Blog do Curso de Medicina da Universidade Estadual de Maringá para a discussão de temas de Educação Médica, Educação das Profissões da Saúde e áreas correlatas.
Blog of University of Maringá Medical School for the discussion of issues of Medical Education, Health Professions Education and related areas.
my pediatrics rotation, the mother of a patient waited until the attending
physician had left the room before she lowered her voice, smiled, and asked,
“Are you wearing your hoodie for Trayvon?” She didn't know what city I was
from, what faith I belonged to, or what tax bracket I was in. She just knew
that I was black, like her. This race-based camaraderie between patient and
physician can improve patient satisfaction,1 and patients from racial minority groups tend
to seek out physicians of their own race if given a choice.2 As a black medical student, I can attest that
the sort of “diversity” that you can see — that allows you to be counted in a crowd
— can significantly influence interactions with peers, instructors, and
the past few decades, medical education's definition of “diversity” has largely
remained the same, as has the social mandate to increase it. With roots in the
Civil Rights Movement, diversity initiatives have focused primarily on racial
groups that had been implicitly and explicitly denied access to the field.
Efforts to increase the numbers of blacks, Hispanics, and Native Americans
served a moral imperative: it was the right thing to do. Such efforts have had
mixed results: the proportion of Hispanic medical school graduates increased by
4.1 percentage points from 1978 to 2012, whereas the proportion of black
graduates increased by only 1.8 percentage points during the same period (see
Perspective article by Iglehart, pages 1471–1474). Moreover, this “good
intentions” approach fails to critically examine diversity's true meaning and
strips it of its potential to advance the field of medicine.
“Diversity 3.0.” The term, coined by IBM, reflects a new way of thinking about
diversity in education and the workforce. Building on the 1.0 model, in which
diversity was seen as a necessary evil, and the 2.0 version, in which a diverse
population was recast as a nice thing for the majority to have around, the
current vision defines “achieving the full potential of this diversity [as] a
business priority that is fundamental to our competitive success.”3 This reframing is not lost on Marc Nivet,
chief diversity officer of the Association of American Medical Colleges. “1.0
is where diversity is competing with excellence,” Nivet explains. “Diversity
2.0, which is where we are, has not been viewed as central to the institution's
drive for excellence.” In addition to integrating diversity into institutions'
core missions, the 3.0 version, Nivet has written, “requires a focus on
differences beyond race and ethnicity,”4 the traditional emphases of multicultural
this model, medical-student diversity becomes a prerequisite for an optimal
learning environment, where various ideas, opinions, and experiences create a breeding
ground for innovative solutions to problems. Version 3.0 can thus bridge the
gap between initiatives that make black students feel more welcome in medical
schools and those that harness the power of a diverse workforce to improve
most immediately, the new vision provides a model for cultural competence in
doctor–patient interactions that can improve patient satisfaction. Medical
students, for example, can benefit from observing encounters between
“standardized patients” (actors hired to play patients) and classmates whose
backgrounds may be more similar to those of the hypothetical patients than to
their own. My class met one such standardized patient whose religiosity was
meant to render her “difficult” — and did have that effect for some students.
But having grown up in Texas around many very religious people, I could readily
engage in a rather pleasant conversation with her. The classmates who observed
it may now approach a similar future patient with greater confidence. Indeed,
white graduates of diverse medical schools report that they're better equipped
to care for minority patients and have stronger convictions about inadequate
access to care.3 Long after graduation, other benefits of
racial and ethnic diversity are evident: black and Hispanic physicians are more
likely to practice in areas with larger proportions of black and Hispanic
residents, and they see a larger proportion of Medicaid and uninsured patients.5
worldviews may diverge for many reasons — owing to the experiences of military
service, for example, or to sexual orientation or the language one speaks. All
such characteristics and experiences figure into the new diversity, which
acknowledges that shared experience in this country no longer tracks simply
with race. Diversity is not so black and white anymore.
the push for other forms of diversity, medical schools still place a certain
premium on “visual diversity” — that of race and sex. This emphasis is
understandable: such diversity is easily measurable, and concern about it is a
legacy of systemic discrimination. That history, coupled with certain classroom
and hospital experiences common to medical students from underrepresented
minorities, creates a shared narrative that has supported a collective
consciousness for decades. Some minority students may feel that the new
diversity puts this shared identity at risk. And as we aim to translate earlier
versions of diversity into something serving medicine's core missions, it's
worth remembering that, as with the mother from my pediatrics rotation, I've
often quickly built a rapport with a patient simply because we were both black.
all diversity, visual or not, holds value. It's not just a numbers game or an
annual administrative experiment. Diversity is a process that exists outside
the admissions cycle and promotional photos. It's a mindset that extends into
the classroom and the hospital. If the ultimate goal of diversity in medical
schools and residency programs is to improve patient care, a good first step is
to create a world where all trainees can feel supported while learning and
working to the best of their ability. That goal can be achieved only with a
wholehearted commitment to diversity that is inseparable from an institution's
I started college, I felt drawn to sit with other black students in the
cafeteria. But establishing an inclusive learning environment means that people
from different walks of life can not only have a seat at the same table but
also be comfortable in their chairs. Although embracing this new diversity may
mean broadening an institution's outlook from primarily underrepresented racial
minorities, efforts targeted at those groups still serve an important mission.
Diversity efforts can build on the existing model and borrow from their track
record of progress toward creating better medical schools and hospitals for all
I arrived at medical school, I sought a place where I could be myself. Medical
schools pursuing Diversity 3.0 would do well to remember that everyone with a
unique story to tell wants the same. The ideal diversity initiative would
therefore be a climate control of sorts, striving to create an atmosphere where
everyone feels included in the larger dialogue. Only then will the conditions
be ideal for creating a workforce that's willing and well-equipped to address
the needs of an increasingly diverse population.
5 Marrast LM, Zallman
D. Minority physicians' role in the care of underserved patients:
diversifying the physician workforce may be key in addressing health
disparities. JAMA Intern Med 2014;174:289-291 CrossRef | Web of Science
One of our most-viewed articles is an article about four scales every researcher should remember.
Since that post was written, some changes have taken place that have
affected the four scales, so we figured it was time for an update! Here,
we’ll dive into a bit more about considerations behind which scale or
question type you should be using, as well as an update on the most
powerful questions that can drive insight into what your respondents are
The First Rule of Research
The first rule for any research project – whether it’s a one-time
project or a customer feedback survey distributed regularly – is this:
focus your project to the one primary purpose or question you want to
have answered. This will automatically help you narrow down what type of
scale or question to use for your survey. For example, let’s say your
focus is a feedback survey. The primary question might be: are our
customers having a good experience in our stores? From there, choose the
primary 3-5 items that you want to measure as related to the question.
In this example, they might be: products easy to find; helpful staff;
clean store. Now, you’re ready to check out the scales and questions
that could provide you the best insight into these questions.
Four Types of Data to Measure
There are four types of data. Any data falls under one of these
categories. They are all used for different purposes and are analyzed
Nominal: names, labels. Examples include days of the
week, colors, and geographic area names. These are difficult to analyze
using most statistical methods. Basically, you are limited to count, or
frequency of distribution.
Ordinal: order of items, but no measurable
difference in numbers between the items in the list. Examples include
satisfaction ratings and importance ratings. Analysis includes median
(midpoint of distribution, rather than the average distribution) and
Interval: numeric values for which a difference in
value is measurable, but no true zero exists (a point at which the
quality being measure does not exist). Examples include time and
temperature. Analysis includes most statistical measures, but not any
that would include multiplying or dividing values.
Ratio: numeric values for which a difference in value is measurable AND a true zero exists. Examples include age and height.
Now that we understand the difference between the types of scales, let’s look at some of the most used scales!
Types of Measurement
There are two types of measurement: comparative and non-comparative. They are pretty straight-forward.
Comparative measurement: As the name implies,
comparative measurements typically involves two brands, or two things,
being compared against each other. One example would be comparing one
brand of smartphone against another brand of smartphone to determine
what people like better about one or the other.
Non-comparative measurement: Again, the name says it
all. The scales we’re going to review today all fall in the
non-comparative realm of measurement, where only one item or one brand
is being measured.
The Four Question Types/Scales You Should Know
1. Likert Items
A Likert scale is technically the sum of a list of Likert items. What
makes a question a Likert item? There are equal numbers of positive and
negative options in the scale; Likert items always have a
central neutral option, which means there will always be an odd set of
answers available to the respondent – typically, a Likert item has a
total of seven answer options. Likert items measure ordinal data.
2. Unipolar scales
Where Likert items are bipolar, meaning the respondent has to decide
between opposing items, unipolar scales are more streamlined, allowing
users to instead focus on the absence or presence of a single item. The
scale is still measuring ordinal data, but research has shown that
unipolar scales generate more accurate answers. An example of a unipolar
satisfaction scale is: not at all satisfied, slightly satisfied,
moderately satisfied, very satisfied, and completely satisfied.
3. Slider Scales
Slider scales (also known as continuous rating scales) allow the
survey designer to measure ordinal data (using a categorical slider), or
interval or ratio data (using a numeric slider). For example, a slider
scale could be used for a unipolar satisfaction question, allowing a
respondent to perhaps more precisely define their feeling about an item.
A slider scale could also be used to let respondents answer questions
about how much time they expected to wait for an order versus how much
time they actually waited for the order. Based on what type of data you
are gathering using the slider scale is the type of analysis you can
conduct with the data. If you’re gathering interval data, you can
calculate averages, standard deviations, etc. If you’re gathering
ordinal data, however, be sure to stick to frequencies and medians to
analyze your data.
4. Side-by-Side Matrix
The side-by-side matrix remains another highly-used item for
measuring ordinal data. The side-by-side matrix allows a respondent to
respond to two qualities about an item. The most common use is to
determine a respondent’s opinion about the importance of an attribute
and the satisfaction of their experience with that attribute. This helps
a company determine if perhaps there are items they are focusing on
that respondents don’t find terribly important, versus items that the
respondent finds important, but unsatisfactory.
The most common analysis tool used with the side-by-side matrix is a
Gap analysis, which is actually pretty self-explanatory – it shows where
there are gaps between the two attributes measured, using the first
attribute listed (in this case, importance) as the primary attribute to
measure against. In this example, you can see that the red arrow
indicates the greatest gap exists for the topic On-time Arrival. For the
best impact, this would be where this organization should focus, as
this item is important to respondents but has the lowest satisfaction
“Se realmente quisermos cooperações
instigantes em pesquisa científica e projetos conjuntos em que se pense o
até então impensável, não é suficiente apenas colocar cientistas de um
país em contato com os de outro, ou apenas permitir que se visitem”,
disse Enno Aufderheide, secretário-geral da Fundação Alexander von
Humboldt, durante a FAPESP Week Munich,
simpósio promovido pela FAPESP e pelo Centro Universitário da Baviera
para a América Latina (Baylat) em Munique, na Alemanha, de 15 a 17 de
“Temos que tornar possível que os pesquisadores permaneçam em outros
países. Temos que permitir que eles tenham a perspectiva das pessoas que
vivem lá e com quem eles trabalharão, de modo que haja uma interação
real entre os dois lados”, disse Aufderheide.
Brito Cruz, Aufderheide e Varela falaram sobre os incentivos às colaborações entre pesquisadores de diversos países (foto: H.Shimizu)
Aufderheide foi um dos palestrantes no painel “Colaboração científica
internacional, networking e excelência em universidades – Boas
práticas”, ao lado de Christian Müller, diretor do Departamento de
Estratégia e Gerenciamento do Conhecimento do Serviço Alemão de
Intercâmbio Acadêmico (DAAD); de Torsten Nyncke, diretor regional para
Europa, Brasil e Israel da Associação Fraunhofer; e de Carlos Henrique
de Brito Cruz, diretor científico da FAPESP. O painel teve como
moderador José Arana Varela, diretor presidente do Conselho
Técnico-Administrativo da FAPESP.
Fundada em 1953 e com 15 pesquisadores com prêmio Nobel, a Fundação
Humboldt oferece auxílios que possibilitam a pesquisadores de outros
países passarem períodos em uma instituição alemã. Segundo Aufderheide, a
instituição tem construído uma rede global de excelência em pesquisa
que conta atualmente com 26 mil pesquisadores em quase 140 países, que
têm ou tiveram apoio em algum momento de suas carreiras.
“Essa rede apoia colaborações multilaterais em várias disciplinas,
beneficiando tanto indivíduos em sua busca de conquistas científicas
como países que querem se tornar parte do empreendimento global de
adquirir conhecimento”, disse.
Segundo Aufderheide, as necessidades e oportunidades para a
colaboração internacional em pesquisa têm aumentado enormemente na
última década. “E países que não estão bem integrados em redes
internacionais correm o risco de perder oportunidades importantes para
recrutar talentos”, disse.
Müller falou sobre a longa história de cooperação com instituições
brasileiras, especialmente agências de fomento à pesquisa. Com a FAPESP,
por exemplo, o DAAD mantém um acordo de cooperação desde 1988 – por meio do qual já foram concedidos mais de 130 auxílios e bolsas.
Nyncke falou sobre a estratégia de internacionalização da Fraunhofer,
que se baseia na adição de valor científico para a associação alemã e
nos efeitos positivos tanto para a Alemanha como para o país parceiro
advindos da colaboração.
“O Brasil tem sido um parceiro importante para a Fraunhofer. Mais de
30 institutos da associação tem participado de cooperações com parceiros
brasileiros. Dois centros de projetos da Fraunhofer, um deles no Estado
de São Paulo, demonstram o comprometimento de longo prazo na
colaboração científica com o Brasil”, disse.
Brito Cruz destacou o programa de internacionalização da pesquisa
feita no Estado de São Paulo, apoiado pela FAPESP por meio de mais de
100 acordos de cooperação com instituições de outros países e por
diversos instrumentos de fomento.
“Ciência é um empreendimento social. Não é apenas um empreendimento
individual. Assim como a ciência depende do gênio individual, ela também
depende da comunicação e do trabalho conjunto, especialmente entre os
melhores pesquisadores no mundo. Esse é um dos motivos por que
procuramos desenvolver a colaboração internacional em pesquisa. Queremos
que os melhores cientistas em São Paulo trabalhem mais do que o fazem
atualmente em conjunto com os melhores cientistas no mundo”, disse.
O diretor científico também destacou que, além de permitir que
pesquisadores de São Paulo possam ir a outros países para participar de
projetos binacionais ou internacionais, a FAPESP tem possibilitado a
vinda de pesquisadores de outros países ao Brasil.
“Trouxemos o equivalente a um pesquisador por dia de trabalho [na semana]
em 2013 e queremos aumentar para dois pesquisadores por dia”, disse.
“Também no ano passado, 20% das bolsas de pós-doutorado da FAPESP foram
concedidas a estrangeiros.”
“Há muitas iniciativas para a internacionalização da pesquisa
brasileira e estamos trabalhando duro para isso, mas é claro que há
diversos obstáculos. Um deles é que no Brasil nós falamos português, uma
língua não dominada no resto do mundo. Outro ponto é que o país está
distante dos principais centros científicos mundiais”, disse Brito Cruz.
“Na FAPESP, temos criado incentivos e oportunidades que permitam que
esses obstáculos sejam superados e os resultados têm sido muito bons. Em
2005, por exemplo, tínhamos dois ou três auxílios da FAPESP em parceria
com organizações de outros países para financiar o trabalho
colaborativo de pesquisadores. Hoje, são cerca de 200”, disse Brito
purists among us who would say that we should never lecture, but I don't think
that's terribly realistic, and I'm still not ready to totally rule out
lectures. As faculty, we bring expertise to learners and having an expert
around when you don't know something can be very helpful. Do most teachers
still talk too much? They do. Are lectures fraught with well-established
impediments to learning? They are.
missing from the conversation are guidelines that teachers might use to
determine when they should lecture. And that's what I'd like to propose in this
post. Please consider the questions posed here as an initial exploration, which
can be deepened and made more meaningful with your ideas, insights, and
decision of whether to lecture be influenced by what we are teaching in class
that day? Are some kinds of content better explained by the teacher than
discovered by the students? Is it complex content that you know from previous
experience often causes students to struggle? Can the teacher's explanation lay
the foundation, set the parameters, or provide the context so that students can
start dealing with content from a place that expedites understanding? Is a
lecture the best way to clarify what students find confusing?
Should we use
lecture to present threshold concepts, those building blocks in the discipline
which, if understood correctly from the start, provide stability for the
knowledge structures built upon them? If we do, we should test how effectively
the lecture established those foundations. We should collect data from students
and use it to ascertain the level of their understanding as compared with their
learning via other methods.
determine when a lecture might be needed by watching the learning experiences
of students? If they are attempting something that is challenging, if they are
working hard, but still not getting it, if levels of frustration are rising, is
that the time for a teacher to step in? Most of us know firsthand that
sometimes learning can be so frustrating, emotions so strong and raw, that
insight and understanding escape us. This is what some call just-in-time
teaching. When students experience a learning impasse, the teacher steps in to
provide the answer or additional informationor tells students where they should look for it.
lecturing is simply the most efficient way to share information. We don't give
student blank copies of the periodic table and let them try to fill it in. We
don't let them try to set the basic principles of accounting.
Maybe we know
when to lecture by ascertaining what will best convey the content. Does it need
to be: explained clearly, maybe from different perspectives; illustrated, with
examples or visually represented; structured with main and supporting points
differentiated; or positioned to connect to what's come before and linked to
what will come after? What the content doesn't need is to be transferredpassed from teacher to student. "Don't be a
mother robinchewing up the text for the
students and putting it into their beaks through lecture," Richard Paul
and Linda Elder admonish.
Should we use
lecture when students don't think they care about the content, don't think it's
interesting, or don't think there's any need to know it? A lecture where the
teacher peppers the content with spicy facts, intriguing questions, colorful
anecdotes, and relevant details can cultivate student interest. Teachers
talking about how they connect to and with the content, why they love it, and
why they think everyone else ought to also can be very motivational.
So we still
have lots of questions when it comes to lectures, but we do know that we
shouldn't use lecture as the default instructional method. We need to decide
when lecturing makes sense so that it's a conscious, purposeful choice. And
then there's the matter of length for any given segment of teacher talk. As I
review these possible justifications for lecture, I'm hearing a call for
mini-lectures, not lengthy expositions that take all or most of a class
Now it's your
turn. How do you decide when a lecture is in order? Or, taken from the opposite
direction, how do you know when what's needed to promote learning is not a
A significant proportion (between 5-10%) of the student community at
universities in the UK uses the counselling services, according to the
Heads of University Counselling Services (Hucs). However, it would be
incorrect to accept overly simplistic explanations for this phenomenon.
It is obvious that in many ways life is extremely pressurised and
stressful for university students today, but this is not just caused by
the demands of academic life or the lack of support from universities.
It is equally simplistic to say that this is all due to increased
tuition fees and the pressures they put on students to succeed
academically, so they can then go on to get a good job.
That is not to say that the uncertain economic future does not amplify the pressure on young people.
One of the ironies of increased student fees is that they can
heighten student expectations (often unrealistically) about the support
services at their institutions.
Although students are contributing more, the reality is that there
has been no real increase in university funding, as central government
funding to higher education has been dramatically cut.
A negative consequence of this cut could be for universities to cut
back support services or replace experienced and effective counselling
services with generic “wellbeing support workers”.
Social and mass media: driving unrealistic life expectations
There is a whole range of cultural and sociological issues affecting young adult psychological development today.
Social and mass media often promote unrealistic life expectations and
engender a persecutory perfectionism within young adults. This can
create a self-bullying mentality which can make students feel
dissatisfied with their own achievements and experiences while also
heightening expectations of others.
Unrealistic perfectionism is a key driver for more serious problems
such as depression, anxiety, self-harm and eating disorders. Despite
being more connected in a virtual way, many students feel more isolated,
as they believe they have to hide their true self and present a perfect
image to others.
Changes in secondary education have made the transition to learning
at higher education much harder and more emotionally challenging for
Real learning at degree level often involves going through periods of
not knowing, being confused, until new knowledge emerges. However, some
students may sense that if they don’t understand something immediately
they are failing or being failed by their tutors.
Changes in family structure and parenting styles often lead to
closer, friendlier and more positive relationships between parents and
young adults, but this can also generate mixed messages for young
adults, sometimes leading them to feel more anxious about separating
from their parents and facing the challenges and risks of the outside
Using labels such as “depression” can make young adults feel trapped in a “passive sick role”
There is greater awareness – but not necessarily understanding – of
mental illness. This often leads to an over-medicalised and symptomised
view of normal life difficulties, challenges and struggles. Much of the data cited by student journals
has no statistical validity. Figures are usually based on
impressionistic and subjective questionnaires rather than rigorous
clinical evidence or diagnosis.
Many students can feel they are “depressed” in a common-sense way
when they are going through difficult life struggles, but this is
different from clinical depression and anxiety disorders. The use of
labels such as “depression” or “anxiety disorder” can have the effect of
making young adults feel trapped in a “passive sick role” rather than
helping them to develop the internal skills and resources to cope with
According to psychological and therapeutic models, the way people
make sense of their experiences has a fundamental effect on how they
feel and act. Seeing life in simplistic “all or nothing” categories can
have a detrimental effect on how people feel, as it stops them from
understanding and engaging with the complexities of life.
If student life is constantly portrayed as being some kind of hell on
earth, where most students are depressed with no one to help them, this
creates a self-fulfilling prophesy making students feel worse and
reluctant to seek help.
University counselling services are highly effective
University counselling services have been developing evidence-based
therapeutic interventions, and using professional clinical experience,
for many years.
Evidence from university counselling services
across the UK demonstrates that they are highly clinically effective,
with rates of significant and reliable improvement at 75% or above for
service users. This not only reduces distressing psychological symptoms
but also helps students to function better at university.
After using their universities counselling service, the majority of students report
they are less likely to withdraw from their course, feel better able to
study and feel better equipped to seek future employment. Evaluation of
counselling services by students, through local and national studies,
such as the national student barometer survey, show very high levels of
satisfaction rates of above 90%.
Obviously not all students will find counselling services beneficial,
but those who do not form a relatively small proportion of service
users. Through a variety of interventions, such as individual and group
counselling, psycho-educational workshops, and interactive self-help
resources, university counselling services can help students in a
professional, empathetic and non-judgmental way gain insight and
awareness into their difficulties.
From this perspective students can then make realistic life changes
and build the internal skills which will enable them to develop the
emotional resilience required to face the normal difficulties and
challenges of life.
The vast majority of students have a largely positive experience at
university, although at times they will face very difficult and
Doing a degree should be a challenging process as young adults
develop knowledge, skills and resources. But it should be a largely
enjoyable and creative time. However, if students are having a
distressing time there is a great deal of support available, both
through professional clinical services and also the many student-led
It is always best if students who are having difficulties reach out
for the support available, sooner rather than later. Counselling and
support services cannot take away all life problems, or make people
happy all the time, but they can provide the appropriate support that
for many students will make all the difference.
* Alan Percy is head of counselling at the University of Oxford and
media spokesperson for the British Association of Counselling and
Psychotherapy: Universities and Colleges.
This article was amended on 17 October to correct a statistic that
said 80% of students showed significant improvement from attending
university counselling services across UK higher education. The correct
figure is 75%. The 80% figure is the average across the Russell Group