O conceito de competência: uma análise do discurso docente / The concept of competence: an analysis of the teachers' perspective

As Diretrizes Curriculares Nacionais para o Curso de Medicina de 2001 têm como eixo norteador 28 competências, sem uma definição do conceito de competência utilizado. Na literatura há uma série de definições, sendo esse tema vasto e polêmico. Desse modo, a forma como a competência é compreendida pelo docente terá um impacto direto na formação do aluno. Com a finalidade de clarificar o conceito de competência médica adotado por docentes do curso de Medicina de uma universidade, foi realizada uma pesquisa qualitativa a partir da apresentação e questionamentos frente a um caso clínico comum. Para a síntese, organização e análise desses discursos foi utilizado o método do Discurso do Sujeito Coletivo. Entre os conceitos de competência pode-se notar a aplicabilidade prática dos conhecimentos, das habilidades e atitudes, aliada a uma prática reflexiva e ética. Esta última tem destaque e é um pilar das competências. Atitudes como comprometimento e respeito foram apontadas como essenciais para apresentar competência. As atitudes e a ética têm um papel central na competência do egresso, e estratégias para estimular seu desenvolvimento devem ser um dos focos da formação médica.

The National Curriculum Guidelines for the Medical course of 2001 have 28 core competences, but lack any defined concept of competence used. A number of definitions can be found in literature; this is a vast and controversial subject. Thus, the way in which teachers understand competence will have a direct impact on student education. A qualitative study was conducted among medicine teachers in order to clarify their concept of medical competence, based on the presentation of a common clinical case and related questions. Discourse of the Collective Subject was the method used to organize and analyze these persepctives. The concepts of competence found included the practical applicability of knowledge, skills and attitudes combined with reflective and ethical practice. The latter is given particular merit and can be seen as a pillar of the competences. Attitudes such as commitment and respect were identified as essential for displaying competence. It follows that the attitudes and ethics of graduates are key elements to their competence and encouraging their development should be one of the focuses of medical training.

Reflexiones de los funcionarios del Instituto Teletón Valparaíso sobre la familia y el quehacer técnico profesional: un análisis de contenido latente / Latent content analysis: staff considerations on family, technical and professional work at Valparaíso's Teleton Institute

Introduction: In Chile, as well as in the rest of Latin America and the Caribbean region, a progressive change from a bio-medical to a bio-psycho-socio-environmental paradigm has taken place, with regards to the disability/rehabilitation phenomena. The former, is the reference framework for the current paper, which derived from previous research results from "Teletón Valparaíso's staff member's vision on a profile of social inclusion skills to be developed by children and youngsters with disabilities, who exit the institution: A qualitative study", based on the Grounded Theory (GT) methodology. GT recognizes a "manifest content" and a "latent content", gathered througth the research process. Objetive: Centered on the latent content, the objetive of this study, is to find out Valparaíso's Rehabilitation Institute's staff considerations on family, technical and professional work, related to the change in the rehabilitation paradigm mentioned above. Method: Based on the GT qualitative data gathering method, individual semi-structured interviews were conducted with 96.5 percent of staff. Data was processed with Atlas-ti, and the Constant Comparative Method (CCM). Results: The phenomena "Institute's practice" was indentified, which subdivides into two subphenomena: rehabilitation approach and family. Conclusion: A theorical-practical tension was identified about the institution's mission, which promotes some staff tendency to change technical and professional work, and the conception of the family's role in rehabilitation.

Introducción: El paulatino cambo de paradigma, del biomédico al biopsicosocioambiental, que se ha ido experimentando en Chile tanto como en la Región de América Latina y El Caribe, en relación al fenómeno discapacidad/rehabilitación, es el marco de referencia de este trabajo. Este se basa en los resultados de la investigación "Visión de los/as funcionarios de Teletón Valparaíso sobre perfil de competencias de inclusión social a desarrollar en jóvenes viviendo en situación de discapacidad egresados de la institución: un estudio cualitativo" en la que se utilizó el enfoque metodológico de la teoría fundamentada (T.F). Este reconoce un "contenido manifiesto" y un "contenido latente" en la información obtenida a través del proceso investigativo. Objetivo: Conocer las reflexiones que emergen del contenido latente de los/as funcionarios/as sobre la familia y el quehacer técnico profesional y su relación con un cambio en el enfoque de rehabilitación en el instituto de Valparaíso. Metodología: Abordaje cualitativo basado en el método de la T.F. Las técnicas de recolección de datos utilizados fueron las entrevistas individuales semiestructuradas, aplicadas al 96,5 por ciento de los funcionarios de Teletón Valparaíso. Para el procesamiento de la información se utilizó el software Atlas-ti y el "MCC" Método de Comparación Constante. Resultados: Se identificó el fenómeno análisis "Prácticas en el Instituto" aludiendo al enfoque de rehabilitación que los funcionarios reflejan en su quehacer y visión de las familias. Conclusión: Se percibe una tensión teórico-práctica en relación a la misión institucional, lo cual promueve la tendencia de algunos/as funcionarios/as a transformar el quehacer técnico profesional y la concepción del rol familiar.

Missed opportunities to vaccinate in Peru.

PIP: In October 1995, in Peru, the Ministry of Health (MOH) conducted a follow-up survey of missed opportunities to vaccinate children aged less than 2 years to evaluate the impact of recommendations made following the 1990 survey of missed opportunities. The follow-up survey also examined missed opportunities to vaccinate women of reproductive age with tetanus toxoid. 1784 persons accompanying children aged less than 2 years to a health facility and 4299 women of reproductive age were interviewed at 13 hospitals and 14 health centers in six departmental health units. Vaccination data for the children were collected from vaccination cards (21%) and verbally by the accompanying person (79%). Those for the women were collected from vaccination cards (11%) and verbal histories (89%). Between 1990 and 1995, missed opportunities decreased from 52% to 13%. The reduction was 75% for children aged less than 2 years and 84% for infants. The key causes of missed opportunities were different in 1995 than those in 1990. Between 1990 and 1995 false contraindications increased 60%. Negative attitudes of health workers were responsible for 32% of missed opportunities in 1990, while they were responsible for only 4% in 1995. Other important causes of missed opportunities were policy/logistics (19%) and family attitudes (17%). Missed opportunities were common in 47% of women of childbearing age. The first dose of tetanus toxoid was the most commonly missed dose (40%). Reasons for missed opportunities to vaccinate for tetanus toxoid were policy (31%), personal attitudes (30%), logistics (15%), false contraindications (20%), and health workers' attitude (4%). Based on these findings, MOH developed recommendations to further reduce missed opportunities to vaccinate children and women of childbearing age. For example, training of health workers needs to be improved to reduce the number of false contraindications. MOH must implement strategies to improve accessibility to vaccinations in hospitals.^ieng

Focusing on customer service.

PIP: This booklet is devoted to a consideration of how good customer service in family planning programs can generate demand for products and services, bring customers back, and reduce costs. Customer service is defined as increasing client satisfaction through continuous concern for client preferences, staff accountability to clients, and respect for the rights of clients. Issues discussed include the introduction of a customer service approach and gaining staff commitment. The experience of PROSALUD in Bolivia in recruiting appropriate staff, supervising staff, soliciting client feedback, and marketing services is offered as an example of a successful customer service approach. The key customer service functions are described as 1) establishing a welcoming atmosphere, 2) streamlining client flow, 3) personalizing client services, and 4) organizing and providing clear information to clients. The role of the manager in developing procedures is explored, and the COPE (Client-Oriented Provider-Efficient) process is presented as a good way to begin to make improvements. Techniques in staff training in customer service include brainstorming, role playing, using case studies (examples of which are provided), and engaging in practice sessions. Training also leads to the development of effective customer service attitudes, and the differences between these and organizational/staff-focused attitudes are illustrated in a chart. The use of communication skills (asking open-ended questions, helping clients express their concerns, engaging in active listening, and handling difficult situations) is considered. Good recovery skills are important when things go wrong. Gathering and using client feedback is the next topic considered. This involves identifying, recording, and discussing customer service issues as well as taking action on these issues and evaluating the results. The booklet ends by providing a sample of customer service indicators, considering the maintenance of a customer service focus, and reporting comments from the reviewers of the booklet.^ieng

Wanted: better care for pregnant women.

In three prenatal clinics in Latin America the average attendance time by pregnant women was 129 minutes but the average time spent with a doctor was only 8-10 minutes. In order to improve prenatal care, providers should analyse what happens during visits. Assessments should be made of the usefulness of the services offered and some thought should be given as to who might best provide them.

PIP: An evaluation of 3 prenatal care clinics in Mexico City, Panama City, and Caracas was conducted to examine the effect of long waiting times before appointments on a woman's decision to continue attending clinics. The clinic in Mexico City had more patients per day than did those in Panama City and Caracas (136 vs. 64 and 102). The average daily hours of operation were more or less equal (5 hours, 35 minutes to 6 hours, 31 minutes). There was a wide range in the average waiting time in the clinics (71-190 minutes), but the average time with clinic personnel was about the same (17-21 minutes). The average time patients had with physicians was short (8-10 minutes). Women with high-risk pregnancies were in the clinics for 81-147 minutes, with clinic personnel for 23-25 minutes, and with physicians for 11-15 minutes. The only slightly improved times for high-risk pregnancies suggested inadequate prenatal care. 34% and 47% of the time physicians spent at the clinics in Panama City and Caracas, respectively, consisted of 2-7 minute long interviews. Physical examinations generally lasted on average about 1 minute. They included measurement of uterine height, blood pressure, fetal heart rate, and vaginal and ankle edema examinations. These findings can help clinic staff identify major administrative and management problems and find ways to resolve them. The length of time with clinic personnel and physicians is not conducive to a sympathetic and considerate attitude. Health providers should encourage women to ask questions and express their views. All clinic staff should work to make the clinic atmosphere welcoming. These program managers should use evaluations to analyze what happens during prenatal care visits and to assess the value of the services provided. They can also use evaluations to determine who can best provide prenatal care services.

Breastfeeding gains popularity in Honduras.

PIP: In 1982, a breast feeding support program (PROALMA) first operated in 3 large public hospitals and a large health center in Tegucigalpa and San Pedro Sula, Honduras. It trained health workers about the benefits of breast feeding and lactation management and developed hospital breast feeding policies and practices, e.g., creation of a milk bank for premature newborns. It even convinced hospitals to stop free distribution of infant formula and bottles. In fact, annual expenditures for infant formula at the Social Security Hospital in San Pedro Sula fell from US$ 40,000 to 6000 in 1 year and to 0 by 1990. Hospital practices which were not conducive to breast feeding included separation of newborns from mothers and giving newborns sugar water as their first food. In fact, 69% of mothers at Tegucigalpa hospitals said hospital staff gave their newborns breast milk substitutes within 24 hours of birth. The program began a rooming-in system which made it easier for mothers to initiate early, frequent, and on-demand breast feeding. PROALMA staff were in the maternity wards daily to provide breast feeding counseling. At the end of 3 years, 98% of women delivering at Tegucigalpa hospitals breast fed their infants. The project eventually expanded to hospitals nationwide. Between 1981 and 1988, breast feeding rose from 80% to 93% in cities and from 95% to 98% in rural areas. Further, the median duration of breast feeding increased from 4 months to 10 months (1982-1987) in cities. Yet, just 6% of mothers exclusively breast fed their 3-4 month old infants in 1987. In addition, only 28% exclusively breast fed before introducing the bottle. Staff attitude improved as evidenced by an increase in the percentage of workers promoting breast feeding at birth (37-86% during 1982-1986). PROALMA concluded that increased efforts to promote exclusive breast feeding are needed.^ieng

Assessing the acceptability of NORPLANT implants in four countries: findings from focus group research.

In 1986-87, a qualitative research project was conducted in the Dominican Republic, Egypt, Indonesia, and Thailand to expand understanding of the acceptability of NORPLANT contraceptive implants beyond inferences made on the basis of continuation rates. In each of the four study sites, focus group discussions or in-depth interviews were held with potential acceptors, current NORPLANT users, discontinuers, husbands of women in these three groups, and service providers. Nonclinical participants generally had little formal education and lived primarily in urban or semi-urban areas where NORPLANT has been available for at least five years. The study focused on attitudes, perceptions, and experiences of each group regarding NORPLANT implants. Results suggest that factors having an impact on the acceptability of NORPLANT implants fall into three general categories: medical/technical, cultural/religious, and informational/educational. This article discusses each of these categories, including programmatic implications of the findings, and puts forward recommendations for enhancing NORPLANT introduction efforts on the basis of these findings.

PIP: In 1986-87, a qualitative research project was done in Thailand, Egypt, Indonesia, and the Dominican Republic to expand knowledge of the acceptability of NORPLANT contraceptive implants beyond continuation rates. In each of the 4 studies, in-depth interviews or focus group discussions were held with current NORPLANT users, potential acceptors, discontinuers, husband of women in the 3 groups, and service providers. The 4 countries were chosen because of their diverse cultures and religions. Most participants favored family planning. Many had used other contraceptives. Men and women in all countries were worried that oral female contraceptive agents (the pill) caused cancer. There were many objections to the IUD. In all countries but Thailand, there was little knowledge of NORPLANT. In the Dominican Republic, NORPLANT was used mostly as a child spacing method. In Indonesia, it was used for child spacing and termination of childbearing. Perceived advantages were alike in all countries. Pain during insertion and removal was a big concern of potential users. Men and women in all countries said that religion and traditional beliefs did not influence their family planning decisions. But many said that religion influenced their tolerance of side effects. In Egypt and Indonesia sterilization is unpopular because it is seen as violating Islamic law. Irregular bleeding was the major side effect and the main reason for discontinuation. Many satisfied users felt that the advantaged outweighed the side effects. Primary reasons for removal in all countries were irregular bleeding, amenorrhea, and the desire to give birth. The need for information was mentioned in all countries. In Egypt, Indonesia, and Thailand services providers reported the need for more thorough training in insertion and removal as well as continuing education sessions.

Breast-feeding determinants in Chile.

PIP: In Chile in low income populations, research shows that the longer infants breast feed the lower the incidence of malnutrition (p.05) in these infants. Yet mothers with 9 years of formal education and often members of the low income group are at the highest risk of giving birth to infants 3000 g who are at highest risk of death. Indeed, it is among these groups that infant malnutrition rates are the highest. Therefore, to reduce infant mortality in these groups, more women should breast feed longer. Other determinants of women choosing to not breast feed or not breast feeding for a long period of time in Chile include work, poor nutritional status, smoking, and poor health team attitudes and practices. To counteract the negative trend in breast feeding and thereby increase the duration of breast feeding in low income mothers in Chile, the Ministry of Health (MOH) initiated its National Program for Breast-feeding Promotion (NPBP) in 1980. The educational component included training primary health care and maternity hospital health teams and distribution of educational brochures to pregnant women. If pregnant women weighed less than what the new 1980 standard recommended, they received nutritional supplements as part of the Supplementary Food Program (SPF). A study revealed that in an area where pregnant mothers received educational materials and support from the health team and food supplements, the proportion of 6 month olds exclusively breast fed rose 61.4% (p.001) in 2 years while it rose 40.7% in the area where only the SPF had been implemented. In Santiago, the percentage of breast fed 3 month olds also increased after introduction of NPBP (46%-63% [1977-1982]). The Ministries of Education and Labor could also contribute to healthier babies by preparing a family life curriculum and sponsoring legislation to extend maternity leave for working mothers.^ieng

Primary health care in rural Jamaica.

PIP: 1977 marked the year that the Ministry of Health (MOH) adopted the policy to promote primary health care (PHC) in Jamaica. 1977 health data supported the need for PHC. For example, the birth rate was high (30%), diarrhea and enteric infections were the leading causes of child mortality, and the incidence of sexually transmitted diseases was high. Health committees were formed which provided links with organizations that promoted PHC. Community participation would be crucial to its success. Further, community members were recruited and trained to work as community health aides. The PHC policy included integrating all services--preventive, curative, and rehabilitative--that could be provided at the community level. Specialized preventive and curative medical services would be accessible and feed into the PHC system. Recognizing the need for health care for the entire population, MOH concentrated its efforts in areas where the undeserved and most vulnerable individuals lived, principally in rural areas. The rural population comprised 58% of the population. After a decade of PHC in Jamaica, however, health care has not been dispensed equitably. Constraints to achieving PHC for all include insufficient number of trained personnel, inadequate facilities, and shortage of funds. For example, a substantial expenditure was needed to establish the PHC infrastructure, to allocate manpower, and to provide management of information and technology. Yet the Government's actual expenditure on health care fell 2.9%. Further, traditional attitudes of health care, where users perceive physicians and treatment as the center of health care, continued and often prevailed. In 1987, the Government declared it would reform the national health service so as to provide PHC to all.^ieng

Physicians' views of periodic abstinence methods: a study in four countries.

A study of the knowledge, perceptions, and behavioral intentions of physicians regarding periodic abstinence (PA) methods was undertaken in Mauritius, Peru, the Philippines, and Sri Lanka. Most respondents considered PA to be useful, although even the PA providers prescribed mainly non-PA methods. Detailed knowledge of PA methods was not evident, but most physicians were willing to initiate general discussion about PA with patients. Physicians favored methods perceived as "scientific" and "modern," which primarily prevent pregnancy and secondarily avoid other health risks. When carefully presented as "scientific" and "modern," methods presented to medical audiences may find acceptance and be more likely to result in referral.

PIP: This study attempts to assess the level of knowledge about periodic abstinence methods and willingness to communicate that knowledge to patients among a sample of 375 physicians from 4 developing countries: Mauritius, Peru, the Philippines, and Sri Lanka. For purposes of this study, periodic abstinence includes the calendar method (rhythm), the Billings method (ovulation method), the temperature method (basal body temperature), and the sympto-thermal method (temperature and cervical mucus observation). 54% of the doctors interviewed did not provide periodic abstinence services. 67% were male, 60% were over 40, 92% were not strongly Catholic, and 42% were general practitioners. Older doctors, female doctors, and strongly Catholic doctors were most likely to provide periodic abstinence services. 54% of providers were general practitioners, 46% were gynecologists, and 36% were clinicians. Both providers and nonproviders were most likely to recommend the pill or the IUD as a contraceptive method. The calendar method was the most commonly provided abstinence method. Providers, in general, had more knowledge about abstinence methods than did nonproviders, but even providers were deficient in knowledge about methods that they did not supply. Of the 3 main abstinence methods, the calendar method was perceived as most traditional, the Billings method as most modern. The sympto-thermal method was perceived as modern but also as "artificial." On a scale of 1 to 7 from bad/nonscientific to good/scientific, the pill scored highest (6.4), while the temperature, Billings, and calendar methods scored 5.2 or 5.1. 47% of all the physicians surveyed said that they would not recommend periodic abstinence to their patients. The majority said that they would respond to inquiries about these methods but would not initiate discussions about them. Among nonproviders, 12% said they would seek future training, but 17% said they had no future plans for either training or service.

[Acceptability of medroxyprogesterone acetate among medical and paramedical personnel in family planning]. / Aceptabilidad del acetato de medroxiprogesterona entre personal médico y paramédico en planificación familiar.

PIP: Depot medroxyprogesterone acetate (DMPA) generally injected in doses of 150 mg every 3 months, is offered in the official family planning program of Mexico. The study purpose was to assess the impact of attitudes toward DMPA of medical and paramedical family planning workers on the frequency of prescription and acceptance of DMPA in the national family planning program. A 21-item multiple choice mail questionnaire was returned by 644 persons including 279 physicians, 257 nurses, and 104 social workers from Mexico City and 24 of the 31 states, a response rate of 55.6%. 338 of the respondents worked in health centers, 274 had worked in family planning for less than 1 year, and 427 were female. 365 had previous experience with DMPA. 458 knew the correct quarterly dose. Only 66 persons (10.8%) frequently prescribed DMPA, while 373 (61.1%) occasionally prescribed it and 169 (27.7%) never did so. 582 persons knew of at least 2 other injectable contraceptives. Among side effects, 423 persons mentioned frequent amenorrhea, 267 frequent bleeding, and 329 a reduction of future fertility. 203 mentioned that it did not affect lactation. 361 noted that it has high contraceptive efficacy. 439 considered administration of DMPA simple and 235 thought it was a good contraceptive. Asked what type of injectable contraceptive they preferred, 148 selected a combined monthly injection, 125 selected a progestogen every 84 days, and 115 selected DMPA. 416 considered their information on DMPA to have come from scientific sources. Medical journals were cited by 156, training courses by 271, and commercial promotions by pharmaceutical companies by 236. 612 persons (97.0%) felt that more training on DMPA use should be provided for family planning personnel, and 594 (94.7%) felt that users should receive more information. Discrepancies in the knowledge of DMPA among family planning workers indicate the need for improved training of new family planning workers and for continuing education of experienced workers.^ieng

[Attitude of the physician towards abortion]. / Actitud del médico ante el aborto

PIP: A survey was conducted among 315 physicians in order to understand their attitude and professional opinion about abortion. The number of illegal induced abortions was 62.4 (directly/subject). 78% of the physicians considered that illegal induced abortion in Mexico is greater than 6% of all pregnancies. The attitude against abortion on demand was over 60%. However, in situations of high risk for the mother or fetus, physician attitude was quite favorable (74.9-95.4%). This includes those who are practicing Catholics and who are strongly anti-abortion. The results of this survey as compared with similar data from a previous survey among Mexican women, indicate a great illegality index as to the occurrence of abortion in Mexico. Present legislation is discussed and possible reforms are presented. (author's modified)^ieng

[Attitude of the physician forwards anticonception]. / Actitud del médico ante la anticoncepción

PIP: A survey was conducted in Mexico City among 316 physicians working with the Mexican Institute of Social Security to investigate their attitudes toward fertility control. Most physicians were married with an average family size of 2.1, and with an average length of marriage of 8.4 years. 20% were pediatricians, 15% surgeons, 12% obstetricians; over 25% were nonpracticing catholics, 15% were practicing catholics, and almost 20% professed no religion. Over 80% of doctors had utilized or were utilizing a contraceptive method; 32% the pill, 15% the IUD, and 13% the rhythm method; previous use for the same methods was 38.2%, 3.2% and 18.5%, respectively. The temporal method most recommended was oral contraception, 42.4%, and the IUD, 36.9%; permanent methods recommended were male sterilization, 51.2%, and female sterilization, 25.3%. Married physicians were using or had used contraception more than unmarried physicians. 20.7% of practicing catholics were not using contraception as compared to 31% who were using the pill, and 24.2% who were using the rhythm method. Practicing catholic physicians were the ones that least recommended temporal or permanent contraception, with 9.1% and 15.4%, respectively. There were no significant differences either in use or in recommendation of contraception among the different medical specialties. All doctors were in favor of sexual sterilization for reasons of mental or physical health or for genetic reasons. Over 93% found contraception to be beneficial to the Mexican people for economic, social, and cultural reasons. The sample of doctors investigated cannot be considered as representative of the medical population of the nation.^ieng