Financiamento do SUS

Opiniões sobre os limites com educação e saúde

Entidades do setor de saúde prometem pressionar parlamentares para que não haja perda de recursos no setor. Os limites irão ao Congresso em 2 semanas

O ministro da Fazenda, Henrique Meirelles, disse nesta terça-feira (24) que a proposta de estabelecer um teto para os gastos públicos, limitado à inflação do ano anterior (ou seja, sem aumento real) limitará os gastos do governo federal com Saúde e Educação - Reprodução internet

 

 

O alerta dado pelo conferencista de abertura da 22ª Conferência Mundial de Promoção da Saúde está sendo repercutido na imprensa brasileira – “É na recessão que os governos mais deveriam investir em saúde”. A jornalista Claudia Colucci repercutiu o aviso do professor de economia política e sociologia da Universidade de Oxford, o americano David Stuckler, que fez o alerta, em Curitiba, sobre o desinvestimento em épocas de menor crescimento coincide com a volta de epidemias e aumento de casos de suicídio. “O perigo é como os políticos respondem a isso [recessão]. Quando fazem cortes profundos, podem transformar adversidades [econômicas] em epidemias”, completou. Ele explica que, desempregados, os trabalhadores e suas famílias são desvinculados de planos de saúde privados e há aumento da demanda na rede pública, que precisa estar preparada. Só lembrando que isso já está acontecendo por aqui. No último ano, houve uma debandada de 1,4 milhão de usuários de planos de saúde, a maioria motivada pelo desemprego.

Nesta mesma noite, os participantes da Conferência também ouviram do pesquisador Paulo Goes, que representou o presidente da Abrasco Gastão Wagner, outro alerta – “Nos últimos anos, quase metade do arrecadado em impostos vem sendo gasto com o serviço da dívida interna (processo intensificado pelo aumento constante de juros pelo Banco Central sob o pretexto de controle da inflação) e com a isenção fiscal e transferência direta de recursos públicos para uma não admitida “bolsa empresa”, dois mecanismos de transferência do orçamento público para grupos econômicos minoritários e que já controlam grande parte da riqueza nacional”.

E em sua coluna semanal, Colucci, jornalista da Folha de São Paulo, publicou nesta terça-feira, 24 de maio o seguinte artigo:

Vamos imaginar que o Congresso, acatando a proposta do presidente interino Michel Temer (PMDB), acabe mesmo com as vinculações constitucionais, como gastos obrigatórios com saúde e educação. Qual o risco que corremos com essa desvinculação em saúde?

Atualmente, a União é obrigada a aplicar na saúde ao menos o mesmo valor do ano anterior mais o percentual de variação do PIB (Produto Interno Bruto). Estados e municípios precisam investir 12% e 15%, respectivamente. Na educação, o governo federal deve gastar 18% do arrecadado e as outras esferas, 25%.

Na área da saúde, o assunto divide opiniões. Há quem defenda que mudança decretaria a morte do SUS e há os que pensam que a atual regra já não garante uma boa aplicação do dinheiro, além de colaborar com a piora nas contas públicas. É verdade que os países mais desenvolvidos não costumam vincular o orçamento a gastos fixos, mas há outros tipos de garantias e fiscalização de modo que áreas prioritárias como saúde e educação sejam privilegiadas, mesmo em regiões mais pobres, com menos recursos para investir nessas áreas.

Mas, segundo especialistas, por aqui, a desvinculação pode, de fato, levar a mais cortes no já combalido SUS e uma descontinuidade nas políticas públicas, principalmente nos municípios. Todos estão cansados de saber que, cada vez que há troca de prefeitos, tal como no Jogo da Amarelinha, as coisas voltam dez casas. Imagine acabando com a obrigatoriedade do gasto… (…) Estejamos todos preparados: dias piores virão.

Na edição da Folha de hoje, o jornalista Felipe Maia publicou trechos de uma entrevista concedida por Gastão, na tarde de ontem:

O governo Temer anunciou nesta terça-feira, 24 de maio, que vai propor mudança nas regras que estabelecem quando dinheiro vai para as duas áreas (…) Se for aprovada pelo Congresso, a medida vale a partir de 2017 e o reajuste será, assim, a inflação de 2016. Caso a nova regra implique verba menor que a garantida pela fórmula antiga, ainda será possível aumenta-­la, mas, para isso, será preciso cortar outras despesas.

“Vamos fazer política, pressionar senadores, deputados e o governo para que as regras se mantenham”, diz o médico Gastão Wagner Campos, presidente da Abrasco (Associação Brasileira de Saúde Coletiva). Ele classifica os cortes como “inócuos do ponto de vista econômico e iníquos para o social”. “O que pretende o ministro da Fazenda é impedir que se mantenha o padrão de gasto de 2014 e, pior, reduzi­-lo a um valor que inviabilizará completamente o atendimento à saúde da população”, disse em nota o Conselho Nacional de Saúde.

Campos diz que não há espaço para cortes de orçamento do setor, mas cita exemplos de áreas em que o uso dos recursos pode ser mais eficiente. Caso dos ocupantes de cargos comissionados na direção de unidades básicas de saúde e outros cargos de gestão do SUS que costumam seguir indicações políticas, o que não permite continuidade ou ações de longo prazo. Ele diz também que é necessário que União, Estados e municípios integrem melhor os bancos de dados e suas ações.

Syllabus

The Syllabus: Indicator of Instructional Intentions

By Maryellen Weimer, PhD

The literature on teaching and learning has improved so much over the years. Researchers are now covering important aspects of both in depth, analyzing with creative designs and exploring for practical and theoretical implications. One case in point is a 2015 syllabus review published in Assessment & Evaluation in Higher Education (a cross-disciplinary teaching and learning journal that ought to be on everybody’s radar).

The article describes four syllabus reviews conducted across five years at the University of West Florida. By syllabus review, we are talking about three reviews of all general education courses and one review of all undergraduate courses offered in a given term. Moreover, these reviews were not casual leaf throughs leading to general impressions. No, the research team developed several rubrics including one that identified institutional expectations about content and another that listed best practices, as in evidence-based strategies. They also put together inventories, one listing 21st-century professional skills. Trained syllabus reviewers used these tools (most of which appear in the article) to systematically analyze course syllabi.

The justification for this kind of review is interesting. Even though there is some agreement among faculty on syllabus content and institutional mandates at most colleges and universities, the course instructor still has significant discretion over what ends up in the syllabus. “Instructors describe their best intentions for the course in a syllabus; the topics they intend to cover, the assignments they expect students to complete, and the strategies they plan to use to evaluate student learning and assign grades or marks” (p. 899). Almost always instructors create syllabi without direct oversight or subsequent evaluation. Borrowing from another source, these authors observe, “Outside of direct observation of classroom interactions, course syllabi are ‘unobtrusive but powerful indicators of what takes place in classrooms’” (p. 899).

I will highlight some of what this very thorough review revealed in an upcoming issue of the Teaching Professor newsletter. At this point I’m intrigued by a number of issues an analysis like this raises. For example, how standardized should our syllabi be? Rubrics that dictate content could make syllabi look very similar, and in some cases that already happens, such as when there are multiple sections of a course needing curricular consistency. Maybe more standardization would be helpful to students. It must be rather confusing when you’re new to college, taking five courses, and the assignments, rules, requirements, content, and format of the syllabi are all different. It’s a lot to keep straight. On the other hand, the syllabus can (and usually does) do more than map the geography of the course. It hints at what the instructor believes about students and the kinds of conditions that foster learning, and even bits about the character of the teacher come through. In online environments, written messages like those in the syllabus are what convey the human elements of the course.

Individual faculty aren’t positioned to do a review like this, but the tools provided in the article could expedite critical reviews of our syllabi. One interesting finding in this analysis involved the disconnect between the stated learning goals for the course and sets of assignments unlikely to include experiences that would achieve those goals.

More insights about syllabi are likely to result when colleagues share and discuss them. This can happen informally among a few peers in the same department or across them. We could discuss the question of standardization at the departmental level, provided a few brave faculty would share their syllabi for review. The cumulative effects of a set of syllabi (those from courses taken in a semester or from a collection of courses in a major) are not something we talk about, at all or very much.

Isn’t it time for us individually, in our departments, within our disciplines, and at our institutions to stop keeping syllabi quite so close to the vest? Yes, I know many disciplinary associations post syllabi collections, but they don’t reveal what this review does. Much can be learned about the culture of teaching in our courses, within our departments and at our institutions, from a thorough descriptive analysis of these important artifacts of teaching.

Reference: Stanny, C., Gonzalez, M., and McGowan, B., (2015). Assessing the culture of teaching and learning through a syllabus review. Assessment & Evaluation in Higher Education, 40 (7), 898-913.

Entrustable professional activities

The ABCs of EPAs – an overview of ‘Entrustable Professional Activities’ in medical education

Carlos El-Haddad, Arvin Damodaran, H. Patrick McNeil and
Wendy Hu

DOI: 10.1111/imj.12914

Abstract

Consultants regularly need to decide whether a trainee can be entrusted to perform a clinical activity independently. ‘Entrustable Professional Activities’ (EPAs) provide a framework for justifying and better utilising supervisor entrustment decisions for trainee feedback and assessment in the workplace. Since being proposed by Olle ten Cate in 2005, EPAs are emerging as an integral part of many international medical curricula, and are being considered by the Royal Australasian College of Physicians in the current review of physician training. EPAs are defined as tasks or responsibilities that can be entrusted to a trainee once sufficient competence is reached to allow for unsupervised practice. An example might be to entrust a trainee to ‘Initiate and co-ordinate care of the palliative patient’ with only off-site or indirect supervision. Rather than attempting to directly measure each of the many separate competencies required to undertake such a complex task, EPAs direct the trainee and supervisor's attention to the trainee's performance in a limited number of selected, representative, important day-to-day activities. EPA based assessment is gaining momentum, amongst significant concerns regarding feasibility of implementation. While the optimal process for designing and implementing EPAs remains to be determined, it is an assessment strategy where the over-arching goal of optimal patient care remains in clear sight. This review explores the central role of trust in medical training, the case for EPAs, and potential barriers to implementing EPAs based assessment.

Humans vs. Machines

IBM's Watson is better at diagnosing cancer than human doctors

 

 

by Ian Steadman

IBM's Watson -- the language-fluent computer that beat the best human champions at a game of the US TV show Jeopardy! -- is being turned into a tool for medical diagnosis. Its ability to absorb and analyse vast quantities of data is, IBM claims, better than that of human doctors, and its deployment through the cloud could also reduce healthcare costs.

The first stages of a planned wider deployment, IBM's business agreement with the Memorial Sloan-Kettering Cancer Center in New York and American private healthcare company Wellpoint will see Watson available for rent to any hospital or clinic that wants to get its opinion on matters relating to oncology. Not only that, but it'll suggest the most affordable way of paying for it in America's excessively-complex healthcare market. The hope is it will improve diagnoses while reducing their costs at the same time.

Two years ago, IBM announced that Watson had "learned" the same amount of knowledge as the average second-year medical student. For the last year, IBM, Sloan-Kettering and Wellpoint have been working to teach Watson how to understand and accumulate complicated peer-reviewed medical knowledge relating to oncology. That's just lung, prostate and breast cancers to begin with, but with others to come in the next few years). Watson's ingestion of more than 600,000 pieces of medical evidence, more than two million pages from medical journals and the further ability to search through up to 1.5 million patient records for further information gives it a breadth of knowledge no human doctor can match.

According to Sloan-Kettering, only around 20 percent of the knowledge that human doctors use when diagnosing patients and deciding on treatments relies on trial-based evidence. It would take at least 160 hours of reading a week just to keep up with new medical knowledge as it's published, let alone consider its relevance or apply it practically. Watson's ability to absorb this information faster than any human should, in theory, fix a flaw in the current healthcare model. Wellpoint's Samuel Nessbaum has claimed that, in tests, Watson's successful diagnosis rate for lung cancer is 90 percent, compared to 50 percent for human doctors.

Sloan-Kettering's Dr Larry Norton said: "What Watson is going to enable us to do is take that wisdom and put it in a way that people who don't have that much experience in any individual disease can have a wise counsellor at their side at all times and use the intelligence and wisdom of the most experienced people to help guide decisions."

The attraction for Wellpoint in all this is that Watson should also reduce budgetary waste -- it claims that 30 percent of the $2.3 trillion (£1.46 trillion) spent on healthcare in the United States each year is wasted. Watson here becomes a tool for what's known as "utilisation management" -- management-speak for "working out how to do something the cheapest way possible".

Wellpoint's statement said: "Natural language processing leverages unstructured data, such as text-based treatment requests. Eighty percent of the world's total data is unstructured, and using traditional computing to handle it would consume a great deal of time and resources in the utilisation management process. The project also takes an early step into cognitive systems by enabling Watson to co-evolve with treatment guidelines, policies and medical best practices. The system has the ability to improve iteratively as payers and providers use it." In other words, Watson will get better the more it's used, both in working out how to cure people and how to cure them more cheaply.

When Watson was first devised, it (or is it "he"?) ran across several large machines at IBM's headquarters, but recently its physical size has been reduced hugely while its processing speed has been increase 240 percent. The idea now is that hospital, clinics and individual doctors can rent time with Watson over the cloud -- sending it information on a patient will, after seconds (or at most minutes), return a series of suggested treatment options. Crucially, a doctor can submit a query in standard English -- Watson can parse natural language, and doesn't rely on standardised inputs, giving it a more practical flexibility.

Watson's previous claim to fame came from it winning a special game of US gameshow Jeopardy! in 2011. For those unfamiliar, Jeopardy!'s format works like this: the answers are revealed on the gameboard and the contestants must phrase their responses as questions. Thus, for the clue "the ancient Lion of Nimrod went missing from this city's national museum in 2003" the correct reply is "what is Baghdad?". Clues are often based on puns or other word tricks, and while it's not quite on the level of a cryptic crossword, it's certainly the kind of linguistic challenge that would fox most language-literate computers.

Watson's ability to parse texts and grasp the underlying rules has had its drawbacks, though, as revealed last month when IBM research scientist Eric Brown admitted that he had tried giving Watson the Urban Dictionary as a dataset. While Watson was able to understand some of the, er, colourful slang that fills the site's pages, it also failed to understand the different between polite and offensive speech. Watson's memory of the Urban Dictionary had to (regrettably) be wiped.

Medalha Ouro Verde

Clementino Fraga Filho

Homenagem ao Prof. Clementino Fraga Filho

Um dos maiores nomes da história do Hospital do Fundão, Clementino Fraga Filho faleceu no dia 11 de maio, aos 98 anos. O Hospital Universitário Clementino Fraga Filho presta toda solidariedade aos familiares e amigos desse médico e professor.

Abaixo, confira a carta escrita por familiares do primeiro diretor-geral do Hospital.
Carta da família

“A vida de uma instituição depende de muitas vidas que a ela se dedicam”. Assim, escreveu professor Clementino Fraga Filho na abertura do livro em que narra a implantação do Hospital Universitário, um fato histórico para a Universidade e sua Faculdade de Medicina.
Os que acompanharam sua trajetória acadêmica puderam testemunhar que tal afirmativa está em harmonia com o exemplo que ele próprio legou aos colaboradores e alunos. Sua vida pessoal se entrelaçou à vida da nossa Universidade. Nela se formou, em 1939, e a ela serviu como médico, professor e administrador no curso de quase 50 anos. O sentido de compromisso com a instituição foi constante no curso do tempo.
Eleito vice-reitor, em 1966, assumiu pouco depois a reitoria, em razão do afastamento de Raymundo Moniz de Aragão, nomeado Ministro da Educação e Cultura. Voltou a ocupar o cargo, em 1969, em virtude da renúncia de Aragão. Sua passagem pela reitoria coincidiu com o período de estudos para a Reforma Universitária, na qual teve destacada participação, e com a vigência do regime militar. Em período conturbado, soube manter com equilíbrio a intransigência na defesa da instituição e a tolerância com as manifestações estudantis.
A vitoriosa experiência no Serviço de Clinica Médica, associada à devoção à entidade e às características de líder, estará na origem da indicação unânime da Congregação da Faculdade de Medicina para dirigir a instituição e, paralelamente, conduzir os trabalhos da comissão especial para a implantação do Hospital Universitário, designada pelo reitor. Foi seu primeiro diretor e manteve-se no cargo até 1985, como a consolidar a tarefa.
Nunca se afastou da prática médica, convencido de que o exercício paralelo da atividade docente e da clínica aprimorava a qualidade de ambas. Exerceu a clínica enquanto a saúde permitiu e, após seu afastamento, não foram raros os instantes em que confessou a falta do contato e a saudade dos pacientes, que deram sentido a sua vida, que o fizeram se sentir útil.
Paralelamente aos encargos na Universidade e à prática médica, integrou, sucessivamente, a Comissão de Ensino Médico do Ministério da Educação (MEC), o Conselho Nacional de Saúde e o Conselho Consultivo de Administração da Saúde Previdenciária (CONASP), assim como exerceu a Presidência da Associação Brasileira de Educação Médica. Tais posições lhe permitiram ampliar a ação em benefício da qualidade da formação dos médicos e da prestação de serviços em saúde.

Na doença, manteve comportamento exemplar. Cordato, sorriso amável, trato cortês, sem amargura visível, sem queixumes. Manifestou, por vezes o cansaço dos dias tornados longos pela inatividade. Na madrugada de ontem, faleceu, serenamente, em sua casa, aos 98 anos de idade.
Dos três filhos, um seguiu-lhe o exemplo. Eduardo Gordilho Fraga é Coordenador das Atividades Educacionais do Hospital que tem hoje o nome de seu Mestre, por decisão unânime do Conselho Universitário, a título de reconhecimento e permanente homenagem.

Eduardo Fraga

* Clementino Fraga Filho foi responsável pela inauguração do Hospital Universitário da UFRJ que hoje leva o seu nome. Foi também titular da Academia Nacional de Medicina e presidente da ABEM - Associação Brasileira de Educação Médica (1980-1982).

Learning objectives

A 3 Dimensional Model Of Bloom’s Taxonomy

 

 

 

Well, technically it’s a 2-dimensional representation of a 3-dimensional model, but being limited as we are in 2016 to 2D screens, it is what it is. (Soon you’ll be able to 3D print what you see–download the plans and print it. Or play with it in virtual reality. Eventually a hologram you can manipulate digitally–pass around the room like a tennis ball, then fling it into the ether….).

Rex Heer at Iowa State University, who created the graphic, explains:

Among other modifications, Anderson and Krathwohl’s (2001) revision of the original Bloom’s taxonomy (Bloom & Krathwohl, 1956) redefines the cognitive domain as the intersection of the Cognitive Process Dimension and the Knowledge Dimension.

This document offers a three-dimensional representation of the revised taxonomy of the cognitive domain. Although the Cognitive Process and Knowledge dimensions are represented as hierarchical steps, the distinctions between categories are not always clear-cut.

For example, all procedural knowledge is not necessarily more abstract than all conceptual knowledge; and an objective that involves analyzing or evaluating may require thinking skills that are no less complex than one that involves creating. It is generally understood, nonetheless, that lower order thinking skills are subsumed by, and provide the foundation for higher order thinking skills.

A statement of a learning objective contains a verb (an action) and an object (usually a noun).

The verb generally refers to [actions associated with] the intended cognitive process.

The object generally describes the knowledge students are expected to acquire or construct. (Anderson and Krathwohl, 2001, pp. 4–5)

In this model, each of the colored blocks shows an example of a learning objective that generally corresponds with each of the various combinations of the cognitive process and knowledge dimensions. Remember: these are learning objectives—not learning activities.

It may be useful to think of preceding each objective with something like: “Students will be able to . . .”

It’s a fairly straight-forward interpretation of the original (revised) model, but adds Cognitive Process and Knowledge Dimensions as groundwork to create verbs and example tasks for each level within said domain. If you’re ready to move past the pretty Bloom’s Taxonomy posters and big words and begin to look at strategies for teaching with the Bloom’s model, a relatively advanced model like this may be right for you.

You can find the full pdf on Iowa State University’s site.

Demografia médica

Demografia médica - perfil do médico brasileiro

IFME

2016 International Fellowship in 

Medical Education Recipients

FAIMER is pleased to announce the 2016 recipients of the International Fellowship in Medical Education (IFME):

• Anuj Chawla, M.B.B.S., M.D., Armed Forces Medical College, Pune, India
• Francisco Lamus, M.D., M.P.H., M.S., Universidad de la Sabana, Chía, Colombia
• Champion Nyoni, B.Sc., M.Sc., R.N., Paray School of Nursing, Lesotho, South Africa

All three Fellows will pursue a Master’s Degree in Health Professions Education: Accreditation and Assessment through the FAIMER-Keele Distance Learning program beginning in September 2016.

Flipped classroom