Effectiveness of synchronous vs asynchronous faculty aid in learning how to diagnose, plan and perform a 44C ankle fracture osteosynthesis in a synthetic bone model.

INTRODUCTION: COVID-19 pandemic has disrupted educational activities since 2020. AO Trauma Latin American courses took place in a blended modality during 2021 and participant's feedback was positive. In this study, we aim to identify if there was any difference in learning, planning, and executing an osteosynthesis on a bone model with synchronous or asynchronous faculty support during an online asynchronous learning program. MATERIAL AND METHODS: we designed an online asynchronous course designed for teaching about trimalleolar ankle fractures. We randomized twenty participants into two groups: the control group had synchronous faculty support and the intervention group had asynchronous faculty support. Participants were evaluated with initial and final quizzes, preoperative planning, and execution of an osteosynthesis on a bone model. Comparisons of scores between CG and IG were performed using the Mann-Whitney U test for non-parametric variables. A two-tailed p < 0.05 was considered statistically significant. RESULTS: we did not find a significant difference between synchronous or asynchronous faculty support during our asynchronous learning program in quiz results, preoperative planning, global rating scale or the result of the osteosynthesis as compared to the preoperative plan. CONCLUSION: there appears to be no difference in participant learning with synchronous or asynchronous faculty support during an online, asynchronous course. Asynchronous activities appear to be effective teaching methods and should be considered in continuous medical education in orthopedics. Larger studies are needed to identify differences in participant learning outcomes between synchronous and asynchronous faculty support models.

INTRODUCCIÓN: la pandemia de COVID-19 ha interrumpido las actividades educativas desde 2020. Los cursos de AO Trauma Latinoamérica se realizaron en modalidad semipresencial durante 2021 y la retroalimentación de los participantes fue positiva. En este estudio, nuestro objetivo es identificar si hubo alguna diferencia en el aprendizaje, la planificación y la ejecución de una osteosíntesis en un modelo óseo con el apoyo sincrónico o asincrónico de la facultad durante un programa de aprendizaje asincrónico en línea. MATERIAL Y MÉTODOS: diseñamos un curso asíncrono en línea para la enseñanza de las fracturas trimaleolares de tobillo. Se distribuyó aleatoriamente a 20 participantes en dos grupos: el grupo de control tuvo apoyo docente sincrónico y el grupo de intervención tuvo apoyo docente asincrónico. Se evaluó a los participantes con cuestionarios iniciales y finales, planificación preoperatoria y ejecución de una osteosíntesis en un modelo óseo. Las comparaciones de las puntuaciones entre GC e GI se realizaron mediante la prueba U de Mann-Whitney para variables no paramétricas. Una p de dos colas < 0.05 se consideró estadísticamente significativa. RESULTADOS: no encontramos diferencia significativa entre el apoyo del profesorado síncrono o asíncrono durante nuestro programa de aprendizaje asíncrono en los resultados de los cuestionarios, la planificación preoperatoria, la escala de valoración global o el resultado de la osteosíntesis en comparación con el plan preoperatorio. CONCLUSIÓN: no parece haber diferencias en el aprendizaje de los participantes con el apoyo sincrónico o asincrónico del profesorado durante un curso en línea asincrónico. Las actividades asíncronas parecen ser métodos de enseñanza eficaces y deberían tenerse en cuenta en la formación médica continua en ortopedia. Se necesitan estudios más amplios para identificar las diferencias en los resultados de aprendizaje de los participantes entre los modelos de apoyo docente síncrono y asíncrono.

Effectiveness of synchronous vs asynchronous faculty aid in learning how to diagnose, plan and perform a 44C ankle fracture osteosynthesis in a synthetic bone model / Eficacia de la ayuda docente sincrónica frente a la asincrónica en el aprendizaje del diagnóstico, la planificación y el desempeño de una osteosíntesis de fractura de tobillo 44C en un modelo de hueso sintético

Abstract: Introduction: COVID-19 pandemic has disrupted educational activities since 2020. AO Trauma Latin American courses took place in a blended modality during 2021 and participant's feedback was positive. In this study, we aim to identify if there was any difference in learning, planning, and executing an osteosynthesis on a bone model with synchronous or asynchronous faculty support during an online asynchronous learning program. Material and methods: we designed an online asynchronous course designed for teaching about trimalleolar ankle fractures. We randomized twenty participants into two groups: the control group had synchronous faculty support and the intervention group had asynchronous faculty support. Participants were evaluated with initial and final quizzes, preoperative planning, and execution of an osteosynthesis on a bone model. Comparisons of scores between CG and IG were performed using the Mann-Whitney U test for non-parametric variables. A two-tailed p < 0.05 was considered statistically significant. Results: we did not find a significant difference between synchronous or asynchronous faculty support during our asynchronous learning program in quiz results, preoperative planning, global rating scale or the result of the osteosynthesis as compared to the preoperative plan. Conclusion: there appears to be no difference in participant learning with synchronous or asynchronous faculty support during an online, asynchronous course. Asynchronous activities appear to be effective teaching methods and should be considered in continuous medical education in orthopedics. Larger studies are needed to identify differences in participant learning outcomes between synchronous and asynchronous faculty support models.

Resumen: Introducción: la pandemia de COVID-19 ha interrumpido las actividades educativas desde 2020. Los cursos de AO Trauma Latinoamérica se realizaron en modalidad semipresencial durante 2021 y la retroalimentación de los participantes fue positiva. En este estudio, nuestro objetivo es identificar si hubo alguna diferencia en el aprendizaje, la planificación y la ejecución de una osteosíntesis en un modelo óseo con el apoyo sincrónico o asincrónico de la facultad durante un programa de aprendizaje asincrónico en línea. Material y métodos: diseñamos un curso asíncrono en línea para la enseñanza de las fracturas trimaleolares de tobillo. Se distribuyó aleatoriamente a 20 participantes en dos grupos: el grupo de control tuvo apoyo docente sincrónico y el grupo de intervención tuvo apoyo docente asincrónico. Se evaluó a los participantes con cuestionarios iniciales y finales, planificación preoperatoria y ejecución de una osteosíntesis en un modelo óseo. Las comparaciones de las puntuaciones entre GC e GI se realizaron mediante la prueba U de Mann-Whitney para variables no paramétricas. Una p de dos colas < 0.05 se consideró estadísticamente significativa. Resultados: no encontramos diferencia significativa entre el apoyo del profesorado síncrono o asíncrono durante nuestro programa de aprendizaje asíncrono en los resultados de los cuestionarios, la planificación preoperatoria, la escala de valoración global o el resultado de la osteosíntesis en comparación con el plan preoperatorio. Conclusión: no parece haber diferencias en el aprendizaje de los participantes con el apoyo sincrónico o asincrónico del profesorado durante un curso en línea asincrónico. Las actividades asíncronas parecen ser métodos de enseñanza eficaces y deberían tenerse en cuenta en la formación médica continua en ortopedia. Se necesitan estudios más amplios para identificar las diferencias en los resultados de aprendizaje de los participantes entre los modelos de apoyo docente síncrono y asíncrono.

Botulinum Neurotoxin-A Injection in Adult Cervical Dystonia and Spastic Paresis: Results From the INPUT (INjection Practice, Usage and Training) Survey.

Botulinum toxin-A (BoNT-A) is an effective treatment for cervical dystonia (CD) and spastic paresis (SP), but it requires in-depth knowledge of anatomy and injection techniques. The Ixcellence Network® is an educational programme to provide neurology, neuropaediatrics, and physical medicine and rehabilitation (PMR) specialists with access to best clinical practices and innovations regarding SP and CD management with BoNT-A. To assess the benefits of such educational programmes and identify unmet needs, a multidisciplinary scientific committee designed INPUT (INjection Practice, Usage & Training), an international multicentric survey describing training and practices among this trained and experienced population. A self-completed questionnaire was sent online to 553 trainees and 14 trainers from the Ixcellence Network®. Among the 131 respondents, 92% specialized in PMR (48%) or neurology (44%), with a mean experience of 15.5 years in their clinical fields and 10.9 years of BoNT-A injection. Most of them (98%) reported having received training before performing their first BoNT-A injection and attending specific courses on how to perform it without any instrumental guidance (76%), and with ultrasound (73%), electrical stimulation (44%) or electromyography (41%). In terms of practices, 92% of respondents reported using at least one guidance technique while injecting, with ultrasound being the most used technique (48%). Attending specific courses was significantly associated with greater self-confidence and use, e.g. for injection with ultrasound, mean self-confidence, on a scale from 1 (not confident) to 10 (fully confident), was 7.9 for trained respondents (vs 4.0 for untrained respondents, p < 0.001) of whom 70% stated that they used this technique regularly or systematically (vs. 11% of untrained healthcare professionals (HCPs), p < 0.0001). Moreover, 84% of respondents reported having trained colleagues, residents or fellows through theoretical (70%) or practical teaching in individuals (80%) or in small groups (65%). Overall, 86% of respondents reported a notable increase over the past 5 years of the number of patients treated with BoNT-A. INPUT is the first international survey describing training and practices in SP and CD management of physicians who attended a dedicated educational programme. The results highlighted the importance of training for self-confidence, and the use of specific techniques and new approaches.

De la educación médica continua al desarrollo profesional continuo basado en competencias / From continuous medical education to competence-based continuous professional development

Introducción: En la última década ha existido una evolución conceptual y documental que abarca desde la educación médica continua, el desarrollo profesional continuo hasta el desarrollo profesional basado en competencias. Objetivo: Revisar el estado actual de la educación médica continua en el mundo, su evolución y las posibilidades de su perfeccionamiento en Cuba. Métodos: Se realizó una revisión bibliográfica en las bases de datos MedLine, PubMed, SciELO, LILACS mediante los descriptores: "educación médica continua" y "desarrollo profesional continuo". Se priorizaron las revistas internacionales de educación médica y los artículos de los últimos 5 años. Asimismo, se revisó el sitio web de la federación mundial de educación médica. Resultados: La educación médica continua y permanente constituye un principio de la educación médica. Esta transita desde la educación médica continua hasta el desarrollo profesional continuo, y luego al desarrollo profesional continuo basado en competencias y a la educación continua interprofesional. Se muestra la evolución conceptual, y se relaciona la educación médica basada en competencias con el desarrollo profesional continuo. Se mencionan las características de una efectiva educación médica continua y un desarrollo profesional continuo, que pudieran ser aplicables a nuestro contexto. Conclusiones: La necesidad de perfeccionar y mejorar el nuevo modelo económico y social del país ha requerido nuevas resoluciones ministeriales y estatales acerca del desarrollo profesional continuo de los trabajadores y profesionales del país, incluidos los del sector de la salud. Se requiere actualizar los conceptos y las prácticas en este orden para estar a tono con las tendencias internacionales(AU)

Introduction: In the last decade, there has been a conceptual and documental evolution that ranges from continuous medical education and continuous professional development to competence-based professional development. Objective: To review the updated theory about continuous medical education worldwide, its evolution and the possibilities for its improvement in Cuba. Methods: A bibliographic review was carried out in the databases MedLine, PubMed, SciELO, and LILACS, using the descriptors educación médica continua [continuous medical education] and desarrollo profesional continuo [continuous professional development]. We prioritized international medical education journals and articles within the last five years. We also reviewed the website of the World Federation for Medical Education. Results: Continuous and permanent medical education is a principle of medical education. It evolves from continuous medical education to continuous professional development, and then to continuous competence-based professional development and continuous interprofessional education. The conceptual evolution in this area is shown, and competence-based medical education is presented with a focus on its relation with continuous professional development. The characteristics are mentioned corresponding to effective continuous medical education and continuous professional development, which could be applied in our setting. Conclusions: The need to perfect and improve the new economic and social model of the country has required new ministerial and state resolutions concerning continuous professional development of the country's workers and professionals, including those in the health sector. Updating concepts and practices in this respect is required in order to be in tune with international trends(AU)

Resultados de trabajo del Grupo para el Estudio de las Competencias en Salud / Work outcomes of the Group for the Study of Health Competences

Introducción: las competencias y el desempeño laboral de los profesionales de la salud han constituido una preocupación de los sistemas de salud en el mundo para incrementar la calidad de los servicios y ha exigido a las universidades de ciencias médicas aportarles un profesional con adecuada capacidad y modo de actuación profesional. Objetivo: informar a la comunidad científica los resultados de trabajo y aportes científicos del Grupo para el Estudio de las Competencias en Salud durante los años 2015-2016. Métodos: se realizó un estudio cualitativo de carácter descriptivo de la actividad científica que ha desarrollado el Grupo para el Estudio de las Competencias en Salud. Se efectuaron diversas actividades como talleres, conferencias, presentación de temas y grupo de discusión. Resultados: el grupo integrado por 15 profesionales de la Universidad de Ciencias Médicas de La Habana, se trazó diferentes objetivos de trabajo y debatió sobre temas relacionados con definiciones, historia y evolución de las competencias, metodologías, cienciometría y competencias profesionales en Medicina Interna, Medicina Intensiva y Emergencias y Pediatría, fundamentalmente. Se realizaron 15 publicaciones científicas en 7 revistas nacionales e internacionales, dos tesis doctorales y se aplicó un programa académico en el internado vertical de la carrera de medicina por competencias profesionales. Conclusión: el Grupo para el Estudio de las Competencias en Salud ha realizado un encomiable trabajo de desarrollo tecnológico, prospectivo, propositivo y de proyección estratégica en múltiples esferas de las ciencias biomédicas, con resultados muy positivos en su producción científica para desarrollar y perfeccionar el enfoque de las competencias en salud en Cuba(AU)

Introduction: Competences and work performance of health professionals have been a concern of the health systems in the world for increasing the quality of services, and have required, from the universities of medical sciences, to provide them with professionals with adequate capabilities and professional performance. Objective: To inform the scientific community of the results of work and scientific contributions of the Group for the Study of Health Competences during the years 2015-2016. Methods: A qualitative study of a descriptive nature of the scientific activity developed by the Group for the Study of Health Competences was carried out. Various activities were carried out, such as workshops, conferences, presentation of topics and discussion group. Results: The group made up by 15 professionals from the University of Medical Sciences of Havana, set out different work objectives and discussed issues related to the definitions, history and evolution of competences, methodologies, scientometrics, and professional competences in Internal Medicine, Intensive Medicine and Emergencies and Pediatrics, mainly. Fifteen scientific publications were made in seven national and international journals, two doctoral dissertations and an academic curriculum was applied in the vertical internship of the medical major for professional skills. Conclusion: The Group for the Study of Health Competences has carried out a praiseworthy work of technological development, also prospective, propositive and of strategic projection in multiple areas of the biomedical sciences, with very positive results in its scientific production for developing and improving the approach of health competences in Cuba(AU)

Identificación de las habilidades conductuales y actitudinales del especialista en medicina intensiva y emergencia / Identification of behavioral and attitudinal abilities of the intensive and emergency medicine specialist

Introducción: la Universidad de Ciencias Médicas cubana enfrenta el desafío de cumplir su misión social y lograr la formación con pertinencia y calidad del profesional de la salud que la sociedad necesita. El perfil profesional de la especialidad de Medicina Intensiva y Emergencia (MIE) no refleja la totalidad de las habilidades conductuales y actitudinales a desarrollar por los médicos intensivistas en los servicios. Objetivo: identificar las habilidades conductuales y actitudinales de los especialistas en MIE en correspondencia con la atención que requieren los pacientes graves o críticos. Métodos: se realizó una investigación de desarrollo desde abril 2011 a septiembre 2013. Se empleó una estrategia metodológica diseñada en tres etapas. Se aplicaron técnicas cualitativas y participaron 82 profesionales seleccionados por un muestreo intencional de máxima variación. En la primera etapa se utilizó el análisis documental y criterios de informantes claves. En la segunda, se constituyen dos grupos de expertos, uno trabajó mediante diferentes técnicas grupales y el segundo a través del método Delphi. En la última etapa, se emplearon entrevistas semiestructuradas y a profundidad, y se utilizó el método Delphi con un cuestionario para valoración del grado de importancia por prioridades. Resultados: se identificaron 19 habilidades conductuales y actitudinales que responden a las necesidades de la profesión. Conclusiones: se identifican las habilidades conductuales y actitudinales del médico especialista en MIE, lo cual constituye un producto para el perfeccionamiento educativo y futuras transformaciones del currículo de la especialidad en Cuba.

Introduction: the University Of Medical Sciences Of Cuba meets the challenge of fulfilling its social mission and achieves at the same time a suitable quality formation of the health professionals that the society demands. The professional profile of the intensive and emergency medicine specialty does not show the behavioral and attitudinal skills to be developed by intensive care physicians at work. Objective: to identify the behavioral and attitudinal skills of this specialty physicians in line with the care that the seriously- and critically-ill patients require. Methods: a developmental research was carried out from April 2011 through September 2013. A three-phase methodological strategy was used as well as qualitative techniques. Eighty two professionals, selected by top variation intentional sampling, participated. The first phase used the documentary analysis and the key informant criteria. The second one formed two groups of experts to work with different group techniques and with the Delphi's method, respectively. The last phase used semi-structured and in-depth interviews and the Delphi's method with an assessing questionnaire for the level of importance by priority. Results: Nineteen behavioral and attitudinal skills that meet the professional requirements were identified. Conclusions: behavioral and attitudinal skills of the intensive and emergency medicine specialists were identified, which is a product for the educational improvement and the future changes in the curriculum of this specialty in Cuba.

Evolución histórica y perspectivas futuras de la medicina intensiva y emergencia como especialidad en Cuba / Historical development and future prospects of the intensive and emergency medicine as specialty in Cuba

Las especialidades médicas son una continuación necesaria para el desempeño de la profesión con un carácter más especializado, como expresión de superación permanente y en respuesta a exigencias de la sociedad. En el trabajo se expone el desarrollo histórico y el contexto social en que se ha desenvuelto la especialidad de Medicina Intensiva y Emergencia en Cuba; se conceptualiza la Medicina Intensiva como especialidad en el mundo y se define el modelo cubano de atención relacionado con ella. Se realizó un análisis del macrocurrículo, se enunciaron criterios de expertos e informantes clave y la experiencia de los autores. Se concluyó que, a 15 años de establecida esta especialidad, el currículo necesita renovación y actualización a la luz de los conocimientos científicos actuales, del desarrollo tecnológico, de las tendencias de la especialidad, de las condiciones socioeconómicas del país y del perfil ocupacional del intensivista cubano.

Medical specialties are the necessary continuation of the professional performance but with more specialized characteristics, as an expression of permanent upgrading responding to the demands of the society. This paper presented the historical development and the social context of the intensive and emergency medicine specialty in Cuba; it conceptualized the intensive medicine as a worldwide specialty and defined the Cuban health care model related to it. The macrocurriculum was analyzed; the criteria of experts and key informants as well as the authors' experiences were stated. It was concluded that after 15 years of the emergence of this specialty in Cuba, the curriculum needs to be refreshed and updated in the light of the current scientific knowledge, the technological development, the trends in the specialty, the socioeconomic conditions of the country and the occupational profile of the Cuban intensive medicine specialist.

Subutilization of COPD guidelines in primary care: a pilot study.

SUMMARY: Despite the popularity of chronic obstructive pulmonary disease (COPD) guidelines, studies have reported important deficits among primary care physicians (PCPs) with respect to diagnosis and treatment of COPD; as a consequence, COPD remains underrecognized and undertreated. METHODS: This was a multicenter pilot study to assess prescribing practices for COPD by PCPs according to COPD guidelines. This was a 2-phase study: In phase 1, PCPs from 27 Mexican cities, referred patients for evaluation, including spirometry and in phase 2, PCPs from 10 of those same cities were asked to answer a questionnaire on COPD practice guidelines. RESULTS: A total of 2293 subjects were included in phase 1; 472 (20.6%) had a FEV1/FVC <70%. Only 39% of patients with 30% ≤ FEV1 < 50% and 22% with FEV1 <30% were receiving combination therapy (long-acting bronchodilator + inhaled steroid). In phase 2, we recruited 999 PCPs; 72.5% of them said that they had read a COPD guideline and 59.4% answered that they used one in their practice. When asked which guideline(s) they used, we had 86 different responses with GOLD (Global Initiative for Chronic Obstructive Lung Disease; 34.1%) being the most common, followed by GINA (Global Initiative for Asthma; 12.8%). When asked why they did not used a guideline, we got 33 different answers; "never read them" was the most frequent answer (41.8%) followed by "lack of access to them" (18.2%) and "not enough time to read them" (6.0%). CONCLUSION: Despite the existence and availability of evidence-based guidelines, only a minority of primary health care COPD patients in Mexico are receiving state-of-the-art treatment at the primary care level.

Caracterización de la formación salubrista en docentes del Premédico de la Escuela Latinoamericana de Medicina / Characterization of the public health formation of the undergraduate education professors in the Latin American School of Medicine

Objetivo: caracterizar el nivel de los conocimientos, habilidades y valores salubristas en docentes del Premédico de la Escuela Latinoamericana de Medicina. Métodos: estudio observacional, descriptivo y transversal en la Escuela Latinoamericana de Medicina, curso 2010-2011. La variable Formación salubrista de los docentes de Premédico se representó a partir de las dimensiones: conocimientos, habilidades y valores salubristas. La información para la caracterización y evaluación de los conocimientos salubristas de los docentes, se obtuvo mediante instrumentos elaborados por las autoras y validados por criterios de experto en comprensión y contenido. Se utilizó triangulación de la información procedente de revisión documental, observación directa y no participante para el control a clases y otras actividades metodológicas, que permitió caracterizar el estado de la formación salubrista de los docentes. Resultados: el conocimiento salubrista fue evaluado de regular, las habilidades, de insuficiente y los valores, de excelente. La categoría docente, la superación y el enfoque salubrista del plan de estudio, resultaron insuficientes. Conclusiones: los limitados conocimientos y habilidades salubristas en el plan de estudio del curso Premédico y en los docentes, justifica replantearse estrategias para el perfeccionamiento en esta fase del proceso docente del futuro médico

Objective: To characterize the level of knowledge, skills and values referred to the public health in the undergraduate education professors in the Latin American School of Medicine. Methods: An observational, descriptive and cross-sectional study was carried out in the Latin American School of Medicine in the 2010-2011 academic year. The variable formation in public health of the undergraduate education professors was represented by dimensions such as knowledge, skills and values in public health. Through instruments devised by the authors and validated by the expert's criteria in terms of comprehension and contents, the information for the characterization and the evaluation of the public health knowledge of the professors was obtained. Results: The public health knowledge was considered as regular, the public health skills were poor but the public health values were regarded as excellent in the teaching staff. The teaching category, the upgrading of knowledge in the public health topics and the public health approach of the curricula were also poor. Conclusions: The lack of appropriate knowledge and skills in public health observed in the undergraduate curricula and in the educators supports the reshaping of strategies to improve this phase of the formation process of the future physician

General practice physician knowledge about headache: evaluation of the municipal continual medical education program / Conhecimento dos médicos generalistas sobre cefaléias: avaliação de um programa municipal de educação médica continuada

OBJECTIVE: Headache is a common condition not always managed satisfactorily by primary care providers (PCPs). In an effort to improve headache care, the Curitiba City Hall in consortia with Hospital de Clínicas da Universidade Federal do Paraná - Brazil developed an educational program directed to the PCPs. The goal of the project was to evaluate, to update and to train the PCP on headache knowledge and care. METHOD: The program was designed to have a theoretical phase and a practical phase. Knowledge on headache and medical care of headache were surveyed before and after the theoretical phase thorough a specific questionnaire. RESULTS: Significant improvement in post-CME scores on headache prevalence (p<0.001), migraine diagnosis (p<0.001) and management (p=0.01), secondary headache diagnosis (p=0.005) and management (p=0.005) was reached by the respondents. CONCLUSION: Improvement in post-CME scores confirms that the program had a significant immediate impact on the PCPs knowledge directly affecting the patient's health.

OBJETIVO: Cefaléia é uma condição comum nem sempre tratada de forma adequada pelos médicos generalistas (MG). Com o objetivo de melhorar essa situação, a Prefeitura de Curitiba em parceria com o Hospital de Clínicas da Universidade Federal do Paraná - Brasil desenvolveu um programa para os MG. O objetivo principal desse projeto foi avaliar, atualizar e capacitar médicos a respeito do conhecimento e manejo das cefaléias. MÉTODO: O programa consistiu de uma fase teórica e uma fase prática. O conhecimento sobre cefaléia e seu manejo foi avaliado através de um questionário específico antes e depois da fase teórica. RESULTADOS: Significativa melhora no pós-teste nos itens de prevalência de cefaléias (p<0,001), diagnóstico de migrânea (p<0,001) e seu manejo (p=0,01), diagnóstico de cefaléia secundária (p=0,005) e seu manejo (p=0,005) foram alcançados pelos participantes. CONCLUSÃO: Melhorias na pontuação dos pós-testes confirmam que o programa teve um impacto imediato e significante no conhecimento dos MG afetando diretamente a saúde dos pacientes.