Abstract

Introduction

Most countries in the world present inequalities in access to health services that are repeatedly pointed out as serious and persisting problems over time, resisting to the various strategies adopted to cope with it¹1. Kemper ES, Mendonça AVM, Sousa MF. Programa Mais Médicos: panorama da produção científica. Cienc Saude Colet. 2016; 21(9):2785-96.. Isolated geographic regions, far from larger centers, as well as poorer populations are more vulnerable to the lack of safety in health care¹1. Kemper ES, Mendonça AVM, Sousa MF. Programa Mais Médicos: panorama da produção científica. Cienc Saude Colet. 2016; 21(9):2785-96.,²2. Vanni T, Cyrino AP, Ribeiro ACRC. Provimento médico no sistema de saúde da Austrália: uma conversa com Megan Cahill. Interface (Botucatu). 2017; 21(1):1367-76.. In this background, bridging the gap between health services and medical training allow to foster responses to the population needs, as in Australia and Canada, where medical schools are inserted in so-called remote regions, aiming to expand access to medical care²2. Vanni T, Cyrino AP, Ribeiro ACRC. Provimento médico no sistema de saúde da Austrália: uma conversa com Megan Cahill. Interface (Botucatu). 2017; 21(1):1367-76.,³3. Strasser R, Worley P, Cristobal F, Marsh DC, Berry S, Strasser S, et al. Putting communities in the driver’s seat: the realities of community-engaged medical education. Acad Med. 2016; 90(11):1466-70..

Several initiatives have been proposed to address these issues in the Brazilian National Health System (SUS), however none of them had the scope, breadth and swiftness of the Mais Médicos Program (PMM), encompassing three axes: Provisional Supply, Infrastructure and Formation⁴4. Brasil. Presidência da República. Lei nº 12.871, de 22 de Outubro de 2013. Institui o Programa Mais Médicos, altera a Lei nº 8.745, de 9 de Dezembro de 1993, e nº 6.932, de 7 de Julho de 1981, e dá outras providências. Diário Oficial da União. 23 Out 2013..

The PMM Formative axis launched the proposition of a list of actions for changes in medical education⁵5. Oliveira FP, Pinto HA, Figueiredo AM, Cyrino EG, Oliveira Neto AV, Rocha VXM. Programa Mais Médicos: avaliando a implantação do Eixo Formação de 2013 a 2015. Interface (Botucatu). 2019; 23 Supl 1:e170949.. Scholars in this field have investigated these actions, potentialities and impacts on the training of post-PMM medical professionals. Among them it was possible to notice the expansion of seats in medical courses; the creation of new undergraduate courses in the countryside, including federal universities; the adoption of different devices for changing training, with emphasis on the new National Curriculum Guidelines for undergraduate courses in Medicine (DCN)⁶6. Brasil. Ministério da Educação. Resolução CNE/CES nº 3, de 20 de Junho de 2014. Institui diretrizes curriculares nacionais do curso de graduação em Medicina e dá outras providências. Brasília: Ministério da Educação; 2014.; teaching centered on primary health care, from the perspective of expanded clinic and comprehensive care; and valuing the training and development of teachers and preceptors in medical schools⁷7. Vieira RMM, Pinto TR, Melo LP. Narrativas e memórias de docentes médicos sobre o ensino baseado na comunidade no Sertão Nordestino. Rev Bras Educ Med. 2018; 42(1):142-51.

8. Oliveira FP. As mudanças na formação médica introduzidas pelo Programa Mais Médicos [tese]. Brasília: Universidade de Brasília; 2018.-⁹9. Pedrosa JIS. Implantação e desenvolvimento do curso de Medicina em Parnaíba, PI, Brasil, a partir do Programa Mais Médicos para o Brasil. Interface (Botucatu). 2019; 23 Supl 1:e180012..

Due to the fact that until 2017 there were few studies on the implantation of these new medical schools in federal universities, there was built an inter-institutional project called project “Assessment of the development of the Formative dimension for SUS within PMM: mapping the expansion of seats, the creation of new courses and the implementation of the DCN ” (Mapping Project)¹⁰10. Sordi MRL, Mendes GSCV, Cyrino EG, Alexandre FLF, Manoel CM, Lopes CVM. Experiência de construção coletiva de instrumento auto avaliativo a serviço da formação médica referenciada nas Diretrizes Curriculares Nacionais (DCN) pautadas no Programa Mais Médicos. Interface (Botucatu). 2020; 24:e190527..

The Mapping Project

Developed during 2017 and 2018, the project aimed to map out the creation of new federal medical schools and the implementation of the 2014 DCN. It was based on the construction of a method that allowed approximation to the processes experienced in the realities of the courses¹⁰10. Sordi MRL, Mendes GSCV, Cyrino EG, Alexandre FLF, Manoel CM, Lopes CVM. Experiência de construção coletiva de instrumento auto avaliativo a serviço da formação médica referenciada nas Diretrizes Curriculares Nacionais (DCN) pautadas no Programa Mais Médicos. Interface (Botucatu). 2020; 24:e190527., including documentary analysis and work, through visits to these new schools. The visits were done adopting the posture by the field researchers of a critical friend¹¹11. Leite C. A figura do amigo crítico no assessoramento/desenvolvimento de escolas curricularmente inteligentes. In: Fernandes M, Gonçalves JA, Bolina M, Salvado T, Vitorino T, organizadores. O particular e o global na virada do milênio: cruzar saberes na educação. Lisboa: Editora Colibri, Sociedade Portuguesa de Educação; 2002. p. 95-100., as someone who has a detached view of the experienced process, but who studied about the school and is committed to the situation and support in regard to the learning institutions, fostering reflection about potential, challenges and needs.

During the visits, conversations with coordinators, teachers and students of the courses, managers of the institutions and representatives of the health services, were performed with the completion of the Project’s instruments. In addition, the field researchers wrote a reflective narrative about what was experienced in the meeting with the school. Narratives were not interested in transmitting the “pure itself”, as information or a report, but immersed in the narrators’ experiences¹²12. Benjamin W. O narrador: considerações sobre a obra de Nicolai Leskov. In: Benjamin W. Magia e técnica, arte e política: ensaios sobre literatura e história da cultura. São Paulo: Editora Brasiliense; 2012. p. 213-40..

The Mapping Project found that, from a total of about 80 medical courses at federal universities, 30 of them were courses implemented between 2013 and 2017 under the PMM. These new medical schools are located outside the state capitals, in the five geographic regions of Brazil and in cities where there was no public medical course previously. It was observed that schools are organized in different training arrangements, also seeking to overcome disciplinary fragmentation, using active methodologies, formative assessment, beginning as well the articulation with research and extension. They use the healthcare network in training, giving value to teaching-service-community integration, looking for critical training and focused on SUS. As faculty training lacks incentives, there are experiences that encourage the entry of local students and the creation of medical residences, which are powerful tools for medical retention.

Additionally, other questions emerged in order to understand how the experiences of the field researchers with the new medical schools and their actors had been, based on the narratives written during the Mapping Project. From the perspective of these narrated texts, the present article was born, bringing the wealth of the glance of researchers, hereby called travelers, about their relations in the field of research.

Methodology

This is an exploratory study regarding the experiences of travelers in the research field of the Mapping Project, based on their narratives. We opted for using the qualitative approach, understood as the most adequate to discuss the experiences, positions, perspectives and subjectivities experienced by the field researchers in the encounters with the different schools¹³13. Turato ER. Métodos qualitativos e quantitativos na área da saúde: definições, diferenças e seus objetos de pesquisa. Rev Saude Publica. 2005; 39(3):507-14.,¹⁴14. Minayo MCS. O desafio do conhecimento: pesquisa qualitativa em saúde. 9a ed. São Paulo: Hucitec; 2006..

The Mapping Project allowed visiting 24 of the 30 new medical courses identified. Five courses were not visited due to incompatible schedules, unavailability of schools or logistical issues. The visits happened in the second half of 2018 by nine travelers selected to participate due to their experience with medical education. There were seven females and two males, aged between 35 and 55 years; three nurses, two doctors, a physiotherapist, a psychologist, a pedagogue and a biologist.

From this background, travelers were asked to write narratives shortly after the visit to the medical school, using free format, highlighting reflections on the experience of the visit. No specific form was used, and the recommendation was to record the memories about the impressions and sensations arising from daily convivial experiences in the field of research. It is noteworthy that the narratives were not foreseen at the beginning of the Mapping Project, but they were later introduced in the course of the research with the aim of including experiential and subjective aspects in the construction of data.

The experience was understood using the concept of Larrosa Bondía as what transforms the subject who lives it; not what just happens, but what touches the subject¹⁵15. Larrosa Bondia J. Notas sobre a experiência e o saber de experiência. Rev Bras Educ. 2002; (19):20-8.. The narrative, on the other hand, was understood applying the perspective of Walter Benjamin, in a relationship between experience, time and memory, in a narrating act that does not seek to be a novel, nor a report, but a story woven from the reminiscence itself¹²12. Benjamin W. O narrador: considerações sobre a obra de Nicolai Leskov. In: Benjamin W. Magia e técnica, arte e política: ensaios sobre literatura e história da cultura. São Paulo: Editora Brasiliense; 2012. p. 213-40.. Narrative is an artisanal way of communicating experiences in the form of stories, which highlight aspects previously unknown and that also may represent the individual and collective experience¹⁶16. Sousa MGS, Cabral CLO. A narrativa como opção metodológica de pesquisa e formação de professores. Horizontes. 2015; 33(2):149-58.. By using the theoretical orientation of narrative studies, it also points to the contribution on the relationships between structure and social action and, in the specific case of health, narratives can be seen as central elements for the construction of the experience¹⁷17. Muylaert CJ, Sarubbi JV, Gallo PR, Neto MLR, Reis AOA. Entrevistas narrativas: um importante recurso em pesquisa qualitativa. Rev Esc Enferm USP. 2014; 48(2):184-9..

In total, there were 21 narratives of travelers included in this study. One of the travelers sent the narrative in audio, but was excluded from the materials because it is a different structure from the written narrative. No narratives came from two visits. To guarantee the confidentiality of the information, as assumed in the ethical commitment of this research, a random number was assigned to each of the schools and fictitious names to the travelers.

The material was explored by the authors following the recommendations of Thematic Content Analysis¹⁸18. Castellanos MEP. A narrativa nas pesquisas qualitativas em saúde. Cienc Saude Colet. 2014; 19(4):1065-76., following five moments: 1) Pre-analysis with immersion in the narratives; 2) Construction of individual concept maps on the main aspects narrated in the materials; 3) Presentation of the maps in a meeting, added to the objectives of this research and retrieval of the other results of the Mapping Project, enabling the collective construction of pre-categories of analysis related to the moments experienced in the experience; 4) Fragments of the narratives, putting them in order, relating them to the pre-categories, constituting nuclei of meaning; 5) Final elaboration of the thematic categories, using the procedures of categorization, inference, description and interpretation¹⁸18. Castellanos MEP. A narrativa nas pesquisas qualitativas em saúde. Cienc Saude Colet. 2014; 19(4):1065-76..

The process ended by discussing the results through the related theoretical references. In all the process, selected parts of the travelers’ narratives were used in the elaboration of a narrated fabric, understood not in the sense of bringing up what was narrated from each encounter, but what was selected to narrate.

The Research Ethics Committee of the College of Medicine of Botucatu - Universidade Estadual Paulista, approved this research under CAAE 88186418.7.0000.5411.

Narrated tissue

The experiences of travelers recorded through their individual narratives enabled building a collective narrative, by the way of re-elaborating the meetings with the new medical schools, highlighting three main moments of the experience: expectations and detached contacts; encounters with strangers; and post-visit farewells and reflections.

Expectations and distance contacts

The expectations as narrated by travelers began in the period of planning and organizing the visit. There was an expectation for acceptance, for letting us in. The definition of the school to be visited, sometimes, did not happen by chance, but rather because of something already sensitized the researchers and moved them to that institution. Initially, each future traveler made contact with the coordination of the course and started a planning process, looking for a first approach to the fields to be visited, in a building process in order to apprehend reality, bringing the convergence of several points of view, as fieldwork gives the chance of getting closer to what you want to know and study¹⁴14. Minayo MCS. O desafio do conhecimento: pesquisa qualitativa em saúde. 9a ed. São Paulo: Hucitec; 2006..

Through reading and analysis of the narratives, some travelers reported that from the beginning, they were welcomed by the coordinators and managed, in the few (or many) exchanges of e-mails and phone calls, to present the research objectives, schedule and organize a program for the visit:

However, some travelers encountered different resistances to scheduling, generating quite a feeling of frustration, but also the motivation to elaborate possible paths based on their own expectations and the schools’ needs and possibilities:

Once the initial contacts were made, the visits were scheduled with pre-booked itineraries, tickets in hand; and there they went, towards the five regions of the country, travelers feeling in their skins the long crossings needed to reach the places chosen for the implantation of federal medical schools. They were researchers of a reality to be mapped, in the name of a health project, involved with the rights of Brazilian society, seeking the meanings of struggles, achievements; withdrawals and resistance, sometimes involuntary, sometimes intentional:

The visit was a time to learn to look, hear and speak to people, having a researcher’s stance with the profile of a conversationalist¹⁹19. Minayo MCS, Deslandes SF, Gomes R. Pesquisa social: teoria, método e criatividade. 33a ed. Petrópolis: Vozes; 2013., when there is a horizontal dialogue in the posture of sharing and not of a distant relationship that lack consideration of the local objective realities and setbacks that the courses’ communities face. In this sense, the narratives showed subjects loaded with fears, anxieties and hopes, which meet other subjects involved in the construction of another health reality:

Expectations were well described in the narratives because the visit was an important space to recognize the creative or not creative forms that the institutions built to adhere to the DCN and the PMM Formative axis, something key to this public policy, imbricated with the expansion of medical courses in regions remote from large urban centers and lacking medical schools.

The encounter with strangers

Enduring long trips, the travelers met with unknown places and actors. The unknown Brazilian contexts affected travelers. In the meantime, the researcher was doing the exercise of approximation and detachment at all times, seeking to look at the reality visited in order not to distort or obscure his judgments and conclusions²⁰20. Spink PK. O pesquisador conversador no cotidiano. Psicol Soc. 2008; 20 (spe):70-7..

Little by little, in discoveries and meetings, these strangers became familiar, as they acquired materiality, faces, shapes, contexts and stories, expressed in the travelers’ narratives, a dense and rich material allowing the revival of each one of the trips²⁰20. Spink PK. O pesquisador conversador no cotidiano. Psicol Soc. 2008; 20 (spe):70-7.. Most of the time, the coordinator of the course was the first to be found, in order to plan the activities to be carried out during the visit:

The researchers found schools operating in donated or owned spaces; within an existing university campus or a campus built-for-purpose; in old or new structures; improvised or lavishly finished places; with good equipment or lack of it. In the travelers’ narratives this diversity of realities was described:

The conversations with teachers and the Structuring Teaching Core Group (NDE) were opportunities to rethink medical training according to the DCN⁷7. Vieira RMM, Pinto TR, Melo LP. Narrativas e memórias de docentes médicos sobre o ensino baseado na comunidade no Sertão Nordestino. Rev Bras Educ Med. 2018; 42(1):142-51. as well as within the PMM proposal, as described in the experiences of some of these schools⁷7. Vieira RMM, Pinto TR, Melo LP. Narrativas e memórias de docentes médicos sobre o ensino baseado na comunidade no Sertão Nordestino. Rev Bras Educ Med. 2018; 42(1):142-51.,⁹9. Pedrosa JIS. Implantação e desenvolvimento do curso de Medicina em Parnaíba, PI, Brasil, a partir do Programa Mais Médicos para o Brasil. Interface (Botucatu). 2019; 23 Supl 1:e180012.. Regarding the teachers, at the same time that we perceived them as withdrawn and aloof, it was also possible to observe enthusiasm with the possibility of being heard. The meetings were usually revealing, with heterogeneous valorization and power, according to the group’s adhesion:

We met with health service managers and workers who participated in the training of medical students and the encounters took place in practice settings. The people who were part of the services were welcoming and eager to speak. In the narratives, the travelers described professionals who were satisfied with being able to participate in this new trajectory of medical education, however there were also those who did not find meaning in in-service training. Regarding health managers, it became evident that teaching-service integration was a major challenge, subject to the instabilities of local institutions and a process subject to permanent construction²¹21. Velho G. Observando o familiar. In: Nunes EO. A aventura sociológica. Rio de Janeiro: Zahar; 1978. p. 123-40., concurring with what was reported in the study about one of these institutions⁹9. Pedrosa JIS. Implantação e desenvolvimento do curso de Medicina em Parnaíba, PI, Brasil, a partir do Programa Mais Médicos para o Brasil. Interface (Botucatu). 2019; 23 Supl 1:e180012..

Conversation circles with the students were described as the “best encounter”. Both as provocateurs and participants, the students wanted to speak and to be heard. The encounter with this group was always valued and happened “without filter”, in a sincere way, in a recognition of the space as a possibility to exchange experiences, as well as to recognize the expectations and knowledge of these actors under the light of the new background proposed by the DCN²²22. Pinto TR, Cyrino EG. Com a palavra, o trabalhador da Atenção Primária à Saúde: potencialidades e desafios nas práticas educacionais. Interface (Botucatu). 2015; 19(1):765-77.. Students from all over Brazil - a few foreigners - representing a great cultural, ethnic, socioeconomic and age diversity showed their empowerment in the construction of the schools:

These moments were aimed to give voice to the different stakeholders in these stories, in order to be able to understand the whole. Different subjects and settings brought up the complexity that surrounds the implementation of courses in medical schools that are being built, and also live, fight and resist.

Farewells and post-visit reflections

During the visits, the travelers narrated experiences in a variety of relationships in the field, even allowing comparisons and maturing as researchers. Being in the field after planning and with expectations previously built is an opportunity to readjust and innovate¹⁴14. Minayo MCS. O desafio do conhecimento: pesquisa qualitativa em saúde. 9a ed. São Paulo: Hucitec; 2006., mainly based on what is experienced:

As narrated in this last part, some visits were marked by resistance and difficulties, most of the times generated by a lack of sharing in the planning process, or by the usual understanding of the role of the researcher in the field, often associated with aloofness compared to subjects, based on Cartesian principles of neutrality²³23. Meireles MAC, Fernandes CCP, Silva LS. Novas Diretrizes Curriculares Nacionais e a formação médica: expectativas dos discentes do primeiro ano do curso de medicina de uma instituição de ensino superior. Rev Bras Educ Med. 2019; 43(2):67-78..

The encounters between then-unknowns was also narrated as a learning space in addition to a data-gathering visit, which was related to the proposal of the Mapping Project, which was to have a field researcher as a “critical friend”, provoking reflections, identification of strengths and weaknesses among local players. A visit based on encounters that allowed cooperation and collaboration, with the sharing of ideas and experiences¹¹11. Leite C. A figura do amigo crítico no assessoramento/desenvolvimento de escolas curricularmente inteligentes. In: Fernandes M, Gonçalves JA, Bolina M, Salvado T, Vitorino T, organizadores. O particular e o global na virada do milênio: cruzar saberes na educação. Lisboa: Editora Colibri, Sociedade Portuguesa de Educação; 2002. p. 95-100.:

In this context, the local stakeholders thanked some travelers, as the visit could be perceived as formative, different from institutional assessment visits that sometimes do not build up in this sense. The encounters of the course members with someone from the area, but immersed in another reality, made it possible to exchange knowledge in the movement of recognition and complicity¹¹11. Leite C. A figura do amigo crítico no assessoramento/desenvolvimento de escolas curricularmente inteligentes. In: Fernandes M, Gonçalves JA, Bolina M, Salvado T, Vitorino T, organizadores. O particular e o global na virada do milênio: cruzar saberes na educação. Lisboa: Editora Colibri, Sociedade Portuguesa de Educação; 2002. p. 95-100..

The travelers reported from the visit what they learned from the immersion in a new medical school reality, in an act of learning from the lived experience and not from the neutrality of a controlled experiment¹⁵15. Larrosa Bondia J. Notas sobre a experiência e o saber de experiência. Rev Bras Educ. 2002; (19):20-8..

The travelers were affected and were called to reflect upon the role of these new medical schools and their actors in the regions visited. Unlike data collection or data-building strategies that seek the researcher’s neutrality, here it is evident that the researcher is also involved and finds in research an ethical possibility of building a just and democratic society²⁴24. Batista NCS, Bernardes J, Menegon VSM. Conversas no cotidiano: um dedo de prosa na pesquisa. In: Spink MJ, Brigagão JIM, Nascimento VLV, Cordeiro MP, organizadores. Práticas discursivas e produção de sentidos no cotidiano: aproximações teóricas e metodológicas. Rio de Janeiro: Centro Edelstein de Pesquisas Sociais; 2014. p. 22-41..

Travelers also pointed out that these new schools are closer to social groups and regions that are generally excluded from medical courses. In this sense, in addition to the context of the research carried out, they were also affected by other complexities of Brazilian society, on their way to overcome inequalities and the challenge of building citizenship.

Through this process it became evident that the use of narratives in qualitative research allowed a rescue of the subject, mainly of a descriptive and ethnographic character, enabling the movement towards intervention²⁵25. Rios TA. A ética na pesquisa e a epistemologia do pesquisador. Psicol Rev. 2006; 12(19):80-6.. Thuerefore, the travelers’ narratives put us in contact with the very act of investigating and building science, approaching the social commitment of research for the common good, in an ethical and responsible way²⁴24. Batista NCS, Bernardes J, Menegon VSM. Conversas no cotidiano: um dedo de prosa na pesquisa. In: Spink MJ, Brigagão JIM, Nascimento VLV, Cordeiro MP, organizadores. Práticas discursivas e produção de sentidos no cotidiano: aproximações teóricas e metodológicas. Rio de Janeiro: Centro Edelstein de Pesquisas Sociais; 2014. p. 22-41., making it possible to broaden the glance of all those involved.

Final considerations

Probably it was not feasible to bring up all the poetics of the meetings, due to the fact that the diversity of voices, experiences, smells and emotions are beyond what is narrated. Anyway, we aimed to build a collective narrative based on the diverse experiences of travelers, in the quest for an approximation to the relationships and emotions that emerged in the research meetings.

The travelers were able to experience, from the perspective of the research, what is to be in the field to perform, observe, listen carefully, talk and, from there, produce a narrative. They put themselves in the position of people interested in sharing the experience of others, with complicity and involved with objective and singular listening.

The narrated fabric allowed to reveal the experience of the researchers going to unknown places, where they found the protagonists in the creation and development of new federal medical schools, with the intention to align themselves with the DCN, to meet the health needs of the Brazilian population according to the SUS principles and guidelines.

There were regions, previously unknown to the eyes of these travelers and, at times distant, that served as background of the encounter with a diversity of people, institutions, health services, strengths and weaknesses of the proposal for innovation in medical education. Each experience, under the careful eye of the narrating traveler, showed the contact with the reality in which the new schools were implanted and developed. Each encounter conveyed wishes, doubts and uncertainties in local construction and development. The process of getting closer to these innovative and creative movements in different locations reinforces the understanding that federal nudging policies were decisive for the implementation of courses, even though their maintenance and capacity to transform the reality of local health will depend on a number of other factors.

We highlight as well the possibility given by using the narratives of field researchers to add subjectivities to the investigations about the experienced reality, allowing the construction of an ethical study, committed to social transformation.

Acknowledgments

To the Ministry of Health of Brazil, for financing the research through the SCON Agreement Letter 2017 – 02638. To the the Pan American Health Organization, for providing the opportunity to carry out this research, through shared financing and construction, and through the permanent impulse to medical education in Brazil. To the interlocutors in the federal medical schools and in the health services visited, for their availability, reception and commitment in receiving the field researchers.

References

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