Oferta de Novos Cursos Médicos no Brasil

A Associação Brasileira de Educação Médica apresenta a todos os seus associados, e demais interessados em uma educação médica de qualidade, o documento “Mensagem à Comunidade Acadêmica”. Entre os 27 signatários deste documento encontram-se o atual diretor-presidente e três ex-presidentes da ABEM. É importante ressaltar que alguns associados que participaram do processo de avaliação in loco de municípios optaram por não assinar o documento. E é em nome dos princípios e valores da ABEM, especialmente, democracia, transparência e ética, que estamos divulgando esta mensagem para que nossos associados possam analisar e refletir sobre seu conteúdo e cotejá-lo com sua percepção da realidade. Entre as principais “bandeiras de luta” da ABEM, a “avaliação” sempre recebeu um destaque especial e, exatamente por isto, esta entidade jamais recusou desafios relacionados a quaisquer processos de avaliação. Assim, quando convidados a participar deste processo de avaliação dos municípios relacionados no Edital MEC nº 3, três dos quatro diretores da ABEM prontificaram-se a participar do processo de avaliação liderado pelo Professor Geraldo Brasileiro a convite do então titular da SERES/MEC. A ética da Avaliação pressupõe que os avaliadores sejam respeitados por seus pareceres. A democracia garante o contraditório e o questionamento eventual de um parecer. O princípio da transparência exige que as decisões sejam claramente fundamentadas.

CONSELHO DIRETOR DA ABEM 

 

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MENSAGEM À COMUNIDADE ACADÊMICA

Com a promulgação da Lei no 12.871/2013, que instituiu o Programa Mais Médicos, a autorização de cursos de Medicina em instituição de educação superior privada passou a ser precedida de chamamento público. Em 22/10/2013, foi publicado o Edital MEC no 3, que tornou público o chamamento para que municípios de todo o país que atendessem a certos requisitos pudessem pleitear o oferecimento de curso médico. Entre outras exigências desse Edital, estava a disponibilidade de serviços de saúde em condições de servir como ambiente de prática para os estudantes do curso proposto. Ao todo, 49 municípios atenderam às exigências previstas, foram pré-selecionados e passaram para a etapa seguinte, que foi a de avaliação, in loco, dos serviços de saúde.

Em dezembro de 2013, o então Secretário da Secretaria de Regulação e Supervisão da Educação Superior do MEC (SERES) convidou o Prof. Geraldo Brasileiro Filho a assessorar o Ministério da Educação na tarefa de avaliar os serviços de saúde dos municípios pré-selecionados, a fim de saber quais estavam em condições de sediar curso médico. Logo em seguida, outros professores da área médica se juntaram para formar um Grupo de Trabalho responsável pela condução das atividades. Desde o início do processo, ficou bem explícita a posição dos membros desse grupo de que só se justifica a autorização de um curso médico onde, além da necessidade social, as condições de infraestrutura física (aí incluídos sobretudo os serviços de saúde), o corpo docente e a proposta pedagógica são adequados e suficientes para permitir a boa formação médica. Na opinião dessas mesmas pessoas, sem qualidade acadêmica não se justifica a criação de mais cursos de Medicina.

A avaliação in loco dos serviços de saúde dos municípios pré-selecionados envolveu 63 consultores, todos com experiência em ensino médico, serviços de saúde e/ou hospitais de ensino. A avaliação foi feita com base em instrumento de avaliação elaborado conjuntamente por representantes do MEC, do Ministério da Saúde e da EBSERH, além de membros da Comissão de Especialistas em Ensino Médico e da Associação Brasileira de Educação Médica (ABEM). Os consultores foram designados pelas Portarias Normativas MEC nos 147, 223 e 372/2014. Antes das visitas, os avaliadores estiveram reunidos em Brasília, em duas oportunidades, em oficinas de capacitação sobre o instrumento de avaliação e sobre todos os procedimentos a serem realizados. Em cada cidade, equipes de 2 ou 3 consultores passaram pelo menos dois dias completos, quando visitaram hospitais, unidades básicas de saúde, unidades de pronto-atendimento, pronto-socorros, policlínicas (ambulatórios de especialidades médicas), centros de atenção psico-social (CAPS) e outros equipamentos de saúde existentes. Cada equipe de consultores elaborou relatório circunstanciado e abrangente, descritivo e opinativo, sobre toda a rede de atenção à saúde disponível.

Os relatórios de visita produzidos pelas equipes de avaliadores passaram por análise de uma Comissão Assessora integrada pelos professores Jadete Barbosa Lampert, José Guido Corrêa de Araújo e Geraldo Brasileiro Filho. Esta Comissão analisou a completude dos relatórios (informações sobre todos os itens avaliados), a consistência das informações e a coerência entre o que foi encontrado e relatado pelos avaliadores e a conclusão final destes, tendo emitido parecer e feito recomendações técnicas e acadêmicas sobre cada município. Durante esse trabalho, houve necessidade de nova visita a alguns municípios, sobretudo para avaliar hospitais em cidades vizinhas que não tinham sido avaliados na visita inicial. Também em muitos casos os consultores-avaliadores complementaram informações relevantes, de modo que, em todos os municípios, a Comissão dispusesse de todos os dados necessários para emitir o seu parecer e a sua recomendação.

Todos os municípios foram avaliados segundo o que o Edital MEC no 3/2013 exigia. De um lado, foi verificado se havia o número mínimo de alguns itens, como pelo menos 250 leitos SUS nos hospitais indicados, 17 equipes de atenção básica, um hospital com no mínimo 100 leitos SUS exclusivos para o curso e com potencial para ser certificado como hospital de ensino, unidade de pronto-atendimento e/ou pronto-socorro, CAPS e outros serviços, tudo isso inserido em uma rede de atenção à saúde estruturada de modo a atender as demandas da população nos diferentes níveis de complexidade. De outro, foi avaliado o funcionamento desses serviços, ou seja, os espaços físicos, as instalações (incluindo equipamentos e utensílios disponíveis para o trabalho em saúde), os processos de trabalho e a efetividade da atenção, a fim de se garantir que os estudantes possam ter a oportunidade de atuar nos diferentes ambientes da ação médica e receber boa formação, como é recomendado nas Diretrizes Curriculares Nacionais (DCN) dos cursos de Medicina aprovadas em 2014.

É importante registrar que as etapas de planejamento e execução de todo esse trabalho avaliativo foram acompanhadas de perto pela SERES: desde o planejamento das atividades, passando pela definição das exigências e até a análise final dos relatórios de visita, tudo era de pleno conhecimento do MEC, que não colocou nenhuma objeção nos princípios e no desenvolvimento das atividades realizadas pela Comissão de avaliadores.

De acordo com a Portaria SERES no 543/13, dos 46 municípios avaliados (três foram excluídos por causa de autorização superveniente de curso), 39 passaram à etapa seguinte, de pactuação para oferecimento do curso; sete outros ficaram em processo de saneamento de deficiências. Na opinião da Comissão Assessora e com base estritamente nas informações contidas nos relatórios de visita, nove municípios atenderam plenamente às exigências e poderiam seguir no processo de criação do curso; 17 não atendiam aos requisitos do Edital, por motivos variados; finalmente, 20 atendiam parcialmente os requisitos. Para estes, foi recomendado que somente após se constatar o atendimento integral das limitações apontadas poderia haver continuidade do processo. Frente a essa realidade, causou enorme desconforto em muitos avaliadores o resultado final dessa etapa do trabalho. O que se viu foi uma enorme e preocupante divergência entre a opinião de muitos avaliadores e a decisão final do MEC. Repita-se que, ao longo de todo o processo, todas as atividades dos avaliadores e da Comissão Assessora eram acompanhadas de perto pela SERES, não havendo, em momento algum, sinalização de que estava havendo excesso de exigências ou extrapolação dos limites do Edital no 3/2013. Mesmo assim, a decisão final do MEC não acompanhou boa parte das opiniões de muitos dos avaliadores. Por isso mesmo, os signatários deste documento, que discordam da conduta do MEC, manifestam o seu descontentamento com a decisão tomada pela SERES de autorizar o prosseguimento do processo em municípios com deficiências na estrutura física, nas instalações e/ou no funcionamento dos serviços na atenção primária, secundária e terciária à saúde, evidenciadas nas visitas in loco. Ao mesmo tempo, deixam claro para a comunidade envolvida na Educação Médica que não endossam a criação de curso de Medicina onde os serviços de saúde não estão adequados para servir como campo de prática para a boa formação médica. Nesse sentido, reafirmam a sua preocupação com a decisão tomada, pois, sem condições mínimas, não é possível garantir a formação de profissionais qualificados de que o País tanto necessita.

Novembro de 2014

Assinam este documento os seguintes consultores-avaliadores:

Alberto Schanaider

Angela Regina Maciel Weinmann

Arnaldo Feitosa Braga de Andrade

Carlos Haroldo Piancastelli

Cezar Augusto dos Santos

Eduardo Crema

Evelin Massai Ogatti Muraguchi

Filomena Euridice Carvalho de Alencar

Francisco Barbosa Neto

Geraldo Brasileiro Filho

Gesmar Volga Haddad Herdy

Jadete Barbosa Lampert

José Guido Corrêa de Araújo

José Marcus Raso Eulálio

Leandro Odone Bertelli

Luiz Antonio Vane

Marcelo Demarzo

Márcia da Silveira Charneca Vaz

Maria Neile Torres de Araújo

Olga Akiko Takano

Regina Celes de Rosa Stella

Rosana Alves

Rosana Fiorini Puccini

Rosana Quintella Brandão Vilela

Sigisfredo Luis Brenelli

Tereza Helena Tavares

Walter Vitti Júnior

Medical Education in India

Mapping the rapid expansion of India’s medical education sector: planning for the future

Yogesh Sabde, Vishal Diwan^*, Ayesha De Costa and Vijay K Mahadik

BMC Medical Education 2014, 14:266   
doi:10.1186/s12909-014-0266-1

Background

India has witnessed rapid growth in its number of medical schools over the last few decades, particularly in recent years. One dominant feature of this growth has been expansion in the private medical education sector. At this point it is relevant to trace historically and geographically the changing role of public and private sectors in Indian medical education system.

Methods

The information on medical schools and sociodemographic indicators at provincial, district and sub-district (taluks) level were retrieved from available online databases. A digital map of medical schools was plotted on a geo-referenced map of India. The growth of medical schools in public and private sectors was tracked over last seven decades using line diagrams and thematic maps. The growth of medical schools in context of geographic distribution and access across the poorer and relatively richer provinces as well as the country’s districts and taluks was explored using geographic information system. Finally candidate geographic areas, identified for intervention from equity perspective were plotted on the map of India.

Results

The study presents findings of 355 medical schools in India that enrolled 44250 students in 2012. Private sector owned 195(54.9%) schools and enrolled 24205(54.7%) students in the same year. The 18 poorly performing provinces (population 620 million, 51.3%) had only 94 (26.5%) medical schools. The presence of the private sector was significantly lower in poorly performing provinces where it owned 38 (40.4%) medical schools as compared to 157 (60.2%) schools in better performing provinces. The distances to medical schools from taluks in poorly performing provinces were longer [median 65.1 kilometres (km)] than from taluks in better performing provinces (median 41.2 km). Taluks farthest from a medical school were, situated in economically poorer districts with poor health indicators, a lower standard of living index and low levels of urbanization.

Conclusions

The distribution of medical schools in India is skewed in the favour of areas (provinces, districts and taluks) with better indicators of health, urbanization, standards of living and economic prosperity. This particular distribution was most evident in the case of private sector schools set up in recent decades.

 

The complete article is available as a provisional PDF.

Medical workforce

The Rise of the Employed Physician

Independent and group practice was once assumed as a certainty, now the economics and politics of health care make that path much less likely.

By Brian Secemsky, MD

 

As the youngest member of a family of doctors, it was not uncommon during my childhood to spend summers at my father's private practice. I fondly remember greeting the familiar office staff as I recklessly ran amok among an endless array of rickety cabinets containing an untold amount of aging, yellowed paper charts. My dad's patients would tousle my hair like family and his partners would always leave an insurmountable supply of candy for my taking.

Years later, I found myself accompanying my father and his practice partners for lunch as they discussed the ebb and flow of running a medical practice. Beyond sharing complicated medical cases, conversation often revolved around the complex relationships with local medical practices and the independently-owned hospital that my father and his partners had been affiliated with for the past several decades.

By the time I entered medical school, I developed the fixed assumption that, like my father (and grandfather and great-grandfather), I would ultimately be co-running a small office practice, develop a large but manageable patient panel and become highly involved with a local hospital.

Now, I am not so sure.

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Around the same time health care reform became a central theme to major media outlets, enormous changes quickly presented themselves to my father's workplace. The community hospital to which he was politically and financially bound was rebranded into a multi-institution hospital network. That same corporate system soon bought out his practice and ultimately became his employer. This all occurred in the matter of a few years.

I asked my dad why he didn't resist these marked changes to his career. His response didn't surprise me.

The daunting tasks of billing for multiple insurance networks and keeping up with proper medical coding for hundreds of diseases were becoming unbearably time-consuming and costly. Transitioning to electronic medical records and staying current on meaningful use and quality measures without managerial support was an increasing daily burden. Dictation companies were eating up his bottom line and documentation was eating up his time spent with his patients. He was tired of having to keep up with the business and politics of medicine, but he wasn't ready to let go of his practice of medicine.

And so, at 62, my father started his first employed job since finishing his medical training.

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Selling one's practice to work as an employee, as my father has done, or being hired directly out of medical training, as I am likely to do, is not unique to this era of health care.

Physician-owned practices in 2012 accounted for about 50 percent of all working doctors in comparison to about 75 percent in the late 1980s. The number of physician-owned practices continues to precipitously decline, as the percentage of physicians who were practice owners in 2012 dropped almost 10 percent from the previous five years, according to the AMA 2012 Physician Practice Benchmark Survey. This movement away from physician ownership is expected to continue.

Larger political and economic incentives are certainly influencing these trends. The public national agenda for rapid care integration and coordination and the private agenda for reducing competition and increasing leverage through consolidation are likely to accelerate the move away from self-employment, particularly for emerging physicians.

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How does the shift away from self-employment affect the new wave of practicing physicians?

I can only speculate that newly-trained doctors must learn to be more comfortable with managerial oversight from both physician and non-physician executives. Skill-sets such as effective team building, employment contract negotiation and the ability to "manage up" are likely more relevant now than in prior generations, where self-employed physicians predominated.

Importantly, in an era where patients see an ever-increasing number of non-physician providers, it is likely that young doctors will require a much more conscious effort to maintain a sense of personal responsibility for the health and well-being of the patients they care for.

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I truly believe that this era of health care is providing better care for our patients than ever before, and I couldn't be more satisfied in having the opportunity to take part in it.

Yet it remains to be seen how the trend from the "physician-employer" to "employed physician" will impact my generation of newly licensed physicians.

Leadership

Three Proven Qualities of Great Leaders: #1 Trust

 

By Deepak Chopra

It may sound like a paradox, but a great leader isn't someone who leads. It's someone other people want to follow. This isn't a matter of personal charisma, star power, luck, or ambition. If you expect to lead any group, whether a small team at work or a nation, you will do it best by acquiring real-life skills and applying them.

For decades the Gallup Organization, gathering masses of data worldwide, have asked workers what makes a great boss. The top three answers cut through a great deal of the so-called mystery of leadership.

The first factor was trust. "He's looking out for us" is the most basic and important thing that a worker can say about a good boss. In war a soldier's life depends on trusting that the generals in charge can be trusted. All generals give orders that must be followed. Only a few engender the kind of loyalty that sends people into risk and danger.

To follow isn't a matter of blind trust, however. People judge their leaders pragmatically. Ronald Reagan's famous line, "Ask yourself if you are better off today than you were four years ago" was decisive in winning him the Presidency. It won't matter how good you feel you are at leading if your team's wellbeing is on the decline.

It's easy to get carried away by ego--or at the other extreme by insecurity--so step back and consider the ingredients that make other people willing to trust you.

-- Your actions are consistent.

-- Your words match your deeds.

-- You make promises you can keep.

-- You take responsibility for your decisions.

-- You don't backstab or undercut those around you.

-- You don't focus on yourself.

-- You monitor the success and welfare of your cohorts.

-- You tell the truth.

On any given day you can measure yourself by these criteria. They apply as a parent or as President of the United States. Whatever your self-image may be, these guidelines give you an objective measure of your performance.

There's an opposite to every positive trait, so here's the pattern that failing leaders follow as they cause trust to deteriorate around them.

-- They are fickle and inconsistent. You can't predict what they will say or do tomorrow.

-- They talk the talk but can't be trusted to walk the walk.

-- They are generous with promises but weak on follow through.

-- They make excuses for themselves and pass the blame on to others. They are quick to find a fall guy.

-- They gossip and backstab, in the belief that remaining on top means creating insecurity among potential rivals.

-- They only care deep down about number one.

-- They only care about the success of those who hang on to their coattails.

-- They adjust the truth according to the situation at hand.

Take some time once or twice a week to perform an honest self-evaluation of how much trust you are actually earning. Making this a habit will serve you well on your path to leadership.

Online surveys

6 Problems With Online Surveys And How to Avoid Them

by Ivana Taylor  

 

Have you ever noticed that technology makes a lot of tasks easier — but it doesn’t make them fool-proof?  Online surveys are like that as well.  Twenty or thirty years ago, you had to hire a research company to do surveys. When surveys went online, you could cut a lot of the “cost” out; but while being able to conduct your own surveys online is certainly cheaper than hiring a market research firm on the surface — it can also be like having someone give you building materials and a crew [but without passing along expertise, best practices or a blueprint], and having YOU build your own house.

Technology is awesome, but it doesn’t take the place of crafting surveys that return information that will help you make good business decisions. By identifying what the most common problems are with online surveys, you can most easily overcome the challenges with surveys so that your business can enjoy the benefits they provide.

Are you making these online survey mistakes?

1. The Questions Are Confusing or Misleading

Survey questions generally must clearly ask a specific and pointed question if you want them to yield effective results. When an individual taking a survey is confused by the question, he or she will typically not answer the question in a way that is useful to you. After all, if the respondent believes that the question means one thing and you believe that it means another, the response will not yield any information that is reliable or trustworthy for your needs.

2. The Questions Are Too Long

Another common issue with surveys is having questions that are too lengthy or wordy. It is easy to lose meaning when the questions are too long. More than that, the respondent may feel overwhelmed or may even lose focus when the questions are too long. The best questions are those that are short, direct, and to the point. They have a specific purpose, and they generally have short answer options that are easy to understand. Respondents are busy and may easily become distracted. They typically want to spend a few minutes at most answering questions, so they should have short, direct questions and answer options that help them to feel as though they are progressing through the survey with speed. After all, a survey will reveal limited or meaningless information if the respondent fails to answer all of the questions.

3. The Questions Do Not Identify Specific Issues or Problems

When your survey relates to the pros and cons of a feature or a product, you want to obtain specific information about it. Some questions may simply ask for broad or undefined information about the problems a consumer may have or why a consumer chose one product over another one. However, the information that is provided by the respondents through the survey may not adequately define what the problem specifically is or how a consumer may prefer the company to address the issue.

4. The Questions Use Ambiguous Rating Systems

Many surveys that companies use today ask consumers to rate their experiences on a scale of one to five or one to 10. This may give a general indication about whether a consumer feels neutral, positive or negative about a certain area that is being questioned in the survey, but the response is rather arbitrary. For example, a consumer that rates an area positively on a scale of one to 10 may offer an 8 when they are completely satisfied with the experience, but he or she may not give a 10 as a response because of the belief that a company can always do better. On the other hand, a customer may give a 10 when they were not completely satisfied but because they do not want store staff or management to get fired or in trouble. These are purely arbitrary opinions that are based on a person’s value system or beliefs. They may indicate a positive or negative experience, but they do not provide any useful or real information for a company to improve upon.

5. Surveys Do Not Provide the Customer With the Ability to Clarify Answers

Many surveys ask customers questions with a multiple choice response option, but they do not provide the respondent the opportunity to clarify his or her answers. For example, it may ask a consumer which feature was most important in the buying decision, but it may not ask the consumer why that feature was important. There may be multiple reasons why a specific feature may be important in a buying decision, and obtaining better feedback from respondents is important for companies that want to improve products or improve their marketing message.

6. Freely Written Responses Can Be Difficult to Quantify Through Analysis

While it may be important for companies to obtain freely written or open-ended responses from their target audience through surveys, it can be difficult to quantify or analyze these responses. For example, one question may be an open-ended response option that asks the customer to state why they selected one product over another or to describe their experience. Software programs can be used to analyze the responses by picking up commonly used words in the answers, but when you have hundreds or thousands of unique responses, it can be difficult to fully quantify them in a manner that is beneficial to the company in any real way. This is a contradiction to the fact that customers should be provided with space to clarify their responses freely, and it generally means that businesses may need to read through each of the responses carefully to get a better idea about what the customers actually believe or think.

Overcoming These Challenges

As you can see, there are multiple challenges that companies may face when using surveys, but surveys are nonetheless beneficial and important. They can guide you in facilitating marketing decisions, product development or refinement, customer service and more. Generally, the feedback that you receive through these surveys can be used to give your customers a better overall experience, and they can be used to give your efforts focus and clarity. However, in order to accomplish the goals that you have, you must find a way to overcome the challenges that are common with poorly planned and crafted surveys.

As you research and select a survey software platform, consider not only how they help you create, distribute and analyze surveys but also how they help you make it effective. Best practice articles, how-to guides, in-depth help, blog articles, and training are all things to look for and utilize.

Happy surveying!

Self-assessment

Developing Students’ Self-Assessment Skills

By Maryellen Weimer, PhD

I've been rereading some of the research on student self-assessment and thinking about how students develop these skills. They are important in college, all but essential in most professions, but they're rarely taught explicitly. We assume (or hope) they're the kind of skills student can pick up on their own, even though most of us see evidence to the contrary. Many students, especially beginning ones, routinely overestimate their ability and underestimate the difficulty of course content. How often did I hear this comment about my courses: "A communication course? Gotta be a piece of cake. I've been talking since I was 3."

The research corroborates what we see in our classes. David Boud, who's made student self-assessment a major focus of his career, co-authored a now classic review of research which found that student estimations of their grades were routinely higher than the assessments of their teachers. Part of that may be wishful thinking—students reporting the grade they'd like or hope to have.

But self-assessment, as it's written about by the experts, doesn't replace teacher grades with ones provided by students. This is formative self-assessment—the ability to look at your work and know (or have a pretty good sense) of what's good and what needs to be improved. It's the ability to critique how you did something, the ability to learn from your mistakes, to use more of what works and less of what didn't the next time. It's a two-pronged assessment, an interrogation of what you produce (your work) and how well you completed it (your performance).

The research in this area is significant with many findings well established. Self-assessment ability correlates with achievement in an interesting albeit convoluted way. High achieving students tend to under-estimate their performance and those in low-achieving cohorts over estimate theirs. Low achieving students also have more difficulty learning to make accurate self-assessments.

Boud and various colleagues point out that it's a complex skill that confronts the learner with challenging data. So, for example, a student reports the grade he thinks he's earned on a paper, or using a criteria he rates his contributions to a group project. Students are more honest if they know the instructor giving the grade isn't going to see their self-assessment. Then the student considers both assessments, his own and the teacher's, and reflects on why they aren't the same. For skill development to start, students have to reconsider the reasons they used to justify that self-assessment. What's wrong with those reasons? What did the teacher see in their work or performance that they missed? What's involved is the ability to make judgments, which Boud (and colleagues) point out is not developed after one or two such exercises. Accurate self-assessment requires multiple opportunities to practice within courses and across them. Because the most important goal isn't agreement between teacher and student assessments. The ultimate goal is for students to make accurate judgments on their own.

I fear we are not doing as much as we should to develop this skill. Yes, we already have a thousand and one things we need to be doing with students. So, we use what time we can take, first, to make students aware of the usefulness, indeed necessity, of the skill. Then we can provide efficient self-assessment opportunities, such as group members rating their contributions in specified categories, getting rated by the rest of the group, and then seeing a comparison of those ratings. We can also ask pointed questions: “Given where you're headed professionally, what communications skills do you need that you don't yet have?" We could also be looking at the curricula in our programs, and asking as a department if self-assessment skills are being developed to the extent they should and if not, where and when are they best taught.

References (to the classic review of research and to a more recent study, which is highlighted in the December issue of The Teaching Professor):

Falchikov, N., and Boud, D. "Student Self-Assessment in Higher Education: A Meta-Analysis." Review of Educational Research, 1989, 59 (4), 395-430.

Boud, D., Lawson, R., and Thompson, D. "Does Student Engagement in Self-Assessment Calibrate Their Judgement Over Time?" Assessment & Evaluation in Higher Education, 2013, 38 (3), 941-956.