Pesquisa qualitativa

Dr. Richard Krueger on Qualitative Listening

Susan Eliot 

I thought if I really wanted to learn about listening during qualitative interviews I would go to an expert, someone who has been doing it and teaching it for several years.

So I contacted Dr. Richard Krueger, professor emeritus at the University of Minnesota. You may know Dr. Krueger from a focus group workshop or qualitative methods course you took from him or from one of his many books that you keep as a close reference (as I do).

It was an true honor and a real pleasure to interview Dr. Krueger. I’ve been a dedicated follower of his work since I took my first focus group workshop with him in 2001.

Read on . . . you’re in for a real treat!

Eliot: I think listening is so important to qualitative work; in fact, I believe it’s the very essence of collecting high value data.

Krueger: I think you’re right on target. This is one of the major challenges of people starting to do qualitative research. They underestimate the time, the discipline, the amount of effort and the skills needed to be a good listener. I know of nothing else in life, well, except spouses listening carefully to each other or children listening to their parents, which requires the same level of listening acuity. But many times in qualitative interviews, as in relationships we become casual listeners, tuning in, tuning out and not paying a lot of attention because we’re waiting to speak our views on the topic. And all we hear are the first few words.

Eliot: How would you define listening for someone new to qualitative research? 

Krueger: Everyone thinks they are a good listener. But there’s a considerable difference between informal listening and the listening needed when involved in disciplined inquiry. When listening in a research mode, you need to engage in a different way. It takes preparation, mindfulness, discipline, concentration, and strategies for capturing the data. In addition, you must create the appropriate environment that fosters an effective interview.

Eliot: One word that really pops out at me in your definition is the word discipline. Can you say more about how discipline relates to listening?

Krueger: I’ve watched a lot of novices do focus groups. Part of what they need to learn is the self-discipline it takes to hold back on their own point of view. So often when you’re hearing someone talk, what’s going through your mind is, “How do I feel about that?” One of the key pieces of discipline is to suspend for a while your point of view; also to have the discipline to control your body so that you don’t telegraph certain reactions to it. If the interviewer doesn’t like what they hear, and they react, it can influence the person they’re interviewing. And that can change the results. Discipline doesn’t come easily—it takes lots of practice. The people who have the most problem tend to be those in an administrative or supervisory role—those that are regularly trying to persuade or convince other people to take action. For example, if we ask a public health nurse to go out to do interviews in the community, it can be very hard for them to switch off being a nurse and allow themselves to be able to hear the person’s response and control their own response to that person.

Eliot: It seems like an essential component that should be taught as part of any qualitative course.

Krueger: Yes, but in the courses I’ve seen students take at universities this aspect of self-discipline, of controlling your own reactions and controlling what your body is doing—and being aware of it—is not even mentioned.

Eliot: So, as someone who has taught qualitative methods in academia for a number of years and trained hundreds of people in focus group workshops, how do you teach qualitative listening? 

Krueger: Teaching people to listen is a challenge because they first need to un-learn many habits and patterns that they’ve had for years. Listening to a conversation with friends is different from listening in a research interview.  When listening in a research mode the interviewer is guided by a specific purpose. There is a reason for the interview that is described in a plan that is typically reviewed and critiqued by others. Then the researcher uses systematic and verifiable processes in gathering and analyzing the data. When I teach people to listen in a research mode I emphasize three aspects of the interview process: preparation, interviewing and follow-up.

Eliot: Let’s start with the first of those three aspects. How can an interviewer prepare to listen? What does that entail?

Krueger: Preparation for listening consists of getting your body and mind in tune for the listening experience. It means that you think about setting aside your personal opinions and get yourself focused on understanding the person you’ll be interviewing. Preparation also means carefully thinking through the questions you plan to ask. You spend time developing these questions, sequencing them and considering potential follow-up questions. And you also need to create the proper environment for the interview that will be relaxing and comfortable for the participants.

Eliot: I know that the more prepared I feel the more confident I am going into the interview. What about during the interview itself? You mentioned the need to “un-learn” bad listening habits. Are you talking about things like interrupting, finishing people’s sentences . . . those kind of bad habits?

Krueger: Yes, it’s those things and others. I think there’s a couple of things that people regularly do and don’t even know they’re doing them. Like they may jump in on a topic or move to another topic prematurely. Maybe it’s a feeling they have that they need to be in control. Or it could be even how we look at people. One of the simple things when trying to gain rapport is to make eye contact in such a way that the individual gets the feeling that you think what they are saying is important. In casual conversations we rarely do those kinds of things.  And, at times, you also want to turn your body so your shoulders are square with the interviewee, facing them.

Eliot: You also said we need to set aside personal opinions, especially during the interview. It’s one thing to set aside personal opinions that you’re aware but what about the ones we’re not aware of? My implicit biases sometimes sneak up on me during an interview.

Krueger: Yes, they will catch you by surprise. When I talk about it in class I refer to implicit biases as hot buttons. People have hot buttons they’re not even aware of until someone pushes them—something is said and you feel yourself having an emotional reaction. The person who is inciting it didn’t intend to–it may be something they said quite innocently that caused the reaction. Part of it is just having the awareness. Interviewers should know that it happens to everyone. Things could be said in a group that bother you because they conflict with your values, or your judgment, or something that’s troubling to you. If you’re aware that that might happen that’s the key thing. And if it happens to you, you must have the discipline to control your behavior.

Eliot: In your book (Focus Groups: A Practical Guide for Applied Research), you talk about the need to listen and think simultaneously during the interview. I find doing this particularly difficult since I’m not good at multi-tasking. I’m either listening intently or thinking about a good probe or paraphrase to use next. What strategies would you suggest for developing this parallel talent?

Krueger: Yes, without a doubt this is difficult to do. Some things that might help are to:

• Get very comfortable with your questions ahead of time. Practice asking them and try to anticipate the range of responses that you might receive for each question.  It is difficult to concentrate when everything is new to the interviewer, but if you have already heard or anticipated the comments, then you are able to quickly see the pattern and capture it in your notes.
• Get comfortable with brief pauses. Don’t feel that you need to jump in immediately when someone stops talking. Sometimes the 5 – 10 second pause elicits new insights from another participant.
• Have a colleague with you when doing the focus group, an assistant moderator or recorder, to take notes and observe the conversation. This person doesn’t speak until the end of the group when the moderator invites comments or a summary. If the moderator has missed something important the assistant moderator can bring it up at the end of the focus group.
• Think about three simple things: Are they clear? Do they make sense? Do I need to ask for an example?
• Pay attention to time. In a focused interview your key questions tend to be in the middle or at the end of the interview. Be sure to allow sufficient time for these critical questions.

Eliot: I love your first point about practicing and anticipating responses in order to imagine what could possibly come up. What a fabulous idea but how seldom people actually take the time to do it.

Krueger: Yes. What people don’t often think about is what was not said and if there is a reason for it not being said. For example, if we’re talking about the inconveniences of airline travel and what the airline can do to help with that, one of the things we anticipate someone will say is that they expect a proper apology when things go wrong–not one made on a loud speaker that is garbled but one that is direct and personal. But if we go into a focus group and we don’t hear that, then at some point we may want to bring it up and say, “What about apologies from the airline?” We analyze what we receive but we can’t analyze what we could have received.

Eliot: When you suggested asking yourself, “Are they clear? Do they make sense? Do I need an example?” I thought, if only we could all keep those three little things in mind as a mini-checklist. 

Krueger: Yes, I think it would help. One of the things that’s interesting to do during election year is listen to people who are running for federal or higher level state offices as they are being interviewed. Regularly you find the answer does not fit the question. The answer sounds very good and they use a lot of interesting language but if you’re listening closely you’ll find that they didn’t really answer the question. They used something called a pivot in which they gave part of an answer and then moved to what they really wanted to talk about. There are some interviewers who are very good, like Charlie Rose, where, if the person doesn’t answer a question, they come back with the same question or a modified question.

Eliot: Also in your book, you write: “It is not enough to be an empty vessel, listening and absorbing the comments of participants.” I sometimes find myself lapsing into this passive listening state, especially with a fascinating respondent. What are your suggestions for maintaining a state of active listening?

Krueger: This regularly happens. It tends to occur when you are interviewing someone who is truly entertaining. They are clever with their words, they use humor or they tell fascinating stories. Sometimes you hear about a topic that is spellbinding and you just want to hear more. Some people have a gift for telling stories or describing events. And it can be easy to lapse into the passive listening mode and just enjoy the story. But in these moments you might think about these things:

• If I had to explain this concept to someone else, do I have enough information?
• Is this person telling me something new that I haven’t heard before?
• Is this person taking me off topic?  And if so, will it help my research effort?
• Does this seem logical and rational?
• Do I need to ask for specific examples?

Eliot: Along the same line, what about listening to the rambler. How do we respectfully listen, not knowing if there will be a morsel in there somewhere or how long it will take to get to it? 

Krueger: Ramblers can take you off topic and jump to areas that are of little or no interest to the research. Or sometimes the rambler will stay on topic but continually repeat what they’ve said earlier. The first time someone rambles off topic make a mental note and be ready to interrupt the next time they move off topic. In addition, be sure this person understands the question being asked. Sometimes people ramble because they don’t understand the question. Another way to handle the rambler is to look directly at him or her, and ask the question. You might also consider mentioning in your introductory ground rules that: “My job as moderator is to keep the group on topic and to finish on time. And as a result I may need to interrupt people in order to move to the next questions. So my apologies in advance if I interrupt you.” This becomes a bigger problem when you do telephone focus groups. On the telephone you cannot give people visual signals like not looking at them, laying down your pen, or looking at other people.

Eliot: I find it harder to listen in focus groups than during individual interviews. I notice that when I’m listening to one focus group participant the others kind of blur in the background causing me to get a little anxious about excluding the rest of the group. What suggestions do you have for listening in a group?

Krueger: This is an important reason why audio recordings are essential. When moderating you will need to develop a rapid means of note taking. The audio recording is valuable because it allows you to review all comments in detail at a later time. Also in the focus groups don’t expect everyone to speak for equal amount of time. Some participants often have more insight or experience and you should expect them to be more articulate. But don’t forget those who are silent. Pay attention to who is not talking and look at them. Call on them and invite them to share their thoughts. Some of the most productive comments come from those participants.

Eliot: Good listeners tell us that listening is much more than listening to words. There’s also facial expression, tone, word choice, body language and other stimuli to watch for. Can you speak a little about your experience with this? 

Krueger: Don’t go overboard with body language. Body language is complicated and difficult to interpret in focus groups. Often these are people who you’ve never seen before and you have no history or patterns of their normal behavior. That makes it difficult to interpret body language. Just look for the obvious. When you see something that might be interesting, try to get the person to describe their feelings. It is risky to assume that you know the meaning of the body language unless the person actually tells you what they are feeling.

Eliot: When I’m listening to the response of one participant and catch another participant frowning or shaking their head, reacting in some way, I’ll call on them and say, “It looks like you have something to say about that. What would you like to add?”

Krueger: Yes, that’s good. That’s very good. Or you could say, “Tell me more,” or better yet, “How do you feel about that?” What people say cognitively is not always the driver of behavior; emotions may be more of a driver. So as I’m listening to people I’m watching for when they become engaged, when they become emotional at some level.

Eliot: Finally, I’ve heard you talk several times about the moments immediately after the focus group and how important that window of time is to capture additional information. Is that because your recall is the best at that time in case you might not have been listening as closely as you should have been?

Krueger: The moments immediately after an interview are critical. This is a time to get your notes in order, to jot down additional observations, to discuss the interview with colleagues that were present, and to begin the analytic effort. This is a time when I want to hear from other members of the team about possible things that I missed that I did not pick up the first time—words or concepts or big ideas. I might ask the others, “What of all the things you heard today were the most important?” “Were there any surprises? Were there any quotes that were exceptionally stunning? What things should I have probed deeper on?

Eliot: That sounds like a very valuable process. It’s like you’re taking advantage of the collective listening of all the people who were in the room for the focus group.

Krueger: That’s right. I find it especially helpful if you have someone local from the community. They will pick up on things that others have not. Or people with different backgrounds will see things that others do not pick up on.

Eliot: Wrapping up, what final recommendations would you have for qualitative researchers who want to develop better listening skills?

Krueger: Some things that I think would helpful are the following:

• Get a mentor or a coach to watch you and offer suggestions. It is difficult to self-diagnose your own listening ability. If it is impractical for the coach to watch you, they might listen to the audio recording to help you identify strengths and weaknesses.
• Ask the person interviewed for their feedback (if it’s appropriate). You might say, “I’m going to be doing more interviews like this. What suggestions might you have to make the interview better? Or, “How could I have listened to you better?”
• Use a mirror to fine-tune your facial expressions, such as smiling, looking surprised, and looking like you want more information.
• Don’t forget the power of the pause. The best interviewers I’ve seen know just when to use the pause to elicit more insight. Rookies tend to speak too quickly and move on to the next question. The expert knows when to wait for more.
• Watch others who are really good at it. You can talk about the concept of waiting for an answer, but it’s not until you actually see someone do it, and you think, “Wow, that works really well.” Sometimes just watching a master do some of these things and then having someone sit next to you and say, “Watch this; do this; try this . . .” That’s how you get much better.

Eliot: Thank you Dr. Krueger for sharing such important and useful information. You’ve really helped me unpack the important aspects of good qualitative listening and I know that your practical, well-tested suggestions will inspire many to take qualitative interviewing to the next level.

Recursos para a Saúde

Recursos para a Saúde

A Abrasco - Associação Brasileira de Saúde Coletiva publicou em sua página em 21/08/2013 uma súmula da apresentação feita pelo Ministério de Planejamento, Orçamento e Gestão em reunião de negociação interministerial com representantes do Movimento Saúde +10 para buscar soluções para o financiamento da saúde. Reproduzo o material abaixo para estimular ainda mais o debate. Quanto mais a sociedade opinar, mais rica será a discussão e  mais avançaremos nesta importante questão. Roberto Z. Esteves Administrador - Educação Médica     Governo e Sociedade entendem que é preciso melhorar a qualidade da prestação de serviços com saúde, por melhoria de gestão e Aumento de recursos. Regra Atual: Recursos para saúde no ano anterior corrigido pela variação do PIB nominal do ano anterior.   Nos últimos anos, os recursos efetivos têm sido superiores ao mínimo legal   Pagamento de pessoal em 45 hospitais universitários federais não são computados como recurso para saúde: Em 2012 foram gastos R$ 3 bilhões Estimativa de R$ 6 bilhões/ano quando os 45 hospitais da rede já tiverem feito as ampliações 9 hospitais já tiveram autorização para ampliação – R$ 727 milhões/ano:  Piauí, Brasília, Maranhão, Triângulo Mineiro, Santa Maria, Espírito Santo,   Amazonas, Rio Grande do Norte e Minas Gerais Orçamento da União 2013 – R$ 2,2 trilhões 46% destinados às despesas financeiras – juros e amortização 54% destinados às despesas primárias   RIGIDEZ ORÇAMENTÁRIA Despesas primárias 2013 – R$ 1,2 trilhão Despesas obrigatórias – R$ 893 bilhões previdência, pessoal, abono, seguro-desemprego, LOAS, etc. Despesas Discricionárias – R$ 272 bilhões – 13% do orçamento Áreas protegidas – Educação, Saúde, Brasil Sem Miséria, PAC e Ciência, Tecnologia e Inovação – R$ 206 bilhões Demais obrigatórias – Benefícios dos servidores – R$ 8 bilhões Cortes Efetuados – R$ 22 bilhões Todas demais áreas – R$ 36 bilhões   Proposta de 10% de RCB para a saúde implicaria aumento de R$ 39 bilhões em 2013   Valor superior ao total das áreas não protegidas – R$ 36 bilhões   Logo, para ampliar os recursos para a Saúde é necessário discutir a fonte de financiamento   Por exemplo, CPMF financiava 0,7% do PIB para saúde – representaria R$ 34 bilhões em 2013   INADEQUAÇÃO DA RECEITA CORRENTE BRUTA (RCB) COMO PARÂMETRO DE REFERÊNCIA RCB inclui receitas que pertencem a outros entes     Não é bom parâmetro, pois RCB do ano corrente só é conhecida em janeiro do ano seguinte.   Dificuldade operacional em se apurar o valor mínimo. Outras vinculações usam resultados de anos anteriores:   reajuste do salário mínimo – variação do PIB real de 2 anos antes + INPC regra atual de recursos para saúde – variação PIB nominal do ano anterior   Dificuldade de planejar a despesa de saúde correspondente   O não cumprimento da regra é crime de responsabilidade   RESUMO Governo tem ampliado os recursos para saúde pública e entende a qualidade do serviço de saúde como prioridade. A qualidade do serviço de saúde passa pelo financiamento e pela melhoria da gestão   Dificuldades com a proposta de vinculação com a RCB:   Proposta, sem novas fontes para 2014, implicaria cortes de R$ 39 bilhões em outras áreas prioritárias. RCB não é receita exclusiva do Governo Federal, pois inclui as transferências aos demais entes. O parâmetro do mesmo exercício do gasto traz dificuldades para planejar e executar com qualidade os recursos da saúde   Ministério do Planejamento, Orçamento e Gestão | Agosto de 2013

Público e privado na Saúde

Reflexão

O SUS que temos e o SUS que queremos

Roberto Zonato Esteves

Em países que realmente encaram a saúde como um dever do Estado, as pessoas têm atendimento público de qualidade e a opção de pagarem por um atendimento privado, se quiserem. No Brasil, temos um sistema que estimula o atendimento privado como forma de diminuir a demanda por serviços públicos e deixa o atendimento público para os que não tem escolha.

Vendo a questão como um defensor dos princípios do SUS, fico muito preocupado com políticas de estado que enfraquecem os seus alicerces. Se o Estado deixasse de estimular, com o abatimento no Imposto de Renda da Pessoa Física, o cidadão a ter um plano de saúde e limitasse os gastos crescentes com o financiamento de planos de saúde dos funcionários públicos, teríamos uma classe média instruída e ciente de seus direitos a pressionar pelo adequado financiamento do SUS e a qualidade do atendimento. Aumentaria muito a chance de êxito de conseguirmos a aprovação dos 10% das RBU para a saúde.

Com a redução dos miseráveis observada nos últimos vinte anos, temos uma nova classe média emergente que passa a ser consumidora de produtos e serviços e que tem como “sonhos de consumo”  casa, carro e plano privado de saúde, nesta ordem. A inclusão social está gerando um nicho para os planos privados de saúde de clientes capazes de pagar pouco por um atendimento um pouco melhor ( será?) que o público.

 

É lógico que para atender esta nova demanda, precisaremos de médicos e outros profissionais de saúde, ambulatórios, hospitais, laboratórios etc que drenarão ainda mais recursos públicos. O Estado não injetará mais recursos no sistema público mas estimulará o escape para a saúde suplementar.

Vendo esta questão pelo ângulo de estudioso da Educação das Profissões de Saúde, preocupa-me ver que o Governo propõe ações como o Mais Médicos e a extensão dos cursos de Medicina para 8 anos quando, na verdade, investe maciçamente em estimular o modelo privado. Quando pretende melhorar a distribuição de médicos no Brasil e a sua presença no sistema público mas estimula de forma velada e indireta a criação de postos de trabalho na saúde suplementar, mostra que o pensamento neoliberal que norteia os nossos governos sobrepõe-se claramente aos ideais da reforma sanitária.

Como motivar nossos alunos a formarem e trabalhar para o SUS quando o próprio governo emite sinais tão claros de que considera o SUS um sistema pobre para pobres e que sua visão de sociedade igualitária é aquela onde todos  pagam por seu plano privado de saúde?

 

Educação à distância

Applying the Seven Principles for Good Practice to the Online Classroom

Oliver Dreon, PhD in Online Education

Almost 25 years have passed since Chickering and Gamson offered seven principles for good instructional practices in undergraduate education. While the state of undergraduate education has evolved to some degree over that time, I think the seven principles still have a place in today’s collegiate classroom. Originally written to communicate best practices for face-to-face instruction, the principles translate well to the online classroom and can help to provide guidance for those of us designing courses to be taught online.

1. Encourage contact between students and faculty. Students need to know how to contact their online instructors and should be encouraged to communicate with us when needed. In my online courses, I identify multiple means of contacting me (email, Skype, Twitter, etc) and clearly post times when I’ll be available to chat during online office hours. While few students utilize the online office hours I provide, offering this time communicates to students that I am available if they need assistance and that I value this interaction.

2. Develop reciprocity and cooperation among students. For those of us who believe that people learn through socially constructing their understanding based on their experiences, this principle is critical. Online courses should not be independent study classes. Online instructors need to build collaborative structures into their courses to promote student-to-student interaction. In my experience, I find that students who feel isolated in an online course have difficulty being successful. In my online courses, I incorporate collaborative and interactive ventures early on. I also try to foster discussions where students communicate with one another, share ideas, and debate concepts. While interacting with the instructor is important in an online class, it is also important that students have a space where they can discuss concepts with one another as well.

3. Encourage active learning. Learning is not a passive activity. For students to learn, they must actively engage with the content in thoughtful, purposeful ways. As you develop your online course, consider ways to build active learning into the course content. This can include utilizing tools with a course management system (discussions, for instance) or other tools (GoAnimate, Animoto). But active learning isn’t limited to technological avenues in online courses. Someone teaching science online could utilize hands-on lab activities developed with common everyday items. Someone teaching psychology or sociology online could have students conduct observational work at a park or at the mall.

4. Give prompt feedback. This can be tricky, especially with instructors teaching larger online classes. While grading hundreds of papers can be overwhelming, students need to receive prompt feedback to know whether they are being successful or what they need to do to improve. If you have a few larger assignments in your class that you know will take more time to provide quality, constructive feedback, communicate this to your students. You should also include some smaller assignments that will not take as long to assess. While some experienced online instructors use the course management system to build automated responses into their courses, I believe that some students still need personalized feedback on their work that comes directly from their instructor.

5. Emphasize time on task. Learning takes time. Students and faculty working in online spaces need to realize this. Just because an online course may be more flexible schedule-wise does not mean that it won’t require a significant time commitment. It’s important for instructors to communicate expected time commitments but also be realistic with their expectations. Assigning students to read a 500 page book in a day may not be completely realistic. Have high expectations but respect students’ need to have time to interact with the content and learn.

6. Communicate high expectations. While it’s important to have high expectations for students, it is also critical that these expectations are clearly communicated to students. Likewise, it is helpful to communicate clear expectations for participation and for interaction. Do you want your students to log on daily? Do they need to submit assignments in a certain format? Is it okay for them to use emoticons in their discussion posts? These are just a few of the areas that online instructors need to consider as they develop an online course for the first time.

7. Respect diverse talents and ways of learning. Students learn in a variety of ways. While there will undoubtedly be some text-based content in an online course, it cannot be the only mode of delivery or assessment. Draw on the host of multimedia options available online to deliver content to students and to assess them. Instead of typing out some long lesson on the Middle Ages, check out YouTube or Vimeo for some available videos. Or better yet, use a screencasting tool like Jing to record a customized lesson. Instead of assigning a ten-page paper, have students create a video where they demonstrate what they’ve learned.

Dr. Oliver Dreon is the director of the Center for Academic Excellence at Millersville University.

CEBES e o Mais Médicos

O SUS precisa de Mais Médicos e de Muito Mais!

Saúde em Debate • Rio de Janeiro, v.37, n. 97, p. 200-207, abr./jun. 2013

As manifestações de rua e as consequentes respostas governamentais têm gera­do um intenso debate na sociedade sobre as políticas públicas, entre elas, as de saúde. Para o Centro Brasileiro de Estudos de Saúde (CEBES), o momento é de celebração do aperfeiçoamento e de aprofundamento da democracia brasileira. Nossa contribuição nesse debate expõe nossas posições e propostas para o setor da saúde brasileiro, cotejadas ao Programa Mais Médicos, que o governo apresenta como estratégia para atendimento das demandas populares.

É imprescindível reconhecer que a assistência à saúde é dependente dos tra­balhadores da saúde e de sua capacidade de produzir o cuidado. Em uma época em que se supervalorizam as máquinas, os exames e a tecnologia, é necessário reafirmar que saúde se faz com gente. Todas as profissões da saúde são fundamentais para uma assistência integral, ou seja, é a equipe de saúde que será capaz de atender e resolver todos os problemas apresentados pela população.

A suficiência quantitativa das equipes de saúde, quando bem distribuídas, permitirá o atendimento universal da população residente em todo o território, efetivando o direito constitucional dos brasileiros.

Entretanto, é consenso entre os gestores de todas as esferas do SUS que, entre todas as categorias profissionais da saúde, os médicos são os profissionais mais difí­ceis de prover nos serviços públicos de saúde.

A população também reconhece esse problema quando aponta, como mos­trou recente pesquisa do IPEA, que o principal problema do SUS é a falta de médicos. Mesmo discordando dessa assertiva, que localiza a falta de médicos como o principal problema da saúde, o CEBES não pode deixar de reconhecer o que mostram diversos estudos: que faltam médicos no Brasil, e que essa falta ocorre, principalmente, no SUS. Não concordando com a argumentação das entidades médicas, que insistem na suficiência de médicos, o CEBES diagnostica a deficiên­cia e a má distribuição de médicos como um problema grave.

Por outro lado, ressaltamos que o principal problema do SUS não é a falta de médicos. Na verdade, esse é mais um dos sintomas do descaso crônico na implanta­ção do projeto SUS, relegado pelos sucessivos governos pós-constitucionais ao des­tino de ser um sistema de baixa qualidade para atendimento da população pobre.

É preciso reafirmar que o principal problema do SUS é a subordinação do setor da saúde à lógica de mercado, que se expande sufocando o direito social pre­visto na Constituição. Essa lógica de mercado trata a saúde – assim como a doença – como mercadoria, e o crescimento desse mercado, como vem ocorrendo no país, faz com que a saúde se distancie dos princípios que orientam o SUS enquanto expressão da saúde como um direito de cidadania.

É preciso analisar as razões pelas quais os médicos não se vinculam ao SUS e não ocupam o vasto território vazio desses profissionais. Nesse sentido, refutamos o argumento de que são apenas as más condições de estrutura e trabalho que ex­plicam a ausência de médicos no SUS. Isso só poderia ser verdade se existisse um contingente de médicos desempregados por recusa de condições insuficientes, o que não existe. Ao contrário, praticamente todos os médicos brasileiros possuem um ou mais empregos, como evidenciam os estudos. Outra pesquisa do IPEA, ain­da mais recente, mostra que, em média, os médicos brasileiros trabalham 42 horas por semana, e ganham, aproximadamente, R$ 8.500,00 por mês, o que os coloca no topo de rendimentos entre as profissões de nível superior.

O Brasil vive um ‘boom’ de crescimento do mercado da saúde, e hoje já conta com a presença do grande capital internacional e dos fundos de investimentos. Esse boom expressa a política concreta, que vem sendo praticada, de promover e conduzir o setor da saúde ao mercado, e se aproveita do resultado da política de inclusão social, pautada pela expansão do consumo, tônica da política econômica dos últimos anos.

Essa política de ampliação do consumo, associada à omissão, seja por falta de coragem ou de tendência na correlação de forças, que caracteriza os últimos governos federais, que não enfrentam os interesses dos complexos econômicos da saúde (indústria farmacêutica, de equipamentos, planos e seguros privados de saú­de, prestadores privados de serviços) e seguem promovendo o crônico subfinancia­mento do SUS, criando as condições ideais para a expansão do mercado da saúde. Essa é a principal razão que proporciona a concentração de médicos no setor priva­do e sua consequente escassez no setor público, modelo que saqueia o SUS e gera outras graves distorções na saúde brasileira.

As multidões de brasileiros que foram às ruas em todas as cidades, exigindo saúde e serviços públicos de qualidade, para nós, são a expressão de ser possível ini­ciar novos pactos sociais, dentro e fora do setor Saúde, criando efetivas condições para uma mudança nessa correlação de forças, que privilegie o interesse público ante os interesses econômicos.

Nesse contexto de situar o direito à saúde no centro do projeto político de desenvolvimento social e econômico do país, o CEBES chama a atenção para o fato de que as medidas que compõem o Programa Mais Médicos são necessárias e louváveis, porém, insuficientes para o setor, que necessita, urgentemente, de outras medidas estruturantes de curto, médio e longo prazos. Com essas referências para o entendimento da crise setorial, expressamos nossa preocupação e apresentamos propostas relativas ao Pacto pela Saúde, formulado pelo Governo Federal:

• Mediante a injusta falta de assistência médica que acomete a população e a dificuldade dos gestores em contratar profissionais médicos, é muito bem-vinda a atração de profissionais médicos estrangeiros ao país. Entre­tanto, tal medida deve ter caráter emergencial e focalizado para garantir o clamor do povo brasileiro, que expressou isso nas ruas, denunciando que parcelas significativas da população não tenham garantido seu direito constitucional à assistência médica. Simultaneamente, deverão ser adota­das medidas estruturantes para o problema;

• Mesmo sem tangenciar o grave problema do subfinanciamento setorial, o anúncio de investimentos na infraestrutura das unidades de saúde, espe­cialmente na Rede de Atenção Básica, constitui uma medida importante e necessária, que respeita os profissionais de saúde e, principalmente, os usuários do SUS. A medida adequada e de longo prazo é garantir finan­ciamento para investimentos permanentes no sistema;

• É preciso aprofundar as mudanças curriculares na formação médica, para além da ampliação do tempo do curso. Sob tal perspectiva, o Ministério da Saúde, como gestor nacional do Sistema Único de Saúde, deve fazer valer sua atribuição constitucional de “ordenar a formação de recursos humanos na área de saúde”, expressa no inciso III do artigo 200 da Carta Magna;

• É preciso que as universidades tenham como missão primeira formar os profissionais de saúde com o perfil necessário para as necessidades da população brasileira, ou seja, o trabalho no SUS. Para isso, é fundamental que o ensino seja totalmente integrado à Rede de Atenção à Saúde, e que sejam rompidos os entraves que apartam os Hospitais Universitários do SUS;

• É igualmente necessário que a expansão das vagas e dos cursos de gradu­ação em medicina seja feita essencialmente via universidades públicas, e nas localidades que mais necessitam de médicos. É preciso ampliar acesso e interiorizar as escolas de medicina, e isso deve ser feito pela expansão da rede de Universidades Federais.

• Tão importante quanto formar médicos com perfil ético e humano para trabalhar no SUS é formar os especialistas necessários para garantir a integralidade da assistência. Universalizar a Residência Médica e torná-la obrigatória, garantindo vagas a todos os egressos de acordo com as neces­sidades do Sistema Único de Saúde, é uma necessidade;

• Merece nosso apoio a contratação estratégica de médicos brasileiros, por parte do governo federal, para atuarem nos municípios e nas áreas de di­fícil provimento, onde a ausência desses profissionais é mais sentida pela população. Mas são necessárias mudanças na Lei de Responsabilidade Fiscal, que limita a capacidade dos municípios e estados de contratação de profissionais de saúde, que, preferencialmente, devem estar vinculados institucionalmente aos municípios;

• Imediatamente, deve ser criado e implantado o Plano Nacional de Car­gos, Carreiras e Salários para os trabalhadores do SUS, conforme foi apontado na última Conferência Nacional de Saúde. O CEBES defende a criação imediata da carreira nacional nos moldes definidos pela Mesa de Negociação Permanente do SUS.

É fundamental que o governo federal saiba aproveitar esse momento em que a sociedade brasileira reivindica serviços públicos de saúde com garantia de acesso e qualidade, e corrija o erro que foi a regulamentação da Emenda Constitucional 29, sem a vinculação do percentual de 10% da Receita Corrente Bruta da União para a Saúde.

Com a retirada dos incentivos e as renúncias fiscais aos planos e seguros pri­vados de saúde, e com o incremento de recursos advindos dos royalties do Pré-Sal e da Taxação de Grandes Fortunas, é perfeitamente possível garantir esse patamar mínimo de investimento na saúde dos brasileiros, sem que isso acarrete desequilí­brio fiscal.

Temos convicção de que, com o investimento adequado e com a coragem necessária para enfrentar os interesses econômicos que incidem sobre o setor saú­de, é possível e necessário consolidar o direito cidadão à saúde e o Sistema Único de Saúde, como demanda o povo brasileiro. O SUS precisa de Mais Médicos e de Muito Mais...

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Structures for Student Self-Assessment

Critical thinking is thinking that assesses itself. To the extent that our students need us to tell them how well they are doing, they are not thinking critically. Didactic instruction makes students overly dependent on the teacher. In such instruction, students rarely develop any perceptible intellectual independence and typically have no intellectual standards to assess their thinking with. Instruction that fosters a disciplined, thinking mind, on the other hand, is 180 degrees in the opposite direction. Each step in the process of thinking critically is tied to a self-reflexive step of self-assessment. As a critical thinker, I do not simply state the problem; I state it and assess it for its clarity. I do not simply gather information; I gather it and check it for its relevance and significance. I do not simply form an interpretation; I check my interpretation to see what it is based on and whether that basis is adequate. Because of the importance of self-assessment to critical thinking, it is important to bring it into the structural design of the course and not just leave it to episodic tactics. Virtually every day, for example, students should be giving (to other students) and receiving (from other students) feedback on the quality of their work. They should be regularly using intellectual standards in an explicit way. This should be designed into instruction as a regular feature of it. There are two kinds of criteria that students need to assess their learning of content. They need universal criteria that apply to all of their thinking, irrespective of the particular task. For example, they should always be striving for clarity, accuracy, and significance. Of course, they also need to adjust their thinking to the precise demands of the question or task before them. If there are three parts of the task, they need to attend to all three parts. If the question requires that they find specialized information, then they need to do just that. One simple structure to use in attending to this dual need is to provide students a set of performance criteria that apply to all of their work, criteria that they will be using over and over. Then, make specific provision for encouraging students to think in a focused way about the particular demands of any given task or question before them. There are a variety of additional structures that can be used: Assessing Writing 1. students in groups of four, choose the best paper, then join with a second group and choose the best of the two. This last paper is read to the class as a whole and a class-wide discussion is held about the strengths and weaknesses of the papers chosen, leading to the class voting on the best paper of the day. 2. students in groups of three or four write out their recommendations for improvement on three or four papers (from students not in the group). The written recommendations go back to the original writer who does a revised draft for next time.   3. students in groups of three or four take turns reading their papers and discuss the extent to which they have or have not fulfilled the performance criteria relevant to the paper.   4. one student's paper is read aloud slowly to the class while the instructor leads a class-wide discussion on how the paper might be improved. Then the students work in groups of two or three to try to come up with recommendations for improvement for the students in their group (based on the model established by the instructor). Assessing Listening Since students spend a good deal of their time listening, it is imperative that they learn critical listening. 1. We need to call on them regularly and unpredictably, holding them responsible either to ask questions of clarification or to be prepared to give a summary, elaboration, and examples of what others have said. 2. We ask every student to write down the most basic question they need to have answered in order to understand what is being discussed. You then collect the questions (to see where they are at) or you call on some of them to read their questions aloud or you put them in groups of two with each person trying to answer the question of the other.   Through activities such as these students should learn to monitor their listening, determining when they are and when they are not following what is being said. This should lead to their asking pointed questions. Assessing Speaking In a well-designed class, students engage in oral performances often. They articulate what they are learning: explaining, giving examples, posing problems, interpreting information, tracing assumptions, etc... They need to learn to assess what they are saying, becoming aware of when they are being vague, when they need an example, what their explanations are inadequate, etc. Here are three general strategies that have a number of tactical forms. 1. Students teaching students. One of the best ways to learn is to try to teach someone else. If one has trouble explaining something, it is often because one is not as clear as one needs to be about what one is explaining.   2. Group Problem Solving. By putting students in a group and giving them a problem or issue to work on together, their mutual articulation and exchanges will often help them to think better. They will often help correct each other, and so learn to ³correct² themselves.   3. Oral test on basic vocabulary. One complex tactic that aids student learning is the oral test. Students are given a vocabulary list. They are put into groups of twos or threes and are asked to take turns explaining what the words mean. They are encouraged to assess each other's explanations. When some seem prepared, they are assessed by the teacher. The students who pass then become "certifiers" or "tutors" and are assigned to assess other students (or tutor them). Everyone gets multiple experiences explaining, and hearing explanations of, the basic vocabulary. Assessing Reading In a well-designed class, students typically engage in a great deal of reading. Hence, it is important that they learn to "figure out" the logic of the what they are reading (the logically interconnected meanings). Good reading is a dialogue between the reader and the writer. The writer has chosen words in which to convey the meaning of his/her thoughts and experiences. The reader must translate from those words back into his/her own thoughts and experiences, and capture the meaning of the author thereby. This is a complex process requiring good reasoning. We can teach the students the process best by modeling it in the following way: Structure for teaching critical reading. You put the students into groups of threes, each with a letter assigned (A, B, or C). You then read a paragraph or two out of the text aloud slowly, commenting on what you are reading as you are reading, explaining what is making immediate sense to you and what you need to figure out by further reading. After modeling in this manner for a couple of paragraphs, you ask A to take over and read aloud to B and C, explaining to them, sentence by sentence, what he/she is able to figure out and what he/she is not. After A is finished with two paragraphs, then B and C comment on what they do and do not understand (in the paragraphs that A read). Then you read aloud to the whole class the two paragraphs that A read, commenting as you go. Then B takes over and reads the next two paragraphs to A and C. Then A and C add their thoughts. Then you read aloud what B read. Then you go on to C who reads the next two paragraphs to A and B. And so on. And so forth. As the students are reading in their groups of three, you are circulating around the room listening in and getting an idea of the level of proficiency of their critical reading. The more you use this process, the better students get. Doing A Global Self-Assessment One of the most powerful complex structures is that of requiring students to do a global analysis of the strengths and weaknesses of their performance in a class overall. In order for this tactic to work, the following have to be true: ·         students must be given, early on, performance profiles (correlated with grades) ·         students must be given multiple opportunities to assess their own work and that of their peers using the performance profiles ·         students must be given a thorough orientation on what is and is not expected in the global self-assessment ·         students should be required to support all claims that they make with relevant and representative evidence and reasoning ·         students should understand that if they argue for a higher grade than they deserve, their grade will be lowered. * This article is adapted from the resource: Critical Thinking Basic Theory andInstructional Structures.