Abstract

This articles reviews the changes in the medical education and health teaching - driven, on the one hand, by the sanitary reform and consolidation of the Brazilian National Health System and, on the other hand, by the National Curriculum Guidelines, which fostered the interdisciplinary, interprofessional, and intersectoral aspects of inductive policies for the consolidation of the Inter-professional Education in Health (EIP). In this course, we highlight the contributions of professor Regina Marsiglia, both in her productions as in her activism, in the tireless articulation between theory and practice.

Keywords:
Medical Education; Inter-Professional Education; Inductive Policies

Introduction

The recent history of Brazilian higher education is being marked by new identity traits regarding the conception of professional training in the field of health. From the establishment of the Brazilian National Curriculum Guidelines (Diretrizes Curriculares Nacionais - DCN) in 2001 for medical undergraduate programs, growing efforts have been made to achieve a better harmony between teaching and social needs:

Therefore, health education must contemplate not only diseases, but also human life. Advances provided by technology and scientific knowledge must be recognized, but humanistic training becomes essential for its mode of application. This change of paradigm necessarily assumes an ethical-political commitment, as described in article 3 of the DCN: “Undergraduate Courses in Medicine have as the profile of the egress/professional the doctor, with a generalist, humanist, critical and reflexive education, trained to act based on ethical principles, on the health-disease process in its different levels of care” (Brasil, 2002BRASIL. Ministério da Saúde; Ministério da Educação. Programa de Incentivo a Mudanças Curriculares nos Cursos de Medicina: edital de convocação. Brasília, DF, 2002., p. 1).

Among the many contributions of authors who have studied this subject, such as Almeida (2003ALMEIDA, M. (Org.). Diretrizes Curriculares Nacionais para os cursos universitários da área da saúde. Londrina: Rede Unida, 2003.), Batista, Vilela, and Batista (2015BATISTA, N. A.; VILELA, R. Q. B.; BATISTA, S. H. S. S. Educação médica no Brasil. São Paulo: Cortez, 2015.), Marsiglia (1995MARSIGLIA, R. M. G. Relação ensino/serviços: dez anos de integração docente assistencial (IDA) no Brasil. São Paulo: Hucitec , 1995., ²⁰¹¹MARSIGLIA, R. M. G. Perfil dos trabalhadores da Atenção Básica em Saúde no município de São Paulo: região norte e central da cidade. Saúde e Sociedade, São Paulo, v. 20, n. 4, p. 900-911, 2011., ²⁰¹³MARSIGLIA, R. M. G. (Org.). Ensino de graduação em saúde: ingresso e inserção profissional: FCMSCSP (1963-2013). São Paulo: CDG Casa de Soluções, 2013.; Marsiglia; Ibañez; Ianni, 2010MARSIGLIA, R. M. G.; IBAÑEZ, N.; IANNI, A. M. Z. A experiência do Pró-Saúde na Faculdade de Ciências Médicas da Santa Casa de São Paulo. In: PIERANTONI, C. R.; VIANNA, A. L. A. (Org.). Educação e saúde. São Paulo: Hucitec , 2010. p. 49-80.) and Peduzzi (2001PEDUZZI, M. Equipe multiprofissional de saúde: conceito e tipologia. Revista de Saúde Pública, São Paulo, v. 35, n. 1, p. 103-109, 2001.; Peduzzi; Oliveira, 2009PEDUZZI, M.; OLIVEIRA, M. A. C. Trabalho em equipe multiprofissional. In: MARTINS, M. A. et al. (Ed.). Clínica médica. Barueri: Manole, 2009. v. 1, p. 171-178.; Peduzzi et al., 2013PEDUZZI, M. et al. Educação interprofissional: formação de profissionais de saúde para o trabalho em equipe com foco nos usuários. Revista da Escola de Enfermagem da USP, São Paulo, v. 47, n. 4, p. 977-983, 2013.), we can identify that the training of health professionals covers subjective aspects, the production of specific technical abilities and knowledge of the Brazilian National Health System (SUS) and, to ensure that a real transformation of professional practices and work organization occurs, education must be structured from its insertion in health services; thus promoting the problematization of work by considering its capacity to host and care for the various dimensions and health needs of individuals, collective groups and population as a whole.

In this perspective, Alves et al. (2013ALVES, C. R. L. et al. Mudanças curriculares: principais dificuldades na implementação do Promed. Revista Brasileira de Educação Médica , Rio de Janeiro, v. 37, n. 2, p. 157-166, 2013.) highlights the strategic actions of human resources training proposed by the Brazilian Ministry of Health (MS) and the Ministry of Education (MEC), such as: Program for Incentives to Curricular Changes in Medical Courses (Programa de Incentivo às Mudanças Curriculares nos Cursos de Medicina - Promed), National Program for the Reorientation of Professional Training in Health (Programa Nacional de Reorientação da Formação Profissional em Saúde - Pro-Saúde), Family Health Training Centers, several Residency Programs, among others.

This article proposes a systematization, through scientific production and official government documents, of the transformations in the guiding models of training in undergraduate health courses in Brazil, starting with medical courses, from the second half of the 20^th century until the first decade of the 21^st century.

This article is part of the academic production on the theme of health training, compromised with the improvement of SUS. In this sense, Professor Regina Marsiglia is highlighted here due to her multiple and interrelated activities as a professor, researcher and militant for collective health and health training, who lead the implementation of several professional training processes at the intersection of education, health and work (Silveira et al., 2018SILVEIRA, C. et al. (Inter)conectando o mundo acadêmico e o mundo das práticas de saúde: a trajetória de Regina Marsiglia (1943-2017). Interface: Comunicação, Saúde, Educação, Botucatu, v. 22, n. 66, p. 971-974, 2018.).

Health training in Brazil

Many actions have been directed towards training in health. The movement around Teaching Assistance Integration (Integração Docente Assistencial - IDA) began in the 1950s and, for the last forty years, has unfolded itself into several proposals for reforming the education and reorganization health services throughout Latin America (Almeida; Feuerwerker; Llanos, 1999ALMEIDA, M.; FEUERWERKER, L.; LLANOS, M. (Org.). A educação dos profissionais de saúde na América Latina: teoria e prática de um movimento de mudança. São Paulo: Hucitec, 1999.).

When analyzing the Brazilian proposals, Marsiglia (1995)MARSIGLIA, R. M. G. Relação ensino/serviços: dez anos de integração docente assistencial (IDA) no Brasil. São Paulo: Hucitec , 1995. states that IDA projects have broadened the understanding of teaching-work integration and the possibilities of transformations and insertions of pedagogical practices in health practices, in which students, teachers and workers choose the health/illness situations and living conditions of users of greater social and epidemiological relevance, jointly problematizing responses for the construction of promotion and prevention actions, thus evidencing the connection between theory and practice. IDA projects achieved greater reach during the 1980s, both in Brazil and Latin America.

The 1960s were critical when surfacing the problematization of medical training and its relationship with practice. The movement of integral medicine emerges in this context, focusing on the fragmentation of medical practice, the polarization between basic and clinical education, and the disciplinary approach of programs. Seeking to overcome this scenario, propositions to restructure educational institutions were formulated, with the creation of departments by areas of knowledge rather than isolated disciplines, so students were accompanied from their first years until boarding school, being guided by a biopsychosocial approach of the patient (Aguiar, 2006AGUIAR, A. C. Cultura de avaliação e transformação da educação médica: a Abem na interlocução entre academia e governo. Revista Brasileira de Educação Médica, Rio de Janeiro, v. 30, n. 2, p. 98-101, 2006.; Mota, Schraiber, Ayres, 2018MOTA, A.; SCHRAIBER, L. B.; AYRES, J. R. C. M. Desenvolvimentismo e preventivismo nas raízes da saúde coletiva: reformas do ensino e criação de escolas médicas e departamentos de medicina preventiva no estado de São Paulo (1948-1967). Interface: Comunicação, Saúde, Educação, Botucatu, v. 22, n. 65, p. 337-348, 2018.).

The movement for preventive medicine was also important in this process, leading to discussions about teamwork in health, initially in curricular proposals for medical education, and later in nursing courses (Arouca, 2003AROUCA, S. O dilema preventivista: contribuição para a compreensão e crítica da medicina preventiva. São Paulo: Editora Unesp, 2003.; Peduzzi; Oliveira, 2009PEDUZZI, M.; OLIVEIRA, M. A. C. Trabalho em equipe multiprofissional. In: MARTINS, M. A. et al. (Ed.). Clínica médica. Barueri: Manole, 2009. v. 1, p. 171-178.).

Teamwork refers to health care, administration and professional training, requiring commitment from health professionals and administrators of the health system, educators, and even students, who need to be prepared/trained for interprofessional practice. For such, the articulation with the health care network is crucial, being transformed into teaching-learning environments (Peduzzi et al., 2013PEDUZZI, M. et al. Educação interprofissional: formação de profissionais de saúde para o trabalho em equipe com foco nos usuários. Revista da Escola de Enfermagem da USP, São Paulo, v. 47, n. 4, p. 977-983, 2013.).

In the 1980s, the World Federation for Medical Education (WFME) and its regional associations held meetings to set goals for improving the quality of medical education. The results of these meetings contributed to the elaboration of the principles in the Edinburgh Declaration (WHO, 1988WHO - WORLD HEALTH ORGANIZATION. Learning together to work together for health: report of a WHO Study Group on multiprofessional education for health personnel: the team approach. Geneva, 1988.), which had strong influence on the debate on medical education and its necessary curricular reforms, particularly in Brazil (Martins, 2008MARTINS, M. A. Editorial. Revista Brasileira de Educação Médica , Rio de Janeiro, v. 32, n. 1, p. 5-6, 2008.).

From the implementation of SUS since 1990, changes in medical education in Brazil are driven by the need to reorient the new health care model. Thus, in 1991 the proposal “A new initiative for the training of health professionals: unity with the community: UNI Project” (Uma nova iniciativa na educação dos profissionais de saúde: união com a comunidade: Projeto UNI), with financial support from the W.K. Kellogg Foundation, was implemented in some Schools of Medicine: of Marília (SP); of Botucatu of the Universidade Estadual de São Paulo; of the Universidade Estadual de Londrina (PR); of the Universidade Federal do Rio Grande do Norte (RN). The UNI Project sought to integrate school-service-community, using the service as an environment for teaching and learning, for new forms of structuring the curriculum, models and pedagogical methods (Tempsk, Borba, 2009TEMPSK, P.; BORBA, M. O SUS como escola. Revista Brasileira de Educação Médica, Rio de Janeiro, v. 33, n. 3, p. 319-320, 2009.).

Peduzzi et al. (2013PEDUZZI, M. et al. Educação interprofissional: formação de profissionais de saúde para o trabalho em equipe com foco nos usuários. Revista da Escola de Enfermagem da USP, São Paulo, v. 47, n. 4, p. 977-983, 2013.) drew attention to the importance of the referred changes in the administration of interprofessional education, in which the integration of disciplines in the same professional field strengthens each profession and the multiprofessionality of health teams, favoring interprofessionality and collaborative practices, concepts that updated the notion of teamwork.

Although there is no consensus on the best moment to initiate interprofessional education, the introduction of these programs in the health area has been stimulated and promoted by universities and government agencies in different countries. For example, in the United Kingdom interprofessional education programs have been funded in undergraduate and graduate courses, with investments in research on the field since the 1990s (Carpenter, 1995CARPENTER, F. Interprofessional education for medical and nursing students: evaluation of a programme. Medical Education, Edinburgh, v. 29, n. 4, p. 265-272, 1995.; Hind et al., 2003HIND, M. et al. Interprofessional perceptions of health care students. Journal of Interprofessional Care, London, v. 17, n. 1, p. 21-34, 2003.; Horsburgh; Lamdin; Williamson, 2001HORSBURGH, M.; LAMDIN, R.; WILLIAMSON, E. Multiprofessional learning: the attitudes of medical, nursing and pharmacy students to shared learning. Medical Education, Edinburgh, v. 35, n. 9, p. 876-883, 2001.; WHO, 1988WHO - WORLD HEALTH ORGANIZATION. Learning together to work together for health: report of a WHO Study Group on multiprofessional education for health personnel: the team approach. Geneva, 1988.).

This movement for changes in medical training and the implantation of the new health system in Brazil determined the new DCN for undergraduate courses in health, which were approved between 2001 and 2004, incorporating as general competences to be acquired: health care, decision-making, communication, leadership, administration/management and permanent training; these are common elements of health education that are complemented by the specific skills and abilities required for each course/profession. Curricular flexibility is a fundamental premise of these guidelines, it gives higher education institutions greater autonomy and diversification of training paths, as well as the conception of the specific competences of each area through discussions between committees of teaching specialists and consultation of various documents , such as the 1988 Federal Constitution, the Law on Guidelines and Bases (Lei de Diretrizes e Bases) and the Final Report of the 11^th National Health Conference (Relatório final da 11ª Conferência Nacional de Saúde) (Almeida, 2003ALMEIDA, M. (Org.). Diretrizes Curriculares Nacionais para os cursos universitários da área da saúde. Londrina: Rede Unida, 2003.).

Since 2003, through the installation of the Department of Labor Administration and Health Education (Secretaria de Gestão do Trabalho e da Education em Saúde - Segets) in the Ministry of Health, discussions on the relationship between health practices and higher education in Brazil became broader, being articulated alongside MEC. Government initiatives that sought to stimulate and promote curricular changes became common, emphasizing training oriented to work with multiprofessional health teams and integration among courses (Brasil, 2005BRASIL. Ministério da Saúde; Ministério da Educação. Pró-Saúde: Programa Nacional de Reorientação da Formação Profissional em Saúde. Brasília, DF, 2005.).

Among the joint policies conducted by MEC and MS for changes in professional training we can highlight (Alves et al., 2013ALVES, C. R. L. et al. Mudanças curriculares: principais dificuldades na implementação do Promed. Revista Brasileira de Educação Médica , Rio de Janeiro, v. 37, n. 2, p. 157-166, 2013., Brasil, 2002BRASIL. Ministério da Saúde; Ministério da Educação. Programa de Incentivo a Mudanças Curriculares nos Cursos de Medicina: edital de convocação. Brasília, DF, 2002., ²⁰⁰⁵BRASIL. Ministério da Saúde; Ministério da Educação. Pró-Saúde: Programa Nacional de Reorientação da Formação Profissional em Saúde. Brasília, DF, 2005., ²⁰¹³BRASIL. Lei nº 12.871, de 22 de outubro de 2013. Institui o Programa Mais Médicos, altera as Leis 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, Brasília, DF, 23 out. 2013. Seção 1, p. 1.):

Batista, Vilela, and Batista (2015BATISTA, N. A.; VILELA, R. Q. B.; BATISTA, S. H. S. S. Educação médica no Brasil. São Paulo: Cortez, 2015.) point that a triangulation between teaching-learning-care will always exist in the health area. For Marsiglia (2011MARSIGLIA, R. M. G. Perfil dos trabalhadores da Atenção Básica em Saúde no município de São Paulo: região norte e central da cidade. Saúde e Sociedade, São Paulo, v. 20, n. 4, p. 900-911, 2011., ²⁰¹³MARSIGLIA, R. M. G. (Org.). Ensino de graduação em saúde: ingresso e inserção profissional: FCMSCSP (1963-2013). São Paulo: CDG Casa de Soluções, 2013.; Marsiglia; Ibañez; Ianni, 2010MARSIGLIA, R. M. G.; IBAÑEZ, N.; IANNI, A. M. Z. A experiência do Pró-Saúde na Faculdade de Ciências Médicas da Santa Casa de São Paulo. In: PIERANTONI, C. R.; VIANNA, A. L. A. (Org.). Educação e saúde. São Paulo: Hucitec , 2010. p. 49-80.), inductive policies seek to cover idea: (1) interdisciplinary knowledge; (2) health work focusing in the centrality of interprofessional education; (3) strengthening the relations between IES and SUS. In this context, interdisciplinarity, multidisciplinarity and transdisciplinarity emerge as devices to integrate knowledge, building new theoretical and methodological frameworks, in addition to attributing new meanings to the field of health practices (Peduzzi et al., 2013PEDUZZI, M. et al. Educação interprofissional: formação de profissionais de saúde para o trabalho em equipe com foco nos usuários. Revista da Escola de Enfermagem da USP, São Paulo, v. 47, n. 4, p. 977-983, 2013.).

Health work presents peculiarities that make it different from other works in society. The recognition of its complex nature requires a greater range of knowledge and professional diversity that determine several health practices, the incorporation of technology and organization of services of the area. Technical divisions point to differentiated degrees of professional interrelationship, requiring collaborative action and being guided by the autonomy and complementarity of each profession (multiprofessional), as well as the establishment of competencies and attributions (uniprofessional). However, such conditions are not consolidated in health education, thus requiring Interprofessional Education (Educação Interprofissional - EIP) processes focused on producing effective health care practices for the population (Coster et al., 2008COSTER, S. et al. Interprofessional attitudes among undergraduate students in the health professions: a longitudinal questionnaire survey. International Journal of Nursing Studies, Oxford, v. 45, n. 11, p. 1667-1681, 2008.; Norman, 2005NORMAN, I. Inter-professional education for pre-registration students in the health professions: recent developments in the UK and emerging lessons. International Journal of Nursing Studies, Oxford, v. 42, n. 2, p. 119-123, 2005.).

EIP acts on the health, education and work interfaces, allowing the integration of knowledge and practices through intersectoral and interinstitutional scenarios. Considering this idea, Centers for Training and Continuing Education for Family Health (1998-2002) and Centers for Permanent Education in Health (2003-2006) were implemented, an articulation between Teaching Institutions, the Ministry of Health and Municipal and State Secretariats of Health. These experiences contributed to the formulation of the Brazilian policy on Permanent Health Education (Educação Permanente em Saúde - EPS), established by Ordinance No. 198/2004 of the Ministry of Health (Peduzzi et al., 2013PEDUZZI, M. et al. Educação interprofissional: formação de profissionais de saúde para o trabalho em equipe com foco nos usuários. Revista da Escola de Enfermagem da USP, São Paulo, v. 47, n. 4, p. 977-983, 2013.).

Final remarks

Regina Marsiglia was the great mentor of Pró-Saúde and PET-Saúde at the Faculdade Ciências Médicas da Santa Casa de São Paulo (FCMSCSP), facilitating the dialogue and discussion between this institution and São Paulo’s Municipal Health Department to create a collaborative training network that resulted in the development of a cooperation system between the Basic Units in São Paulo downtown and the specialized services of the central hospital of the Santa Casa de São Paulo.

Students of medical, nursing and speech therapy undergraduate courses participated in health promotion actions that were collectively constructed. One of its most emblematic projects discussed the culture of violence and accident prevention, concepts rooted in the different social groups that live in downtown São Paulo (Marsiglia, Ibañez; Ianni, 2010MARSIGLIA, R. M. G.; IBAÑEZ, N.; IANNI, A. M. Z. A experiência do Pró-Saúde na Faculdade de Ciências Médicas da Santa Casa de São Paulo. In: PIERANTONI, C. R.; VIANNA, A. L. A. (Org.). Educação e saúde. São Paulo: Hucitec , 2010. p. 49-80.).

Considering the pedagogical perspective, this opportunity was used to update faculty members of the FCMSCSP regarding the theoretical basis, pedagogical approach and professional practice, constructing modules in which the contents of social, psychological and clinical disciplines were articulated to highlight the complex nature of health problems and their social determinants.

Brazilian studies on interprofessional education in undergraduate courses in health and its effects on health practices are more recent and refer to specific experiences, thus requiring a more rigorous and systematic approach that compares the results of uniprofessional and interprofessional education. In this perspective, analyzing the practices of students with different learning experiences during their training can contribute and increase knowledge about interprofessional education.

References

Publication Dates

History