Barreras y factores asociados al uso de mecanismos de coordinación entre niveles de atención en México / Barriers and factors associated with the use of coordination mechanisms between levels of care in Mexico / Entraves e fatores associados ao uso de mecanismos de coordenação entre níveis de atenção no México

Resumen: El objetivo fue analizar el nivel y caracterizar el uso de mecanismos de coordinación clínica entre niveles de atención, y sus factores asociados, en dos redes públicas de servicios de salud en México. Se realizó estudio transversal mediante el cuestionario COORDENA a médicos de atención primaria y especializada del estado de Veracruz. Se encontraron diferencias entre redes y niveles de atención, según el mecanismo. En ambas, la referencia/contrarreferencia es sobre todo utilizada para canalizar al paciente a otro nivel, principalmente por parte de los médicos de atención primaria. Se identificó una alta recepción de referencias por especialistas, pero escasa recepción de contrarreferencias en atención primaria. Ser hombre y reconocer al médico/a de atención primaria como responsable del seguimiento del paciente en su trayectoria asistencial, fueron factores asociados al envío frecuente de la contrarreferencia por especialistas. El informe de alta se utiliza en ambas redes para enviar información clínica al otro nivel, con mayor envío por médicos/as especialistas, y con menor recepción en atención primaria. En ambas redes, el seguimiento a las recomendaciones de los mecanismos para estandarizar la atención clínica (guías de práctica clínica, etc.) por parte médicos/as de atención primaria que de especializada. La utilización de mecanismos de coordinación entre niveles de atención es deficiente y limitada, con mayor uso de mecanismos para transferir información que para la gestión clínica. Se evidencia la necesidad de implementar estrategias que consideren la participación de los profesionales, para favorecer la adaptación local, apropiación y mejorar su uso.

Abstract: The aim was to analyze the level and characterize the use of clinical coordination mechanisms between levels of care, and their associated factors, in two public networks of health services in Mexico. A cross-sectional study was carried out using the COORDENA questionnaire to primary and specialized care physicians in the state of Veracruz. Differences were found between networks and levels of care, according to the mechanism. In both, the referral/counter-referral is mostly used to channel the patient to another level, mainly by primary care physicians. A high reception of referrals by specialists was identified, but few counterreferences in primary care. Being a man and recognizing the primary care physician, as responsible for monitoring the patient in his/her healthcare career, were factors associated with the frequent sending of the counter-referral by specialists. The discharge report is used in both networks to send clinical information to the other level, with more sending by specialist doctors, but with less reception in primary care. In both networks, the follow-up to the recommendations of the mechanisms to standardize clinical care was greater by primary care physicians than specialized ones. The use of coordination mechanisms between levels of care is deficient and limited, with greater use of mechanisms to transfer information than for clinical management. The need to implement strategies that consider the participation of professionals is evident, to favor local adaptation, appropriation and improve their use.

Resumo: O objetivo era analisar o nível e caracterizar o uso de mecanismos de coordenação clínica entre níveis de atenção e seus fatores associados em duas redes públicas de saúde no México. Estudo transversal por meio do questionário COORDENA aplicados a médicos da atenção primaria e especializada do Estado de Veracruz. Foram encontradas diferenças entre redes e níveis de atenção conforme o mecanismo. Em ambas, a referência/contrarreferência é sobre tudo utilizada para encaminhar o paciente para outro nível, principalmente por parte dos médicos da atenção primária. Foi identificado um alto recebimento de referências por especialistas, porém raras são as contrarreferências na atenção primária. Ser homem e reconhecer o médico/a de atenção primária como responsável pelo acompanhamento do paciente na sua trajetória de atendimento foram fatores associados ao envio frequente da contrarreferência por especialistas. O relatório de alta é utilizado nas duas redes para enviar informação clínica ao outro nível, com mais envios por médicos/as especialistas e menos recebimentos na atenção primária. Em ambas as redes, a observância das recomendações de mecanismos para padronizar a atenção clínica foi maior por parte dos médicos/as da atenção primária do que da especializada. O uso de mecanismos de coordenação entre níveis de atenção é deficiente e limitado, com o emprego maior de mecanismos para transmitir informação do que para a gestão clínica. Ficou evidenciada a necessidade de implementar estratégias que levem em conta a participação dos profissionais, para promover a adequação local, a apropriação e melhorar a sua utilização.

Mecanismos de coordinación en la red de salud municipal de Rosario: conocimiento y uso, estudio comparativo 2015-201 / Coordination mechanisms in Rosario´s municipal health network: knowledge and use. Comparative study 2015-2017

INTRODUCCIÓN: En Argentina, como en el resto de Latinoamérica, el sistema de salud está fragmentado; los mecanismos de coordinación (MC) entre niveles de atención son un insumo para su mejora. El objetivo fue analizar, como parte del proyecto EQUITY LA II, el conocimiento y uso de MC entre niveles de atención en médicos de atención primaria (AP) y especializada (AE) en la red de Salud Municipal de Rosario, y sus cambios entre 2015 y 2017. MÉTODOS: Se realizó un estudio transversal con aplicación del cuestionario COORDENA Argentina a médicos de AP y AE. Se encuestó a 350 médicos en 2015 y a 352 en 2017. Las variables fueron nivel de conocimiento, frecuencia, finalidad y dificultades en el uso de los MC de información (MCI): hoja de referencia/contrarreferencia-interconsulta (HR/CR), informe de alta hospitalaria, teléfono; y los MC de gestión clínica (MCGC): guías de práctica clínica (GPC) y reuniones conjuntas. Se efectuó un análisis comparativo entre años y niveles. RESULTADOS: En 2015 la mayoría conocía MCI, aunque hubo diferentes porcentajes de uso según niveles de atención. Los MCGC eran menos conocidos, pero muy usados entre quienes los conocían. Hubo cambios significativos en 2017: disminuyó el envío de CR y el uso del teléfono en AP, y aumentó el conocimiento de reuniones conjuntas y de GPC (solo entre AP). DISCUSIÓN: Existen diferencias en la implementación de MC entre niveles. La adecuación al contexto local es clave para lograr una efectiva y eficiente implementación.

Conhecimento e uso de mecanismos para articulação clínica entre níveis em duas redes de atenção à saúde de Pernambuco, Brasil / Awareness and use of mechanism for clinical coordination between levels in two health care networks in Pernambuco State, Brasil / Conocimiento y uso de mecanismos para la coordinación clínica entre niveles de asistencia en dos redes de atención de salud en Pernambuco, Brasil

O artigo avalia o conhecimento e o uso dos mecanismos de articulação clínica entre níveis assistenciais em duas redes de atenção à saúde no Estado de Pernambuco, Brasil. Trata-se de estudo descritivo e transversal, do tipo inquérito. Foram entrevistados 381 médicos das redes públicas de saúde da atenção básica e atenção especializada dos municípios de Caruaru e Recife (Distritos Sanitários III e VII). Foi aplicado um questionário estruturado (COORDENA) para avaliar o conhecimento, frequência e características no uso dos seguintes mecanismos: formulário de referência e contrarreferência, resumo de alta, telefone e bilhetes (mecanismos de adaptação mútua), protocolos do Ministério da Saúde e sessões clínicas conjuntas (mecanismos de padronização). Os dados foram analisados por meio de frequências simples, médias e percentuais. De modo geral, os médicos da atenção básica conhecem e utilizam mais os mecanismos que os médicos da atenção especializada. Na comparação entre redes, Recife apresentou os melhores resultados. Os formulários de referência e contrarreferência foram os mais usados (61,4%) e as sessões clínicas conjuntas as de menor uso (8,6%), além da existência de mecanismos informais (telefone 58%, bilhete 56,6%, WhatsApp 2,6%). A subutilização dos mecanismos, a divergência de informações no envio e recebimento entre os profissionais da atenação básica e atenção especializada, e o uso inadequado dos mesmos sugerem falhas na comunicação entre os profissionais e entre os níveis de atenção. Os achados revelam a necessidade de investimentos que propiciem o conhecimento, a comunicação e a colaboração entre profissionais, contribuindo para uma melhor articulação entre os diferentes níveis assistenciais.

This article assesses awareness and use of mechanisms for clinical coordination between service levels in two health care networks in the Pernambuco State, Brasil. It is a descriptive, cross-sectional, survey-based study. We interviewed 381 doctors from the public primary health care and specialized health care networks in the cities of Caruaru and Recife (Sanitary Districts III and VII). We used a structured questionnaire (COORDENA) in order to assess awareness, frequency and characteristics of the use of the following mechanisms: referral and reply letters, discharge summary, phone and notes (mutual adaptation mechanisms), Health Ministry protocols and joint clinical sessions (standardization mechanisms). We analyzed the data using simple frequencies, means and percentages. In general, primary health care doctors are more familiar with the mechanisms, and use them more frequently, than specialized health care doctors. In the comparison between networks, Recife had better results. Referral and reply letters were the most used (61.4%) and joint clinical sessions were the least used (8.6%), in addition to the existence of informal mechanisms (phone 58%, notes 56.6%, WhatsApp 2.6%). Underutilization of mechanisms, divergences in information sent and received between primary health care and specialized health care professionals and inadequate mechanism use suggest communication failures among professionals and service levels. The findings reveal a need for investments that enable awareness, communication and collaboration between professionals, contributing to a better coordination between the different services levels.

El artículo evalúa el conocimiento y el uso de los mecanismos de coordinación clínica entre niveles asistenciales en dos redes de atención de salud en el Estado de Pernambuco, Brasil. Se trata de un estudio descriptivo y transversal, basado en una encuesta. Se entrevistaron a 381 médicos de las redes públicas de salud en la atención básica y atención especializada de los municipios de Caruaru y Recife (Distritos Sanitarios III y VII). Se aplicó un cuestionario estructurado (COORDENA) para evaluar el conocimiento, frecuencia y características en el uso de los siguientes mecanismos: formularios de referencia y contrarreferencia, resumen de alta, teléfono y notas (mecanismos de adaptación mutua), protocolos del Ministerio de Salud y sesiones clínicas conjuntas (mecanismos de estandarización). Los datos se analizaron mediante frecuencias simples, medias y porcentajes. De manera general, los médicos de la atención primaria conocen y utilizan más los mecanismos que los médicos de la atención especializada. En la comparación entre redes, Recife presentó mejores resultados. Los formularios de referencia y contrarreferencia fueron los más utilizados (61,4%) y las sesiones clínicas conjuntas las de menor uso (8,6%), además de la existencia de mecanismos informales (teléfono un 58%, nota un 56,6%, WhatsApp un 2,6%). La subutilización de los mecanismos, la divergencia de información en el envío y recepción entre los profesionales de la atención primaria y atención especializada y el uso inadecuado de los mismos sugieren fallos en la comunicación entre los profesionales y entre los niveles de atención. Los hallazgos revelan la necesidad de intervenciones que propicien el conocimiento, la comunicación y la colaboración entre profesionales, contribuyendo a una mejor coordinación entre los diferentes niveles asistenciales.

Los especialistas en psiquiatría en México: su distribución, ejercicio profesional y certificación / Phychiatrists in Mexico: their distribution and practice

There are few available and reliable data regarding the number and geographic location of psychiatrists in Mexico. It is important to have these data in order to know if the mental health needs of the country are being met. This study is an attempt to update both the current data on this subject by locating the most psychiatrists possible, and also to learn more about how they manage their medical practice. Methods Descriptive and cross-sectional study. Several sources available in Mexico were consulted such as Mexican Psychiatry Associations, health care institutions, universities, telephone directories among several others, to locate psychiatrists and to identify where and what kind of practice they have. Results According to our several data bases, 3823 psychiatrists were counted in Mexico, 225 of these being child and adolescent psychiatrists. The rate of psychiatrists obtained was 3.47 psychiatrists per 100 000 inhabitants and 0.69 child and adolescent psychiatrists per 100 000 inhabitants under 15 years. 56% of psychiatrists practiced in the Federal District. There are 1.8 male psychiatrists for every female psychiatrist. Discussion The number of psychiatrists in Mexico is still below the rate that the World Health Organization recomends. The distribution by gender is shifting towards more equality. Psychiatrists were found to be grouped in urban areas of the country. The number of psychiatrists and child and adolescent psychiatrists seems to be insufficient to cover the needs of the country.

Existe poca información disponible y actualizada acerca del número de psiquiatras en México y sobre su localización geográfica. Es importante conocer estos datos para saber si se cubren las necesidades de salud mental del país. Este estudio busca actualizar tanto los datos disponibles sobre este tema al localizar el mayor número de psiquiatras posibles, como el tipo de práctica en su especialidad y si cuentan con la certificación correspondiente. Metodología Se trata de un estudio descriptivo y transversal. Se consultaron múltiples fuentes disponibles en México, como las asociaciones psiquiátricas mexicanas, las instituciones hospitalarias, las universidades, los directorios telefónicos y otros, para localizar a los psiquiatras, identificar dónde ejercen y conocer el tipo de su práctica profesional. Resultados Considerando nuestras diversas fuentes de búsqueda, se contabilizó un total de 3 823 psiquiatras para una población total de 112 000 000 de habitantes. Del número total de psiquiatras, 225 tienen la subespecialidad de paidopsiquiatría. Se obtuvo una tasa de 3.47 psiquiatras por cada 100 000 habitantes y de 0.69 paidopsiquiatras sobre una población de 100 000 habitantes menores de 15 años. El 56% se encuentra en el Distrito Federal. Hay 1.8 psiquiatras varones por cada mujer en esa especialidad. Discusión El número de psiquiatras en México aún está por debajo de la tasa recomendada por la Organización Mundial de la Salud. La distribución por género está cambiando hacia una más equitativa. Se encontró que los psiquiatras están agrupados en las zonas urbanas del país. El número de psiquiatras y paidopsiquiatras es insuficiente para cubrir las necesidades de salud mental del país.

Factores asociados al rendimiento académico en alumnos de la Facultad de Medicina: estudio de seguimiento a un año / Factors related to the academic performance in medical students: a one year follow-up

The study and analysis of different factors related to the academic performance of medical students remains a topic of interest, either for selection processes or for the establishment of strategies and interventions to support students who may need it. It is said that there are two groups of features associated with academic performance: the academic (high school grades, scores on entrance exams) and non-academic (personality traits, presence or absence of psychopathology, sociodemographic aspects) characteristics. The purpose of this study was to identify the influence that different features of a group of medical students from the High Academic Performance Program (HAPP) at Universidad Nacional Autonoma de Mexico (UNAM) had on their school performance. Materials and methods This paper presents the one year follow up of a cohort of students initially studied during the selection process to entry the HAPP of Medicine School at UNAM. We evaluated all first-year medical students of UNAM who, during 2009-2010, continued to be part of the HAPP and who agreed to participate in this research. At the end we studied 94 students (48 men, 46 women) with a mean age of 18.3 years. The analyzed variables were: academic performance, demographic factors, academic background, personality, abstract thinking, creative thinking, mental disorder. For the initial evaluation at the entrance to University we used the Minnesota Multiphasic Personality Inventory -2 (MMPI-2), the sub-scale of abstract reasoning from the Differential Aptitude Test (DAT), a semi-structured interview to investigate demographic and academic characteristics, and the figural test from the Torrance Test of Creative Thinking. In a second assessment (at the end of the first year), we applied the MMPI-2 (for a second time with the intention to avoid the pressure that students could have during the selection process to enter the HAPP) and Mini-International Neuropsychiatric Interview (MINI) to assess the presence of psychopathology. Also, final grades were collected from the academic file of each student. For statistical analysis we used ANOVA, multiple linear regression models, bivariate correlations and cluster analysis. Results The general knowledge test was presented as the only significant predictor for both the final average for all subjects separately, and for the final general average. Results: The general knowledge test was the only significant predictor for both the final average and the final grades for each subject. Characteristics of creative thinking (e.g fluency) or personality traits (such as MMPI-2 Mania scale) were significant predictors for the final average for most of the subjects, however they were not consistent at all. Anatomy (r= 859), developmental biology (r=852), biochemistry (r=. 893) and cell biology and tissue (r=.889) were subjects whose average had a high correlation with the global final average, while public health (r=.696) and medical psychology (r=.670) showed a moderate correlation. The score of abstract thinking (r=.029) had not any correlation with the final average that these students got at the end of the year. A comparison between the two measurements (one at the entrance to Medicine School and the other one year later) of the MMPI-2 was made and we found that there was a pattern of consistency between measurements and all correlations among the different scales that shape the inventory were significant (p<.001). Hypochondriasis, Depression, Hysteria and Psychasthenia scales, tended to rise significantly. In order to evaluate the presence of psychopathology in these students at the end of the first year of Medicine School, the MINI it was used. Of the 96 students, it was found that 77 (80.20%) had no psychopathology, and that 19 (19.79%) had one or more mental disorders at the moment of the interview. The disorders that presented the participants were: major depressive disorder (n=15), generalized anxiety disorder (n=7), bipolar disorder (n=1) and anorexia nervosa (n=1). To determine the influence of the presence of psychopathology on the students final grades, we analyzed the differences between the group of students without any mental disorder and the group with psychopathology. There was no statistically significant difference in the general final average (U=678 500, Z0-.503, p=0.615), and it was a characteristic that only made a difference for the final grades of Anatomy (U=475, Z=-2.50, p=0.012) and Public Health (U=544, Z=-2.007, p=0.045). None of the socioeconomic aspects influenced the students' academic performance. Discussion For the group of the evaluated students, we only found that the general test scores of knowledge is a significant and consistent predictor for average subjects in the first year and the final general average. Conclusions The general knowledge test was a useful predictor for final grades because it seems to summarize many of the skills and habits related to student academic success.

Antecedentes El estudio y análisis de los factores relacionados con el desempeño escolar de los estudiantes de Medicina continúa siendo un tema de interés, ya sea con fines de selección o para el establecimiento de estrategias o intervenciones de apoyo para los alumnos. El propósito de este estudio fue identificar la influencia que tenían las diferentes características de un grupo de estudiantes del Programa de Alta Exigencia Académica (PAEA) al finalizar el primer año de la carrera de Medicina en la Universidad Nacional Autónoma de México (UNAM) en su rendimiento escolar. Material y métodos En este artículo se presenta el seguimiento a un año de una cohorte de alumnos del PAEA inicialmente estudiada a su ingreso a la Facultad de Medicina de la UNAM. En total se estudiaron 94 alumnos (48 hombres, 46 mujeres), con una media de edad de 18.3 años. Las variables evaluadas fueron: desempeño académico, factores sociodemográficos, trayectoria académica, rasgos de personalidad, pensamiento abstracto, pensamiento creativo, trastorno mental. Estas se midieron a través del Inventario Multifásico de la Personalidad Minnesota-2 (MMPI-2), la sub-escala de razonamiento abstracto del Test de Aptitudes Diferenciales (DAT); una entrevista semi-estructurada, la prueba figural del test de Pensamiento Creativo de Torrance, y la Mini-entrevista Neuropsiquiátrica Internacional (MINI). Para el análisis estadístico se emplearon ANOVA, modelos de regresión lineal múltiple por pasos hacia atrás, correlaciones bivariadas y análisis de clusters. Resultados El Examen General de Conocimientos se presentó como el único predictor significativo tanto para el promedio final de todas las asignaturas por separado, como para el promedio final general. Características del pensamiento creativo (como la fluidez) o de los rasgos de personalidad (como la escala de Manía del MMPI-2) se mostraron como predictores significativos para el promedio final de la mayoría de las materias, sin embargo no fueron constantes en todas. Anatomía (r=859), biología del desarrollo (r=852), bioquímica (r=.893) y biología celular y tisular (r=.889) fueron asignaturas cuyo promedio tuvo una correlación elevada con el promedio final general; mientras que salud pública (r=.696) y psicología médica (r=.670) presentaron una correlación moderada, y el puntaje de pensamiento abstracto (r=.029) no tuvo ninguna correlación con el mismo. Se realizó una comparación entre las mediciones (inicial y un año después) del MMPI-2 y se observó que existía un patrón de constancia entre las mediciones y todas las correlaciones resultaron significativas (p<.001). De los 96 alumnos evaluados un 19.79% resultó positivo para algún trastorno mental (el depresivo mayor fue el más frecuente). Sin embargo esto sólo afectó en el promedio de Anatomía (U=475, Z=-2.50, p=0.012) y en el de Salud Pública (U=544, Z=-2.007, p=0.045). Ninguno de los aspectos socioeconómicos influyó en el desempeño académico de los estudiantes. Discusión Para el grupo de alumnos evaluados, sólo se encontró al puntaje del examen general de conocimientos como un predictor significativo y constante para el promedio de las asignaturas del primer año y el promedio final general. Conclusiones El examen general de conocimientos se mostró como una evaluación de utilidad pues parece resumir muchas de las habilidades y hábitos del estudiante que se relacionan con un buen desempeño académico.

Perfil integral del candidato al Programa de Alta Exigencia Académica (PAEA) de la Facultad de Medicina de la Universidad Nacional Autónoma de México (UNAM) / Comprehensive profile of candidates to the High Academic Performance Program (PAEA) of the Faculty of Medicine at Universidad Nacional Autónoma de México (UNAM)

The importance to assess in a comprehensive way the cognitive, emotional, personal and social features of the students entering medical school is recognized nowadays in order to select from the candidates, not just those with high cognitive abilities, but also the ones with a vocation and interest in the study of this science. These are characteristics that should be specially sought among the students of high performance academic groups. In the Department of Medicine, as it is in some other departments at the Universidad Nacional Autónoma de México (UNAM), there is a special plan called High Academic Performance Program (PAEA), which aims to test innovative teaching models to generate health resources able to operate in special working conditions. Medicine students enrolled at the PAEA have a particular schedule which includes, in addition to the program established at the regular curriculum, some other specific activities, meaning greater demand for them. These special training includes activities such as: early introduction to research labs, based-problem learning, methodology workshops, introductory course in computing, and personalized assistance from academic tutors. It is because of these peculiar features, that, with this study, we aim to determine the profile of the students of the PAEA from the analysis and comparison of the candidates' characteristics. Materials and methods This was a comparative cross-sectional study that included all the first entry students at the Department of Medicine who applied to enter the selection process of the PAEA at the 2009-2010 period. These candidates were required to ask voluntarily to be included in the selection process to be part of PAEA, and to demonstrate at least a high school grade of 8.5, and to complete the assessment instruments. For this study, the assessment instruments used were: Minnesota Multiphasic Personality Inventory (MMPI-2), Differential Aptitude Test (DAT) sub-scale of abstract reasoning, and a semi-structured interview designed specifically for this evaluation. The variables considered for this research were: • Sociodemographic characteristics: All those features that define the economical, social and demographic situation of a person or population. • Academic background: All the information of studies and activities that the student has done throughout his/her school years. • Vocational features: Preferences, perceptions and attitudes of the student for his/her own autonomous choice of career or profession. • Personality traits: Generalized and focused mental systems that have the ability to convert external stimuli to guide different forms of behaviors. • Abstract reasoning: Mental process that allows people to solve logic problems, forecasting and planning. Data obtained from the instruments were analyzed with descriptive statistics, multiple linear regression, logistic regression, cluster analysis and factor analysis. Results The study included 194 candidates (100 of them were accepted to be included at the PAEA). In general, the studied population had a greater percentage of women (61.86%) and a mean age of 18.35 + 1.5 years old. Around a quarter of this population studied high school at Escuela Nacional Preparatoria (National High School), but it was observed that the highest percentage (20.1%) of students accepted to enter PAEA had the antecedent of being graduate from private high schools with high academic standards. This last finding is important since the candidates from these private schools are students who not only have access to a history of multiple academic and extracurricular activities, but they also come with certain academic stimulation, and so, it is expected that they have developed strategies to contend in competitive environments. The average grade of high school was lightly higher for the group of accepted students (9.27+0.41) than for those not accepted (9.13+0.47). Compared to those who were not accepted, more students in the group of accepted candidates were fluent in English (46.91%), French (1 4.43%) or other foreign language (3.61 %) besides Spanish. The personality profile obtained from the MMPI-2 was similar for both groups of candidates, accepted and not accepted. It was determined that accepted students were characterized by: having high energy and strength to achieve their goals, being sociable but with little commitment to the others, questioning the statu quo, being creative. However, within this group it was also observed that there was a tendency to manipulate other people to get what they wanted and that some of their behaviors may be governed by impulsivity. The group of candidates not accepted to the Program seemed to have the same personality features with greater energy, which could lead them into disarray. Characteristics such as social introversion and hypochondriasis have been aspects of interest in some previous studies. Both personality features have revealed significant long-term predictors, whether to have an adequate academic performance (associated to low levels of both social introversion and hypochondriasis) or to develop any psychopathology (related to high levels of social introversion and hypochondriasis). For this population, professional interests were directed towards the medical practice, while teaching was not considered as a priority interest (but it prevailed in the group of not accepted). Promotion of humanitarian aid discriminated those accepted candidates. At least 10% of the students in the group of accepted candidates said that they could see themselves having a successful future. The difference in interests within these students reflects distinct experiences in each group, and therefore dissimilar life projects that make them having diverse perspectives of present and future circumstances. The fact that the group of approved candidates has high motivation for success is consistent with their acceptance to be part of a group of high performance. However, it may be advisable to promote a training throughout their social awareness in order to enable them to have an overall performance of their profession. The best predictors of acceptance were: the rating of the overall review of knowledge (an exam that every first entry student does at the beginning of Medicine School) and the score of DAT's abstract reasoning, which correlated with r = 0.485. It is important to say that neither the grade of high school nor the age were good predictors to be accepted to PAEA. Conclusions Since PAEA seeks to select students with characteristics and skills that enable them to function in the field of medicine under a high rate of academic achievement, it is expected that, as it was confirmed in this research, accepted students where those who had greater cognitive abilities, who were fluent in other languages, with interest focused on successful clinical practice and research, and with less concern about socio-economical aspects of their environment. However, there are still many questions regarding the defining characteristics of this population and the way these features will impact their education. It is necessary to continue characterizing and studying the groups of students entering PAEA, and follow up their outcome in order to determine if the evaluated aspects have an influence on their academic performance during medical school.

En la Facultad de Medicina, como en algunas otras de la Universidad Nacional Autónoma de México, existe un Programa de Alta Exigencia Académica (PAEA), el cual busca probar métodos de enseñanza novedosos para formar recursos capaces de desarrollarse en condiciones especiales de trabajo. Esto se lleva a cabo por medio de un programa en que el alumno lleva, además de las actividades regulares establecidas en el currículum de la carrera, algunas otras planeadas específicamente para estos grupos y que demandan mayores exigencias para los estudiantes que forman parte de ellos. Dadas estas características del PAEA en la Facultad de Medicina, es prioritaria una evaluación integral de los candidatos que formarán parte del programa, la cual debe incluir aspectos cognoscitivos, emocionales, personales y sociales. Por ello, el objetivo de este estudio fue establecer el perfil de los alumnos del PAEA a partir del análisis y la comparación de las características de la población de candidatos que se postularon para ingresar a este programa durante la promoción 2009-2010. Material y métodos Estudio transversal comparativo en el cual se incluyó a todos aquellos estudiantes de primer ingreso (ciclo 2009-2010) que solicitaron de manera voluntaria ingresar al proceso de selección del PAEA, que tuvieron por lo menos 8.5 de promedio en el bachillerato y que completaron los instrumentos de evaluación. Se aplicaron: el Inventario Multifásico de la Personalidad Minnesota-2 (MMPI-2), la subescala de razonamiento abstracto del Test de Aptitudes Diferenciales (DAT), y una entrevista semiestructurada diseñada expresamente para esta evaluación. Los datos obtenidos se manejaron con estadísticos descriptivos, regresión lineal múltiple, regresión logística, análisis de clusters y análisis factorial. Resultados Se incluyó a 194 aspirantes, de los cuales fueron aceptados 100, con un predominio en la población femenina (61.86%) y una media de edad de 1 8.35 ± 1.5. Una cuarta parte de la población estudiada provenía de las Escuelas Nacionales Preparatorias, pero el mayor porcentaje de aceptación (20.1%) para ingresar al PAEA se observó entre los alumnos egresados de escuelas preparatorias privadas de alto nivel académico. El perfil de personalidad obtenido por medio del MMPI-2 fue similar para los candidatos aceptados y los no aceptados. Los alumnos aceptados para ingresar al PAEA se caracterizaron por: presentar una gran energía y consolidar sus metas, ser sociables pero con poco compromiso con los demás, cuestionar el status quo y ser creativos; no obstante, se observó una tendencia a manipular a los demás para conseguir sus fines. Algunas de sus conductas pueden estar regidas por impulsividad. Los alumnos no aceptados presentaron estas características con una mayor energía que pudiera llevarlos a la desorganización. Los intereses profesionales se dirigieron hacia la práctica médica. Aunque la docencia no fue considerada como un interés, predominó entre los no aceptados, mientras que la promoción de ayuda humanitaria discriminó a los aceptados. Los mejores predictores de la aceptación fueron la calificación del examen general de conocimientos y el razonamiento abstracto, los cuales se correlacionaron con r=0.485. Ni la edad, ni el promedio de bachillerato fueron buenos predictores en cuanto a la aceptación para entrar al PAEA. Conclusiones Dado que el PAEA busca seleccionar alumnos con características y habilidades que les permitan desempeñarse en el campo de la Medicina con un ritmo de alto rendimiento académico, resulta esperable que, tal como se corroboró en esta investigación, se aceptaran alumnos con una mayor competencia cognoscitiva, con dominio de otras lenguas, con intereses centrados en la práctica clínica exitosa y en la investigación, y con menor preocupación por aspectos socioeconómicos de su entorno. Sin embargo, será preciso continuar perfilando y estudiando a los estudiantes de este programa con el fin de determinar aquellos rasgos que influyen en su desempeño durante la licenciatura.

Integrated health care networks in Latin America: toward a conceptual framework for analysis / Redes integradas de atención sanitaria en América Latina: hacia un marco conceptual para el análisis

Las inequidades e ineficiencias de los sistemas de salud de América Latina motivaron algunas reformas, concentradas en las últimas dos décadas, particularmente en el financiamiento y el suministro de la atención sanitaria. Este trabajo se enfoca en la introducción de redes integradas de atención sanitaria (RIAS) en varios países de América Latina y los ubica en el contexto internacional. La descripción y el análisis de las RIAS, ya fueran regionales o de afiliación, resaltan el debate actual sobre sus posibles beneficios y riesgos. El impacto de las RIAS -en términos del mejoramiento del acceso a la atención sanitaria o de la promoción de la eficiencia y la equidad en los sistemas de salud- se ha evaluado en muy pocas oportunidades. Para contribuir al tema, se propone un marco conceptual abarcador para el análisis del desempeño de las RIAS, que trata el proceso interno y los factores externos considerados críticos para alcanzar sus objetivos intermedios y finales.

Equidad y reformas de los sistemas de salud en Latinoamérica / Equity and health systems reform in Latin America

The aim of any health care system is to help improve the people's health, and to do so as efficiently as possible. In order to improve the efficiency and equity of health services provision, many countries around the world have implemented reforms, including several Latin American nations. However similar the objectives may appear, the various ways societies implement such reforms reflect different values and concepts. This article analyzes the egalitarian and neoliberal values underlying different concepts of equity in health care. The authors develop criteria to interpret selected health services funding and provision strategies in Latin American health system reforms. These criteria are then applied to health care financing and delivery policies under the reforms currently being implemented in Colombia and Costa Rica.