Aprendizagem

Four Student Misconceptions about Learning

By Maryellen Weimer, PhD

"Efficient and effective learning starts with a proper mindset," Stephen Chew writes in his short, readable, and very useful chapter, "Helping Students to Get the Most Out of Studying." Chew continues, pointing out what most of us know firsthand, students harbor some fairly serious misconceptions that undermine their efforts to learn. He identifies four of them.

1. Learning is fast — Students think that learning can happen a lot faster than it does. Take, for example, the way many students handle assigned readings. They think they can get what they need out of a chapter with one quick read through (electronic devices at the ready, snacks in hand, and ears flooded with music). Or, they don't think it's a problem to wait until the night before the exam and do all the assigned readings at once. "Students must learn that there are not shortcuts to reading comprehension." (p. 216) Teachers need to design activities that regularly require students to interact with course text materials.
2. Knowledge is composed of isolated facts — Students who hold this misconception demonstrate it when they memorize definitions. Chew writes about the commonly used student practice of making flash cards with only one term or concept on each card. The approach may enable students to regurgitate the correct definition, but they "never develop a connected understanding or how to reason with and apply concepts." (p.216) The best way for teachers to correct this misconception is by using test questions that ask students to relate definitions, use definitions to construct arguments, or apply them to some situation.
3. Being good at a subject is a matter of inborn talent rather than hard work — All of us have had students who tell us with great assurance that they can't write, can't do math, are horrible at science, or have no artistic ability. Chew points out that if students hold these beliefs about their abilities, they don't try as hard in those areas and give up as soon as any difficulty is encountered. Then they have even more evidence about those absent abilities. Students need to bring to learning a "growth mindset," recognized by statements like this, "Yes, I'm pretty good at math, but that's because I've spend a lot of time doing it." Teacher feedback can play an important role in helping students develop these growth mindsets.
4. I'm really good at multi-tasking, especially during class or studying — We've been all over this one in the blog. "The evidence is clear: trying to perform multiple tasks at once is virtually never as effective as performing the tasks one at a time focusing completely on each one." (p. 217) Chew also writes here about "inattentional blindness" which refers to the fact that when our attention is focused on one thing, we aren't seeing other things. "The problem of not knowing what we missed is that we believe we haven't missed anything." (p.217)

Pointing out these misconceptions helps but probably not as much as demonstrations. Students, especially those in the 18-24 age range, don't always believe what their teachers tell them. The evidence offered by a demonstration is more difficult to ignore.

Please be encouraged to read Chew's whole chapter (it's only eight pages). It's in an impressive new anthology which is reviewed in the February issue of The Teaching Professor newsletter. Briefly here, the book contains 24 chapters highlighting important research on the science of learning. The chapters are highly readable! They describe the research in accessible language and explore the implications of those findings. Very rarely do researchers (and most of these chapters are written by those involved with research) offer implementable suggestions. This book is full of them.

And here's the most impressive part about this book: you can download it for free. It's being made available by the American Psychological Association's Society for the Teaching of Psychology. Yes, it's a discipline-based piece of scholarly work, but as the editors correctly claim it's a book written for anyone who teaches and cares about learning. Kudos to them for providing such a great resource!

Reference and link: Benassi, V. A., Overson, C. E., & Hakala, C. M. (Editors). (2014). Applying science of learning in education: Infusing psychological science into the curriculum. Available at the Teaching of Psychology website: http://teachpsych.org/ebooks/asle2014/index.php

Pesquisa médica

Ser médico ou cientista, eis a questão. Na dúvida, por que não os dois?

Edimilson Montalti

 

Angelo Brito e Guilherme Rossi são jovens, talentosos e inteligentes. Escolheram uma das profissões mais cobiçadas e valorizadas na atualidade: a medicina. Seus ídolos são o inventor Thomas Edison, o evolucionista Charles Darwin, o gênio Leonardo Da Vinci, os médicos Paulo Vansolini, Leopoldo de Meis, Rudolph Virchow e José Lopes de Faria – algo inusitado para quem tem apenas 22 anos de idade. Um sonho eles têm em comum: ser cientista e descobrir a cura do câncer. Não à toa, ambos desenvolvem pesquisas nessa área.

Guilherme procura moléculas chamadas de microRNAs que intermedeiam a ação da quimioterapia e o desenvolvimento do câncer nos casos chamados de indolentes – que não respondem ao tratamento. Angelo busca descobrir os caminhos que levam ao desenvolvimento de novos vasos para a nutrição do tumor, processo conhecido por angiogênese, mas na área de leucemia.

O incentivo para a pesquisa começou na graduação – já no primeiro ano do curso de medicina – e levou-os para dentro de vários laboratórios de pesquisa da Faculdade de Ciências Médicas (FCM) da Unicamp. A visão romântica do que é ser cientista começou a ruir em meio a tantos processos, livros, artigos e técnicas que tiveram que aprender. As dificuldades, no entanto, só fizeram aumentar ainda mais o desejo de seguir uma carreira diferente e pouco conhecida: a de médico-pesquisador.

No quarto ano do curso de medicina, ambos trancaram a graduação e decidiram iniciar uma nova jornada com direito a diploma de doutorado, oferecido pelo Programa Médico-Pesquisador da FCM da Unicamp. Uma guinada e tanto na vida de quem até então ‘andava com a turma’, seguia calendários, provas e tinha uma rotina de aulas preestabelecida.

“Da noite para o dia, você deixa de ser o aluno de medicina e passa a ser aluno de pós e tem que aprender a lidar com a liberdade e a fazer tudo sozinho. É um choque de realidade. Você fica maduro, independente e até mais humilde”, diz Angelo Brito que é o primeiro aluno a ingressar no Programa Médico-Pesquisador, conhecido como MD-PhD.

Guilherme Rossi começa o MD-PhD em 2014 já considerando a experiência do amigo e sabe que tudo vai depender dele daqui para frente. Por dois anos, ele vai se dedicar ao sonho de criança. Após esse período, ele volta para a graduação e conclui o curso de medicina. Em oito anos – seis de graduação e dois de pós – ele fecha um ciclo de estudos que normalmente seria de 12 anos ou mais, se escolhesse fazer residência-médica primeiro.

“O pesquisador é aquele que está na fronteira do conhecimento, procurando descobrir algo que ajude os outros. O jovem tem a mente aberta e mais pique para ler, participar de congressos e grupos de pesquisa. Quanto antes começar a pós, melhor. Eu quero aprender e ensinar”, revelou Guilherme.

Segundo o coordenador da pós-graduação da FCM, Licio Augusto Velloso, o Programa Médico-Pesquisador é para poucos. Pelos menos 95% dos alunos querem ser médicos com atuação clínico-cirúrgica e apenas entre um a três alunos, por turma, tem o perfil voltado para a atividade médica de pesquisa. Para esses alunos, a FCM criou o Programa Médico-Pesquisador, em 2010, na administração do professor José Antonio Rocha Gontijo e do diretor-associado Gil Guerra-Júnior. O modelo é similar ao norte-americano. No Brasil, apenas a Universidade Federal do Rio de Janeiro (UFRJ) oferece o curso há trinta anos. A Escola Paulista de Medicina tem uma modalidade um pouco diferente. A Unicamp, portanto, é a terceira.

“O MD PhD é para aquele aluno que gosta de medicina, mas que tem um pergunta a mais: como a doença se desenvolve ou como melhorar o tratamento. E só tem um jeito de responder: pesquisando”, disse Velloso.

A cada ano são oferecidas duas vagas. O orientador de iniciação científica é quem identifica o aluno que tem potencial, “aquele que vem à noite, aos finais de  semana e trabalha mais que a média”. Mas tem a parte do aluno interessado, que deve se candidatar, preparar o memorial, não ter reprovação na graduação e escrever um projeto de pesquisa. A última etapa é a entrevista.

“O Programa é uma estratégia administrativa da FCM para melhorar aquilo que ela já oferece de bom. Estamos abrindo caminho para formar melhores médicos-pesquisadores. No futuro, isso irá repercutir positivamente”, disse Velloso.

Uma coisa Angelo e Guilherme sabem: não querem ficar atrás de uma mesa de consultório ou fazer residência médica, o que é a tendência natural da carreira de médico. Ambos querem estar na Universidade, produzindo conhecimento novo e, quem sabe, dando aula para novos alunos.

 

“Eu decidi que seria melhor investir na pós-graduação. Tem que querer. A gente supera as dificuldades. Quero, um dia, ser professor e pesquisador aqui na FCM”, revela Guilherme.

“Pode ser que eu passe 40 anos estudando o câncer e não chegue a uma descoberta que vai ser capa de revista ou capítulo de livro, mas se eu construir nem que seja uma frase, terei contribuído muito para o conhecimento e isso vale a pena”, disse Angelo.

Fotos: Marcelo Oliveira - CADCC/FCM-Unicamp

Ensino e Aprendizagem

Seven Characteristics of Good Learners

Maryellen Weimer, PhD

I've seen lots of lists that identify the characteristics of good teachers. They're great reminders of what we should aspire to be as teachers. I haven't seen many corresponding lists that identify the characteristics of good learners. I decided to put one together and invite your input. This could be a list for our students or anybody who aspires to learn well. 

1. Good learners are curious – They wonder about all sorts of things, often about things way beyond their areas of expertise. They love the discovery part of learning. Finding out about something they didn't know satisfies them for the moment, but their curiosity is addictive.
2. Good learners pursue understanding diligently – A few things may come easily to learners but most knowledge arrives after effort, and good learners are willing to put in the time. They search out information—sometimes aspiring to find out everything that is known about something. They read, analyze, and evaluate the information they've found. They talk with others, read more, study more, and carry around what they don't understand; thinking about it before they go to sleep, at the gym, on the way to work, and sometimes when they should be listening to others. Good learners are persistent. They don't give up easily.
3. Good learners recognize that a lot of learning isn't fun – That doesn't change how much they love learning. When understanding finally comes, when they get it, when all the pieces fit together, that is one special thrill. But the journey to understanding generally isn't all that exciting. Some learning tasks require boring repetition; others a mind-numbing attention to detail; still others periods of intense mental focus. Backs hurt, bottoms get tired, the clutter on the desk expands, the coffee tastes stale—no, most learning isn't fun.
4. Failure frightens good learners, but they know it's beneficial – It's a part of learning that offers special opportunities that aren't there when success comes quickly and without failure. In the presence of repeated failure and seeming futility, good learners carry on, confident that they'll figure it out. When faced with a motor that resists repair, my live-in mechanic announces he has yet to meet a motor that can't be fixed. Sometimes it ends up looking like a grudge match, man against the machine, with the man undeterred by how many different fixes don't work. He's frustrated but determined to find the one that will, all the while learning from those that don't.
5. Good learners make knowledge their own – This is about making the new knowledge fit with what the learner already knows, not making it mean whatever the learner wants. Good learners change their knowledge structures in order to accommodate what they are learning. They use the new knowledge to tear down what's poorly constructed, to finish what's only partially built, and to create new additions. In the process, they build a bigger and better knowledge structure. It's not enough to just take in new knowledge. It has to make sense, to connect in meaningful ways with what the learner already knows.
6. Good learners never run out of questions – There's always more to know. Good learners are never satisfied with how much they know about anything. They are pulled around by questions—the ones they still can't answer, or can only answer part way, or the ones without very good answers. Those questions follow them around like day follows night with the answer bringing daylight but the next question revealing the darkness.
7. Good learners share what they've learned – Knowledge is inert. Unless it's passed on, knowledge is lost. Good learners are teachers committed to sharing with others what they've learned. They write about it, and talk about it. Good learners can explain what they know in ways that make sense to others. They aren't trapped by specialized language. They can translate, paraphrase, and find examples that make what they know meaningful to other learners. They are connected to the knowledge passed on to them and committed to leaving what they've learned with others.

Good teachers model this kind of learning for their students, which makes me believe that "good learner" belongs on those lists of good teacher characteristics.

Flipped Classes

The Flipped Classroom: A Course Redesign to Foster Learning and Engagement in a Health
Professions School

Jacqueline E. McLaughlin, PhD, MS, Mary T. Roth, PharmD, MHS, Dylan M. Glatt, Nastaran Gharkholonarehe, PharmD, Christopher A. Davidson, ME, LaToya M. Griffin, PhD,
Denise A. Esserman, PhD, and Russell J. Mumper, PhD

Academic Medicine, Vol. 89, No. 2 / February 2014

Abstract

Recent calls for educational reform highlight ongoing concerns about the ability of current curricula to equip aspiring health care professionals with the skills for success. Whereas a wide range of proposed solutions attempt to address apparent deficiencies in current educational models, a growing body of literature consistently points to the need to rethink the traditional in-class, lecture-based course model. One such proposal is the flipped classroom, in which content is offloaded for students to learn on their own, and class time is dedicated to engaging students in student-centered learning activities, like problem-based learning and inquiry-oriented strategies.

In 2012, the authors flipped a required first-year pharmaceutics course at the University of North Carolina Eshelman School of Pharmacy. They offloaded all lectures to self-paced online videos and used class time to engage students in active learning exercises. In this article, the authors describe the philosophy and methodology used to redesign the Basic Pharmaceutics II course and outline the research they conducted to investigate the resulting outcomes. This article is intended to serve as a guide to instructors and educational programs seeking to develop, implement, and evaluate innovative and practical strategies to transform students' learning experience.

As class attendance, students' learning, and the perceived value of this model all increased following participation in the flipped classroom, the authors conclude that this approach warrants careful consideration as educators aim to enhance learning, improve outcomes, and fully equip students to address 21st-century health care needs.

* To read this article, click here and download a .pdf

(C) 2013 by the Association of American Medical Colleges

Currículo Médico

 

How long does it take to become a doctor? Some medical schools shaving off a year of training

Sandra G. Boodman

For Travis Hill, it was an offer too good to refuse. Last year when the 30-year-old neuroscientist was admitted to a new program at New York University that would allow him to complete medical school in only three years and guarantee him a spot in its neurosurgery residency, he seized it. Not only would Hill save about $70,000 -- the cost of tuition and living expenses for the fourth year of medical school -- he would also shave a year off the training that will consume the next decade of his life.

"I'm not interested in being in school forever," said Hill, who earned a PhD from the University of California at Davis last June and started med school in Manhattan a few weeks later. "Just knowing where you're going to be for residency is huge." 

So is Hill's student loan debt: about $200,000, dating back to his undergraduate days at the University of Massachusetts. 

And he won't begin practicing until he is 40. 

The chance to finish medical school early is attracting increased attention from students burdened with six-figure education loans: The median debt for medical school graduates in 2013 was $175,000, according to the Association of American Medical Colleges. This year, the combined cost of tuition and fees for a first-year medical student ranges from just over $12,000 to more than $82,000.

Need For More Primary Care Doctors

Some medical school administrators and policymakers see three-year programs as a way to produce physicians, particularly primary-care doctors, faster as the new health-care law funnels millions of previously uninsured patients into the medical system. Enormous student loans are cited as one reason some newly minted doctors choose lucrative specialties such as radiology or dermatology, which pay twice as much as pediatrics or family medicine. 

But debt and the shortage of primary-care doctors are not the only factors fueling interest in accelerated programs. 

Some influential experts are raising questions about the length of medical school in part because much of the fourth year is devoted to electives and applying for a residency, a process that typically takes months. (Similar questions are being raised about the third year of law school.) 

In a piece published in the Journal of the American Medical Association in 2012, University of Pennsylvania Vice Provost Ezekiel Emanuel and Stanford economist Victor Fuchs proposed that a year of medical school could be eliminated "without adversely affecting academic performance." The overall time it takes to train physicians, they wrote, is an example of waste in medical education and could be shortened without affecting patient care or eroding clinical skills; students could be assessed on "core competencies rather than on time served." 

A 2010 report by the Carnegie Foundation recommended that fast-tracking be considered. 

So far, fewer than a dozen of the nation's 124 medical schools are offering or actively considering three-year programs, which typically involve the elimination of electives, attendance at summer classes and the provisional guarantee of a residency -- offered because three-year graduates might be at a disadvantage compared with other applicants. 

NYU launched its program in September with Hill and 15 other students chosen from a pool of 50 applicants -- nearly a third of the medical school's 160-member class. 

Texas Tech University Health Sciences Center in Lubbock graduated its first three-year class in 2013; its nine students are training in family medicine. Fifteen more students started this fall. 

In September, Columbia University's College of Physicians and Surgeons launched a "fast track MD" for candidates who already hold doctorates in biology; there were 40 applicants for four slots. 

Despite the growing popularity of such programs, critics question the wisdom of jettisoning the fourth year of medical school, which they say plays a crucial role in preparing doctors for residency and subsequent practice. 

Some note that the three-year track was offered by a few dozen medical schools in the late 1970s but subsequently abandoned, largely because of student burnout from trying to cram too much into three years. 

Supporters of the three-year option say that contemporary medical school programs are different from 1970s curricula, which relied more heavily on rote memorization, and that the new programs have been designed to minimize burnout. 

"This has been tried before, and it was a miserable failure," said Stanley Goldfarb, associate dean for curriculum at the University of Pennsylvania's Perelman School of Medicine, who co-authored an essay opposing three-year programs in a recent New England Journal of Medicine. 

"Since the 1970s things have gotten so much more complex in medicine," he said. The more relaxed fourth year, he said, gives students the chance to pick the field that best suits them and to carefully evaluate residencies. More than three-fourths of students, he said, enter medical school uncertain about their eventual specialty. Goldfarb said he favors enhancing the fourth year, not eliminating it. 

Medical students have mixed feelings about three-year programs, said Nida Degesys, president of the Reston-based American Medical Student Association. While many are eager to reduce their debt, they are also concerned about missing opportunities; fourth-year electives can include ophthalmology, critical care and emergency medicine. 

"I personally changed my mind" during med school, Degesys said. "In the first year I thought I was going to do OB-GYN, but I later found that emergency medicine is truly the right fit for me." 

Century Old System

For more than a century, medical schools have largely designed their programs around a template: two years of preclinical or classroom work in basic medical science, followed by two years of clinical rotations, mostly in hospitals. 

After med school, students continue their training in residencies lasting from three to seven years, which increasingly is followed by a fellowship of one year or more. 

"There have always been some individuals who wondered about the length of medical school," said John Prescott, former dean of the medical school at West Virginia University and chief academic officer at the Association of American Medical Colleges. 

To speed the production of doctors, medical training during World War II was shortened to three years with no ill effect, he said. 

Prescott calls the current three-year programs "well-designed experiments" that may provide models about how to prepare students "in the most cost-effective way." But he doubts they will supplant the conventional four-year track for most students. 

Steven B. Abramson, vice dean of NYU's medical school, agrees, but he said he expects three-year programs to multiply over the next five years. 

NYU's accelerated program, he said, is best suited for highly qualified students who are typically older, more mature and certain of their choice of specialty. Because three-year students take the same core courses as their classmates, they will be equally well prepared, he said. And Abramson noted the proliferation of dual-degree programs: students who earn an MD along with a graduate degree in science, business administration or public health. 

"The core content we deliver is rigorous, comprehensive and very well monitored," he said. To stay in the three-year program, students must remain in the upper half of the class; they retain the option of switching to the four-year track if they find it too taxing. First-year students are also assigned mentors in their intended residency. 

While students at NYU can designate a variety of specialties, the three-year Family Medicine Accelerated Track at Texas Tech is limited to those who intend to pursue that specialty. 

"There weren't enough primary-care doctors before the Affordable Care Act," said Texas Tech medical school dean Steven Berk, who trained as a family physician. "There are lots of towns in Texas with 25,000 people and no doctor. And it's the primary-care physicians who find the small breast mass or control patients' blood pressure. They are essential to the functioning of the health-care system." 

Many students who chose the three-year course have committed to primary care based on their previous work experience. "We have students who have been PAs, EMTs and RNs," he said, referring to physician assistants, emergency medical technicians and registered nurses. 

Texas Tech students are awarded a $15,000 full tuition scholarship to cover the first year. When they graduate, their average debt for tuition and living expenses totals about $60,000, Berk said. Like the NYU program, students have the option of switching to the four-year track -- none has so far -- and are granted a residency spot when they enter med school. 

Fears that they will not perform as well as their four-year counterparts have not been validated, Berk said. Scores on licensing exams are equivalent, and burnout has not been a problem. 

Charles Willnauer, 30, a graduate of Texas Tech's first three-year class, said the accelerated program worked well for him. 

The promise of a residency in family medicine, a specialty that "fits with my values and goals," was enticing, as was the lower price tag. 

"A lot of people have to apply to 30 or more residency programs," said Willnauer, now a first-year resident. "That's a very large cost and a lot of time." 

It was also a bonus in other ways. Married and the father of two toddlers born while he was in medical school, Willnauer, age 30, said, "I bought a house and knew I wouldn't have to uproot my family."

Read more: http://medcitynews.com/2014/01/long-take-become-doctor-medical-schools-shaving-year-training/#ixzz2qTATu0Pl

Atenção Primária à Saúde

Atención Primaria fuerte es aquella que dispone de instrumentos que le permiten medir la calidad que ofrece (para su continuo mejoramiento)

Juan Gérvas

 

Hay que evitar dar respuestas simples a situaciones y problemas complejos. Tales soluciones suelen ser erróneas. Por ejemplo, en el sector de la salud cada vez hay más personas, familias y comunidades que presentan problemas más complejos, mientras que el sistema sanitario pretende ofrecer soluciones simples, aquellas que en el pasado ayudaron a resolver otros problemas y otras situaciones. ¿Los actuales pacientes, familias y comunidades son algo complejo o es el sistema sanitario con el que pretendemos dar respuesta algo demasiado simple para la cambiante situación epidemiológica, social y tecnológica?

El sistema sanitario precisa de un cambio continuo para responder a las cambiantes necesidades de la salud. Por ejemplo, la llegada del teléfono móvil (celular) ha cambiado las comunicaciones para los miembros de todas las clases sociales en todos los ámbitos de la vida. Sólo el sector sanitario se mantiene ajeno a tal revolución silenciosa. Así, el teléfono móvil (celular) rompe las barreras geográficas y administrativas y proporciona accesibilidad con sus muchas “aplicaciones” (electrocardiograma, ecografía, fotografía y tele-consultas, entre otras) que llevan tecnología no sólo a la casa del paciente, sino también a las zonas rurales y/o aisladas. ¿Qué ha hecho al respecto el sistema sanitario público? ¿Los agentes comunitarios utilizan el teléfono móvil (celular) para mejorar su calidad de atención? ¿Lo utilizan los médicos de familia para facilitar el seguimiento de pacientes en situaciones de crisis, como en los casos de esquizofrenia mal controlados? ¿Facilita el teléfono móvil (celular) el trabajo a domicilio de las enfermeras y técnicos?

En todos los países del mundo hay cambios que obligan al re-diseño de la atención sanitaria, con el objetivo de responder más eficientemente a las nuevas y más complejas necesidades. Tales cambios se refieren básicamente a (1):

• El impacto de las mejoras de los determinantes sociales y del sistema sanitario en la salud de los individuos y poblaciones. En lo que respecta a las intervenciones sanitarias, éstas son más precoces, más potentes y más variadas, siendo aplicadas por muy diferentes profesionales (poco coordinados pues trabajan en lugares muy heterogéneos). Las mejoras sociales, económicas y políticas han permitido la redistribución de la riqueza, el incremento de la equidad, la mejor y mayor seguridad frente a los avatares de la vida (cobertura sanitaria universal, establecimiento de un sistema de pensiones y de desempleo, etc.), la disminución del analfabetismo, las mejoras en las condiciones de vivienda y trabajo, el suministro de agua y el alcantarillado, etc. Todo ello conlleva una mayor expectativa de vida y, al aumentar ésta, el aumento consecutive de las enfermedades y los problemas crónicos, junto con una mayor probabilidad de que las intervenciones sanitarias sean perjudiciales; 

• Las mejoras en las tecnologías. El citado ejemplo del teléfono móvil (celular) ha cambiado las comunicaciones e, incluso, las dinámicas económicas, laborales y sociales. En otro ejemplo, la nueva tecnología también es aquella que facilita el diagnóstico rápido de la muestra de esputos con probables bacilos de tuberculosis, y, además, permite “tipificar” el ADN de los mismos para “trazar” el contagio. También es tecnología el cambio organizativo que facilita, por ejemplo, el trabajo de un equipo “funcional” en Atención Primaria, de forma y manera que cada miembro aumenta su capacidad de respuesta a los problemas de salud de pacientes, familias y comunidades. La tecnología ha cambiado todo lo relacionado con la prevención, diagnóstico, tratamiento y rehabilitación. Se trata de aplicarla de manera que provoque cambios positivos en la salud. Un buen ejemplo del uso adecuado de la tecnología es la que se ve en la trayectoria vital de pacientes con poliomielitis en Noruega (país nórdico y rico), a diferencia de la de Estonia (país báltico, ex república soviética de la extinta dictadura comunista): en el primer caso logran realizarse plenamente, mientras que en el segundo quedan socialmente relegados (2);

• El aumento de las expectativas sociales en lo que respecta a salud y bienestar vital. Los individuos y poblaciones han visto cambios casi “milagrosos”, como una apendicitis intervenida quirúrgicamente y de forma indolora, o una crisis de depresión grave curada con la medicación correspondiente, o la vacuna infantil contra el sarampión, y por todo ello es fácil que esperen la progresiva eliminación de todo dolor, sufrimiento y enfermedad, e, incluso, la inmortalidad. Siguiendo esta lógica, lo que se espera es la juventud eterna. También han visto la transformación en la oferta de servicios, que se vuelven más inmediatos y accesibles; por ejemplo, el servicio a domicilio abarca desde libros comprados por Internet a comida encargada por teléfono. En esta lógica resulta absurda la existencia de “colas” (“listas de espera”) para ser atendido en el sistema sanitario, o incluso el hecho de tener que desplazarse para recibir tales servicios.  

Los cambios señalados (y otros muchos más) exigen la mejora en la respuesta sanitaria. Sobre todo, “piden” una Atención Primaria fuerte (1,3). Tal Atención Primaria tiene instrumentos para medir la calidad de los servicios que ofrece y así poder introducir los cambios precisos con los que dar respuestas apropiadas a problemas cada vez más complejos. Barbara Starfield destacó en este campo, de elaboración de conceptos, medidas e instrumentos, para medir la calidad de los servicios prestados en Atención Primaria. Por ejemplo con el “Primary Care Assessment Tool” (PCATool) (4). Un buen ejemplo es el presente número de la “Revista de la Sociedad Brasileña de Medicina Familiar y Comunitaria”, donde se presentan los resultados prácticos de su aplicación en Brasil. Con ello se demuestra que la Atención Primaria brasileña tiene capacidad para ser “fuerte” y mejorar la calidad de sus servicios, de forma que responda a las “complejas” necesidades de pacientes, familias y comunidades (5).

No es casual el interés brasileño por el PCATool, pues éste se debe tanto al rigor científico, académico y profesional de la Atención Primaria brasileña como a la especial relación de Barbara Starfield con Brasil, país que ocupaba un lugar preferente en su corazón.


Texto completo:  PDF (ESPAÑOL)

 

Referências

Gérvas J. What role for primary health care in modern health service. 2011. [acesso em 2013 Out 9]. Disponível em: http://equipocesca.org/new/wp-content/uploads/2011/09/modern-primary-health-care-draft.pdf

Starfield B, Gérvas J, Mangin D. Clinical care and health disparities. Ann Rev Public Health. 2012; 33: 89-106. http://dx.doi.org/10.1146/annurev-publhealth-031811-124528

Starfield B. Atención primaria, una creciente e importante colaboradora en la eficacia. la equidad y la eficiencia de los servicios de salud. Informe SESPAS 2012. Gac Sanit. 2012; 26. http://dx.doi.org/10.1016/j.gaceta.2011.10.009

Johns Hopkins Primary Care Policy Center. Primary Care Assessment Tool. [acesso em 2013 Out 9]. Disponível em: http://www.jhsph.edu/research/centers-and-institutes/johns-hopkins-primary-care-policy-center/pca_tools.html

Gérvas J, Pérez Fernández M. Una Atención Primaria fuerte en Brasil. Madrid: Informe sobre: “Cómo fortalecer los aciertos y corregir las fragilidades de la Estrategia de Salud de Familia”. 2011. [acesso em 2013 Out 9]. Disponível em: http://equipocesca.org/una-atencion-primaria-fuerte-en-brasil/

Simulação clínica

 

Medical school actor lives the part: Fake aneurysm patient becomes real one

Stephanie Baum

 

It’s part of a longstanding practice in medical schools to use actors as patients so that students can develop critical skills for conducting physical exams and taking medical histories. But at the University of Virginia, one student’s actor-patient turned out to be the real thing.

Jim Malloy was assigned an illness.  University of Virginia Medical School student Ryan Jones was supposed to form a diagnosis based on the symptoms Malloy described on the card he was given, according to a report by CBS News.

Malloy was instructed to act out symptoms for an abdominal aortic aneurysm, an enlargement of the lower part of the aorta — the main blood vessel that delivers blood to the body. But as Jones examined his patient, he realized that in this rare occurrence, his patient actually had the condition. This made him think Malloy was some sort of ringer to keep the med students on their toes. But Malloy said he had no symptoms.  A supervising physician confirmed the aneurysm.

The dangerous condition can lead to a burst blood vessel or leaking along the blood vessel wall that can cause internal bleeding and death. Once discovered, the condition is closely monitored by doctors since its progression may be slow or rapid. Among the risk factors are men over 60 who are smokers or a family history of  abdominal aortic aneurysms.

Jones advised Malloy to see his doctor as soon as possible. He later had stent replacement surgery. As Jones moves on to a residency in his chosen field of oncology radiologist, he can take comfort that he's chosen the right profession.

 

Read more: http://medcitynews.com/2014/01/medical-school-actor-lives-part-fake-aneurysm-patient-becomes-real-one/#ixzz2qBbNkkA9

PROVAB

PROVAB 2014

O Ministério da Saúde, através da Secretaria de Gestão do Trabalho e da Educação na Saúde (SGTES), publicou no Diário Oficial da União na data de hoje ( 07/01/2014 ), o edital de adesão de médicos ao Programa de Valorização do Profissional da Atenção Básica  (PROVAB), edição de 2014.

A publicação regulamenta o funcionamento do Programa e a possibilidade de transferência de médicos do Programa Mais Médicos para o PROVAB.

Para acessar o Edital de Convocação Nº 01/2014 que trata sobre o tema, clique aqui.

Tecnologia para a inclusão

3D sonograms let blind expectant parents "see" their babies

 

Morgen Peck

Jorge Roberto Lopes dos Santos, an industrial designer with the Instituto Nacional de Tecnologia in Brazil, is giving doctors a new way to print sonograms for their patients — as life-size replicas.

The prenatal sonogram is a life-changing moment for many expectant parents, giving rise to the inherent value these images hold whether as printouts passed among family members or posts on social media.

It’s one of the joyous benchmarks of pregnancy, but one that has been elusive to the visually impaired. Innovations in 3D printing, however, could change that.

Dos Santos's company, Tecnologia Humana 3D, has been developing new ways to build three-dimensional computer models using data from sonograms and other imaging techniques after initially setting out to enhance prenatal diagnostic tools.

The work took a new direction when dos Santos realized that printing these models would give visually impaired mothers-to-be a chance to meet their babies in utero.

“We work mainly to help physicians when there is some eventual possibility of malformation,” dos Santos said. “We also work for parents who want to have the models of their fetuses in 3D.”

Tecnologia Humana designs the models with sophisticated programs that produce highly detailed simulations of a fetus’ anatomy that doctors can examine virtually.

They can swoop through the lungs and explore the cavities of the heart in search of problems that may require intervention. Prior journeys have found Down syndrome and cleft lip, dos Santos said in a recent paper.

Making a tangible model of a fetus requires one other step — plugging that data into a 3D printer, a device that can create objects by laying down successive layers of material.

Neva Fairchild, the resident expert on independent living at the American Foundation for the Blind, said the models would also benefit visually impaired family members looking to share in the experience of seeing their loved one’s unborn child for the first time.

A model would allow people with impaired vision to know the size of a fetus while giving them a new appreciation of those tiny toes and fingers. Fairchild, who is legally blind and can only discern shapes and shadows, speaks from experience.

“Fifteen months ago, my first grandchild was born and they had numerous sonograms and I missed out on all of that,” she said.

Fairchild said it’s important, however, for the producers of these models to keep cost in mind. Many recent inventions designed to aid the visually impaired are too expensive for the people they’re meant to help, and most insurance policies are reluctant to cover these kinds of expenses, she said.

But dos Santos said his reliance on common imaging techniques, such as the MRI and the CT scan, keeps costs relatively low — about $200 for a full model of a fetus at 12 weeks, and about $300 for the face and arms of a fetus at 24 weeks.

This article originally appeared at Tech Page One.

Relação Médico-paciente

What do You Expect From a Doctor?

Six Habits for Healthier Patient Encounters

David Loxterkamp, MD

Ann FamMed. 2013;11(6):574-576. 

Abstract

Expectations lie at the heart of America's health care crisis. Although doctors cannot control for the unrealistic demands of a consumer-centric society, we might ask what we would want in a physician. Someone who listens longer and lets us express ourselves in our own words? Someone who cares about the outcome—our personal outcome—and not just the "clinical course"? Most patients do not demand perfection. Not cure. Not even relief, no matter what the TV commercials promise or how badly they wish them to be true. What we all desire is a plan that connects us to another human being—our doctor—which is a kind of relief all its own. The author identifies 6 simple habits that will lead to healthier, happier encounters with patients and their illness.

Introduction

Expectations lie at the heart of the American health care crisis. That's because we Americans expect a lot. As patients, we expect to live long, productive lives with replaceable joints, clear lenses, and revitalized hearts. We expect to receive a diagnosis and treatment for every complaint. We expect high-tech solutions for commonsense problems. We expect our doctors to be flawless and self-confident, and doctors, in turn, expect to be compensated for the stress of their relentless demands. Americans—or at least those with means—are said to enjoy the best health care system in the world, but even the most fortunate soon discover that health is a gift, as much dependent on genetics and good luck as it is on lifestyle choices and access to care.

When patients demand specific drugs, tests, or diagnoses, they prevent us from being a doctor—a professional whose training, skill, and dedication are put in the service of their recovery. Likewise, when we take a chief complaint at face value, our patients are short-changed. Neither patient nor doctor should expect the doctor to be a booking agent, approving parent, or frat brother. Yet bedside manner, face-to-face time, and a sense of connection—what we once unabashedly called the doctor-patient relationship—matter as much as the services that are delivered.

The son of my neighbor was brought to me with a high fever. The child was healthy in every other respect, so I advised a wait-and-see approach: clear liquids, ibuprofen, call if the condition worsens. I saw the boy each day thereafter and over the busy on-call weekend—his most worrisome findings morphing from uncontrolled fever to a loss of appetite, stiff neck, and enlarged lymph nodes. On Monday, I consulted the closest infectious disease specialist by telephone, but her tests proved inconclusive. The next night the boy developed pain with swallowing, and another on-call physician suggested a CT scan that revealed an abscess behind the boy's throat. He was hospitalized at the referral center and quickly recovered on intravenous antibiotics.

Without a solid diagnosis or signs of improvement, the boy's parents and I were emotionally adrift, each of us swamped by our respective responsibilities and worries. I later admitted to the mother that her son's retro-pharyngeal abscess was the first I had seen in a child. I consoled myself in the belief that the delay in diagnosis caused no harm, but ruminated anyway on the boy's prolonged suffering, the mother's loss of trust in me, and the damage to my own self-confidence.

The 2 things that patients should expect from their doctor are competency, which diplomas and board certification attest to, and a moral compass that puts others' needs above the physician's. Beyond that, a few simple habits might assure that mutual satisfaction flows from the patient's encounter:

Identify

Patients need know to whom they are speaking—specifically, the health professional's level of training and responsibility. When continuity of care is challenged by after-hours coverage, urgent care visits, and the increasing presence of nurse practitioners, physician assistants, medical students, and residents-in-training, the patient may no longer recognize the "doctor" by sight or voice, and feel fortunate to see anyone at all.^[1]

Listen

Patients want their doctors to listen and instinctively know that talk alone is therapeutic.^[2] Instead, doctors interrupt them within the first 12 seconds.^[3] It saves so little time. Most patients will tell their story in 2 minutes or less.^[4] Moreover, listening demonstrates the doctor's respect and concern. It involves more than the auditory nerve; intentional listening requires eye contact, the interpretation of body language, and positioning oneself so that both pairs of eyes are level.

Touch

A careful physical examination often provides invaluable clues to the correct diagnosis. Even when an examination is unnecessary, its performance conveys a commitment to thoroughness. Touching establishes a physical connection and sense of intimacy between the doctor and patient that invites communication and reassures the patient that there is no need to conceal or loathe their wounded part.

Look

Much of the patient's time at the doctor's office is consumed by waiting and then is delegated to others—secretaries, medical assistants, mid-level practitioners, scribes. Though this delegation allows physicians to practice "at the top of their license," it subtracts from the time it takes to get to know their patients and earn their trust. With whatever time remains, it is imperative that the doctor look at the patient and not at the computer, smart phone, or clock.

Plan

After taking a history, performing a physical examination, and making an assessment, the doctor then outlines the specific steps that will lead to the patient's recovery. Though we recognize that the plan is a tentative and educated guess, patients cling to it like a life preserver, relieved that a doctor is holding the rope that will pull them from their pain, uncertainty, and fear. A plan is never more necessary than when patients lack a definitive diagnosis or clear prospects for recovery. And although patients want to be involved in creating the plan, most are happy to leave the final decisions to their doctor.^[5]

 

My neighbors needed to know why their son was sick, when his symptoms would abate, and what signs might signal a setback in his recovery. Plans should also identify the costs, risks, markers, and likelihood of success. The most important plan is often the one we keep in the back of our minds.

Follow-up

Even when doctors arrive at a brilliant diagnosis or offer cutting-edge cures, the job isn't done. We must also prepare patients with a prognosis, provide test results, and guide them through the travails of their illness. Much goes on after an office visit to assure that this happens. On a typical day, primary care doctors will see 18 patients whom they can bill. But they will also initiate, return, or review more than 90 telephone calls, e-mail messages, prescription refills, laboratory results, imaging reports, and outside consultations.^[6]

 

Medicine is a performing art, and so it is that on some days our actions disappoint. What recourse do disgruntled patients have? Some will leave their doctor, though departures are rarely noticed and relocation offers no guarantees. Some will file a complaint or initiate a lawsuit, but their cases are almost always settled out of court, dismissed, or decided in favor of the defendant.^[7] Patients have come to expect professional interactions that are scrubbed of warmth, personal attention, and effective communication, and that is sad. Reform, when it comes, often hinges on patients' initiative—a letter of complaint or an arranged meeting with the doctor or office manager, but they should know that their doctor wants to be understood and respected as badly as they do.

The parents of the boy did not expect me to diagnose his problem right away (though they assuredly wished I had). But they had reason enough to thank me for their son's recovery, as their card of thanks conveyed:

We are writing to express our gratitude for making yourself so available when [our son] was sick. It was a trying time, but it would have been far worse had we no one to turn to. We consider ourselves especially fortunate to live in a community where our family doctor cares so much about the health and well-being of our children….

Many physicians receive such notes, but not for their medical prowess (which, again, is expected, and not easily judged) but for their compassion—for actions that arise out of love and kindness, not duty and fear. Patients want their doctor to listen longer and allow them to express themselves in their own words. They want doctors who care about the outcome—the patient's personal outcome, not just the clinical course —even if, in bearing witness to it, doctors will absorb their distress (what Anatole Broyard once described as "brooding").^[8] Patients want to know that there is way out of their loneliness, confusion, panic, and pain. Most are not demanding perfection. Not cure. Not even relief, no matter what the TV commercials promise or how badly they wish them to be true. What we all desire is a plan that connects us to another human being—our doctor—which is a kind of relief all its own. Patients come to us for conversation, friendship, and hope, trusting in this well-worn path to recovery.

* David Loxterkamp is the author of a new book, What Matters in Medicine: Lessons from a Life in Primary Care.

References

1. Harris G. Who gets to be called a doctor? NY Times Well Blog. Oct 1, 2011. http://well.blogs.nytimes.com/2011/10/01/who-gets-tobe-called-a-doctor/.
2. Tannen D. Why sisterly chats make people happier. NY Times. Oct 25, 2011. http://www.nytimes.com/2010/10/26/health/26essay.html.
3. Rhoades DR, McFarland KF, Finch W, Johnson AO. Speaking and interruptions during primary care office visits. Fam Med. 2001;33(7):528–532. http://www.interruptions.net/literature/Rhoades-FM01.pdf.
4. Langewitz W, Denz M, Keller A, Kiss A, Ruttimann S, Wössmer B. Spontaneous talking time at start of consultation in outpatient clinic: cohort study. BMJ. 2002;325:682–683. http://www.bmj.com/content/325/7366/682.full.
5. Chung GS, Lawrence RE, Curlin FA, Arora V, Meltzer D. Predictors of hospitalised patients' preferences for physician-directed medical decision-making. J Med Ethics. http://jme.bmj.com/content/38/2/77.short.
6. Baron RJ. What's keeping us so busy in primary care? A snapshot from one practice. N Engl J Med. 2010;362:1632–1636. http://www.nejm.org/doi/full/10.1056/NEJMon0910793
7. Kane C. Medical liability claim frequency: a 2007–2008 snapshot of physicians. AMA Economic and Health Policy Research. August 2010.
8. Broyard A. Doctor talk to me. NY Times Book Rev. Aug 26, 1990. http://www.nytimes.com/1990/08/26/magazine/doctor-talk-to-me.html?pagewanted=all&src=pm.

Ann Fam Med. 2013;11(6):574-576. © 2013 Annals of Family Medicine, Inc.