimes, they challenge the body’s limits. This is the case of the 60 weekly hours of work that are required of the residents, which are translated into tiredness and exhaustion because of the way in which they are prescribed and executed, in a single possible form.

Governmentality is also exercised based on the knowledge of those who direct about the detail of each person that is directed. Thus, the need to implement evaluation systems is presented as indispensable to the Residency process. The demands coming from the educational machinery also put the possibility of evaluating preceptors, learning fields, etc. in the service of a democratization of the evaluative procedures. We do not intend to say that they should not be evaluated, or that this evaluation is not important for the qualification of the programs. What we want to say is that they, too, are connected with a gear that is processed with the objective of detailing, separating, scanning and/or classifying all the members so that they can be better known. Therefore, it is possible to ask: is it valid to propose a curriculum so that all the education programs are similar and the professional profile is the same to any Residency education?

Knowing each field, each preceptor and each resident (each tutor, supervisor, team and higher education institution), does it make sense to say that there are diversities and that they are not beneficial to learning? It is in the service of governmentalization that the proposals to evaluate programs for accreditation are justified. The Multiprofessional Residencies have existed for more than three decades. Many of them, perhaps all, happened through public funding and are oriented towards Public Health. Socially, it seems fair that some type of regulation is performed, but it sounds strange that the investment that has already been made does not deserve any recognition. Why is it not interesting to reset this account to zero and start hereafter? That is, why does CNRMS not certify all the residents who have already completed the Residencies which received public funding as belonging to the regulation that is being currently proposed? How can one justify all the money invested in education programs at the public health network which are not accepted in public exams for the hiring of professionals, and are not even valorized? What is the use of the evaluation that CNRMS has been trying to perform since 2008, with the alleged objective of accrediting programs and certifying graduates only from the accredited institutions?

Together with this procedure of enrolment, accreditation, evaluation and curricularization of programs, there are instruments to collect information, strategies of knowing, modes of governmentalizing. The constitution of the database of evaluators also happens with the aim of knowing people who are involved in the Residencies, but are not necessarily linked to the programs. If the evaluators are linked to a program, with the possibility of knowing other realities, they can qualify their reality. But can they redefine what was instituted by CNRMS?

Analyzing evaluations in the Residencies as procedures that are part of the set that configures governmentality55. Foucault M. Segurança, território, população. Curso no Collège de France (1977-1978). São Paulo: Martins Fontes; 2008. would mean to consider these procedures as organizers of regulations. The residents are evaluated to organize the regulation of the professional identities that will be formed, and the programs are evaluated to organize the regulation of the ones that have been instituted.

Another mechanism of recognition and control was the proposal of elections in CNRMS. Based on the segments defined by directive 1077/09, the enrolment of voters in the Sistema de Informação da Comissão Nacional de Residência Multiprofissional em Saúde (SisCNRMS - Information System of the National Committee of Multiprofessional Healthcare Residencies) was instituted1717. Portaria Interministerial no 1.077, de 12 de Novembro de 2009. Dispõe sobre a Residência Multiprofissional em Saúde e a Residência em Área Profissional da Saúde, e institui o Programa Nacional de Bolsas para Residências Multiprofissionais e em Área Profissional da Saúde e a Comissão Nacional de Residência Multiprofissional em Saúde. Brasília (DF): Ministério da Saúde, Ministério da Educação; 2009.. We believe that this is another mode of incidence of governmentalization. In the previous system, the indication was the basis that was autonomously organized in the proper forums. So that each individual could exercise their right, it became necessary that it was told and classified.

Therefore, diverse mechanisms can be employed to know everyone and each one in the Residency programs: enrolment in programs, the imposition of a form of curriculum, the imposition of a school form, evaluations of residents (together with evaluations of preceptors and fields), evaluations of programs for accreditation in CNRMS (and the constitution of a database of evaluators), and the enrolment of voters in the SisCNRMS to hold elections to compose the CNRMS.

One of the social control tools that is widely used in the area of health are the forums or meetings of segments interested in discussing specific themes. We believe that this is a very powerful space for the democratization of decisions and for the possibility of collective action about a certain matter. However, it is necessary to mention that this can also be an expression of the governmentalization of a process; in this case, of the Residencies. The potentiality of social control in evidence with the offer of “alternatives” or “the government of the form”, which were announced as transmutation, headed towards the form itself.

It is in the forums or meetings that the residents, positioned in a circle, narrate their experiences. When they talk about themselves and their experiences, they trigger conversations that easily identify negative points that are common in the programs, and have difficulties in showing positive similarities among these programs. Therefore, they give visibility to the learning meetings as positivities that are possible and exist in the work and teaching processes in which they are immersed. The spaces for these narratives are occupied by negative aspects of the Residency proposal. In spite of this, the professionals still want to graduate in the Residency program. Is it really so bad that it is only possible to express countless negative points? It seems that the negative points are, in fact, what the programs have in common, and the positive points are an exception. And it is in the exception that the differences that are impossible to be narrated emerge. They are also impossible to be standardized. Therefore, there seems to be no space for a single curricularization, or for curriculum parameters, or for a single graduate profile to be established a priori.

Therefore, in these forums and meetings, narratives about work and education in the programs take place, as well as operations and strategies to know everyone and each one, classify the participants, governmentalize. We highlight that there is nothing bad in this. This is the way that is recognized and that has been historically used to qualify the participation processes in the health area. It is in these spaces that things are discussed and decided, but the changes requested in these places, and which are agreed by the participants as operations that should be undertaken by the CNRMS, are not materialized.

Final remarks

The empirical perception that was experienced in practice, concerning the concept of governmentalization in the Residencies, was confirmed by the study’s participants, called inhabitants of Wonderland. The official documents that were analyzed, some of them issued by CNRMS, present this concept to organize the daily learning routine in the Healthcare Residencies. It is necessary that these rules approach what should be different in the education of these workers. Furthermore, it is not possible to deny that it is through these rules that invention, singularities and the future can be born. It is through these rules that Residency education reaffirms its commitment to the qualification of the SUS, to education for comprehensive care and for teamwork. Together, these three pillars sustain, configure and guide Residency education.

Therefore, the governing scenario in the Residencies has many actors: coordinators of programs and Higher Education Institutions, preceptors, tutors, supervisors and residents, and also people who write and research about the theme. The government of CNRMS, as one of the governmentalization apparatuses, however, uses rules and regulations, the delegitimation of the spheres that do not produce rules, and the institution of mechanisms to capture, adjust to bureaucracy and reject heteronormativity, conversation and decentralization.

Therefore, we ask: in what ways do these rules interact with the pleasure of working? With the pleasure of being a resident, of being a preceptor, of being a program coordinator?

Acknowledgements

The Odilo Kreutz, by review and portuguese correction. The Ananyr Port Fajardo, the translation of the summary into english. The Lairton Cemin, the translation of the abstract to the spanish language.

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  • Translated by Carolina Ventura

Publication Dates

  • Publication in this collection
    02 Feb 2016
  • Date of issue
    Apr-Jun 2016

History

  • Received
    20 Jan 2015
  • Accepted
    15 Sept 2015
UNESP Botucatu - SP - Brazil
E-mail: intface@fmb.unesp.br