Formação em tomada de decisão compartilhada de estudantes de medicina na graduação: uma análise na Universidade Federal do Tocantins
Data
2022-07-26
Autores
Pedreira, Paulo Geovanny 
Orientadores
Batista, Nildo Alves
Tipo
Tese de doutorado
Título da Revista
ISSN da Revista
Título de Volume
Resumo
Introdução: Tomada de decisão compartilhada (TDC) é uma abordagem em que médicos e pacientes compartilham as melhores evidências disponíveis quando confrontados com a tarefa de tomar decisões, nas quais pacientes são apoiados a considerar opções a fim de obter preferências. Apesar de cada vez mais incorporadas no currículo de educação médica, não são encontradas muitas evidências de quais estratégias são mais eficazes para instruir os estudantes de Medicina sobre Atenção Centrada no Paciente (ACP) e TDC durante o curso da sua graduação, especialmente no internato. Objetivos: Analisar a formação em tomada de decisão compartilhada no curso de graduação em Medicina da Universidade Federal do Tocantins (UFT). Métodos: Análise documental do projeto pedagógico do Curso de Medicina da UFT e de 118 atas de reunião de colegiado para investigar proposta a formativa referente ao desenvolvimento de competências relacionadas a ACP e TDC. Para analisar a aprendizagem em TDC, foram realizadas duas etapas de coleta de dados: aplicação de uma escala atitudinal tipo Likert junto a 116 internos do internato da clínica médica; e entrevista de aprofundamento realizada com 7 internos e 7 professores do curso de Medicina da UFT. Resultados: Análise documental do projeto pedagógico do curso de medicina e 2 das atas de reunião de colegiado mostraram que a formação com base na ACP ainda se mostra incipiente, principalmente se levarmos em conta o ensino de TDC. Contudo, foram encontrados indicativos indiretos de preparo para a perspectiva do cuidado baseado na integralidade do sujeito. Os resultados conjugados da escala atitudinal e entrevistas de aprofundamento mostraram percepções de prejuízo no ensino de TDC antes e durante o internato de clínica médica; prejuízo de ensino das habilidades de comunicação e das considerações dos aspectos emocionais e as preferências dos pacientes; contudo já dizem estimular a formação do aluno nas competências de comunicação e preferências do paciente. Os entrevistados reconhecem que os estudantes do curso de Medicina, principalmente os internos de clínica médica, são prejudicados quanto à concessão de autonomia ao abordar o paciente para TDC. Sobre o ensino de TDC na etapa pré-internato os entrevistados reconhecem o ensino formal de TDC, mas de maneira deficitária, e a abordagem do ensino na forma de currículo oculto é muito presente. Durante o internato, os entrevistados reconhecem que há ensino planejado de TDC durantes as práticas na forma de discussão dos casos, práticas acolhedoras e consideração das preferências do paciente baseadas em evidências. Contudo, a presença do ensino na forma de currículo oculto também é muito evidente. Reconhecem que a pouca abordagem do ensino de TDC se dá pela falta de tempo acarretada pela alta demanda de pacientes e por deficiência da qualificação dos preceptores em metodologias centradas no paciente; reconhecem que no internato de clínica médica existe pouco protagonismo do interno para realizar a TDC, muitas vezes acentuada pela hierarquia dos cenários de ensino, onde o residente tem a preferência no manejo do paciente. Conclusões: Mesmo com o surgimento de matrizes curriculares teoricamente voltadas para ACP, a sua implantação e o seu desenvolvimento nas escolas médicas têm sido um grande desafio para as instituições de ensino. Ainda que o currículo de Medicina da UFT aponte para ações centralizadas no paciente, a formação tanto teórica e principalmente prática – como no internato, revela fragilidades e desafios a serem superados. Nas práticas do internato a relação do estudante com o paciente tende a ser de maior proximidade com importante reconhecimento dos seus valores, sejam eles emocionais, culturais e afetivos podendo marcar sua futura práxis nas relações terapêuticas que irá desenvolver ao longo de sua carreira.
Introduction: Shared decision making (SDM) is an approach in which physicians and patients share the best available evidence when faced with the task of making decisions, in wich patients are supported to consider options in order to obtain preferences. Despite being increasingly incorporated into the medical education curriculum, there is not much evidence of which strategies are most effective for instructing medical students on Patient-Centered Care (PCC) and SDM during their undergraduate course, especially in internship. Objectives: To analyze the training in shared decision-making in the undergraduate medical course at the Tocantins Federal University (UFT). Methods: Documental analysis of the pedagogical project of the UFT medical course and 118 documents of a collegiate meeting to investigate a training proposal regarding the development of competences related to PCC and SDM. To analyze the learning in SDM, two stages of data collection were carried out: application of a Likert-type attitudinal scale with 116 interns of the medical clinic internship; and in-depth interview conducted with 7 interns and 7 professors of the Medicine course at UFT. Results: Documentary analysis of the pedagogical project of the UFT medical course and 2 documents of the collegiate meeting showed that training based on pedagogical course project is still incipient, especially if we take into account the teaching of SDM. However, indirect indications of preparation for the perspective of care based on the integrality of the subject were found. The combined results of the attitudinal scale and in-depth interviews showed the participants' perceptions: impairment in the teaching of SDM before and during the medical clinic internship; loss of teaching communication skills and considerations of emotional aspects and preferences of patients, however, they already say that it stimulates the formation of the student in communication skills and patient preferences. Respondents recognize that medical students, especially interns, are harmed in terms of granting autonomy to approach the patient for SDM. About the teaching of SDM in the pre-boarding stage, the interviewees recognize the formal teaching of SDM in the pre-boarding stage, but in a deficient way, and the approach to teaching in the form of a hidden curriculum is very present. During the medical internship, the interviewees recognize that there is planned teaching of SDM during the practices in the form of case discussion, welcoming practices and consideration of the patient's preferences based on evidence, however the presence of teaching in the form of a hidden curriculum is also very evident. Respondents recognize that the lack of approach to SDM teaching is due to the lack of time caused by the high demand of patients and the deficiency in the qualification of preceptors in patient-centered methodologies; recognize that in the medical clinic internship there is little role for the medical intern to perform SDM, often accentuated by the hierarchy of teaching scenarios, where the resident has the preference in patient management. Conclusions: Even with the emergence of curricular matrices theoretically focused on PCC, its implementation and development in medical schools has been a major challenge for educational institutions. Although the UFT Medicine curriculum points to patient-centered actions, both theoretical and mainly practical training - as in internship, reveals weaknesses and challenges to be overcome. In internship practices, the student's relationship with the patient tends to be closer, with important recognition of their values, whether emotional, cultural and affective, which can mark their future praxis in the therapeutic relationships that they will develop throughout their career.
Introduction: Shared decision making (SDM) is an approach in which physicians and patients share the best available evidence when faced with the task of making decisions, in wich patients are supported to consider options in order to obtain preferences. Despite being increasingly incorporated into the medical education curriculum, there is not much evidence of which strategies are most effective for instructing medical students on Patient-Centered Care (PCC) and SDM during their undergraduate course, especially in internship. Objectives: To analyze the training in shared decision-making in the undergraduate medical course at the Tocantins Federal University (UFT). Methods: Documental analysis of the pedagogical project of the UFT medical course and 118 documents of a collegiate meeting to investigate a training proposal regarding the development of competences related to PCC and SDM. To analyze the learning in SDM, two stages of data collection were carried out: application of a Likert-type attitudinal scale with 116 interns of the medical clinic internship; and in-depth interview conducted with 7 interns and 7 professors of the Medicine course at UFT. Results: Documentary analysis of the pedagogical project of the UFT medical course and 2 documents of the collegiate meeting showed that training based on pedagogical course project is still incipient, especially if we take into account the teaching of SDM. However, indirect indications of preparation for the perspective of care based on the integrality of the subject were found. The combined results of the attitudinal scale and in-depth interviews showed the participants' perceptions: impairment in the teaching of SDM before and during the medical clinic internship; loss of teaching communication skills and considerations of emotional aspects and preferences of patients, however, they already say that it stimulates the formation of the student in communication skills and patient preferences. Respondents recognize that medical students, especially interns, are harmed in terms of granting autonomy to approach the patient for SDM. About the teaching of SDM in the pre-boarding stage, the interviewees recognize the formal teaching of SDM in the pre-boarding stage, but in a deficient way, and the approach to teaching in the form of a hidden curriculum is very present. During the medical internship, the interviewees recognize that there is planned teaching of SDM during the practices in the form of case discussion, welcoming practices and consideration of the patient's preferences based on evidence, however the presence of teaching in the form of a hidden curriculum is also very evident. Respondents recognize that the lack of approach to SDM teaching is due to the lack of time caused by the high demand of patients and the deficiency in the qualification of preceptors in patient-centered methodologies; recognize that in the medical clinic internship there is little role for the medical intern to perform SDM, often accentuated by the hierarchy of teaching scenarios, where the resident has the preference in patient management. Conclusions: Even with the emergence of curricular matrices theoretically focused on PCC, its implementation and development in medical schools has been a major challenge for educational institutions. Although the UFT Medicine curriculum points to patient-centered actions, both theoretical and mainly practical training - as in internship, reveals weaknesses and challenges to be overcome. In internship practices, the student's relationship with the patient tends to be closer, with important recognition of their values, whether emotional, cultural and affective, which can mark their future praxis in the therapeutic relationships that they will develop throughout their career.
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Citação
PEDREIRA, Paulo Geovanny. Formação em tomada de decisão compartilhada de estudantes de medicina na graduação: uma análise na Universidade Federal do Tocantins. 2022. 230 f. Tese (Doutorado Interdisciplinar em Ciências da Saúde) - Instituto de Saúde e Sociedade, Universidade Federal de São Paulo, Santos, 2022.