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The medical education and the Unified Health System

Alexandre V. Brick

DOI: 10.5935/1678-9741.20120052


NCBB: National Conference of Brazilian Bishops

NCG: National Curriculum Guidelines

UHS: Unified Health System

UNESCO: United Nations Educational, Scientific and Cultural Organization

The 2012 Fraternity Campaign had as its theme "Fraternity and Public Health" and the motto "Let health be spread all over the Earth." The objective of the National Conference of Brazilian Bishops (NCBB) was to reflect on the reality of Brazil's healthcare and encourage the mobilization for improvements in public service and reinforces the need for greater attention to the sick in their quest for a healthy life.

It focuses on the inefficiency of the Unified Health System (UHS) at variance with the particular services, which is still reinforced by budget cuts, subjecting the patient to long lines for the service, taking a long time to take exams, lack of vacancies in hospitals and even medications.

Noting that health promotion is not a favor from the government, but a social right, the campaign urged Brazilian students to this debate, because there is no point examining the inefficiency of this service without a commitment to promote improvements, an important factor for their own professional training of students, including the implementation of interdisciplinary training.

In evidence to the setting of public policies in health, training of health professionals (here, specifically, medical training) represents an arid terrain that raises questions and conflicts and the changes it requires.

In the management, it is really hard to make the school / university to work as a hospital or an orchestra. In hospitals, the excuses are in cemeteries. In orchestras, the discord is answered by people booing them.

Representing privileged sites of knowledge production and discussion, the schools still reflect and reproduce the logic of the fragmented scientism itself, failing to leverage the very richest in the field of education: possible relationships to be developed between professor and student, and later on, revert to the relationships established between professionals and their patients, or between those who care and who are cared for. The neglect of the area of interpersonal relations has been expressed, among other results, the low rates of resolution of the UHS, the dissatisfaction of many professionals and users of services and use of high-cost procedures, which are often unnecessary.

We can assume that, as constitutionally guaranteed, the USH as the ordering of human resources in health is still restricted to the theoretical dimension. Recognizing it as a training officer requires extensive restructuring in medical curriculum, specifically to be held by successive and ongoing curricular innovations, guided by the principle of comprehensiveness - complex notion that articulates concepts and practices of health - and the review process labor and management in health. For this purpose, disruptions of the biomedical paradigm are necessary, which still maintains health practices and many of the medical curricula in Brazil, and the simplistic concept that "being healthy is not a disease," which means removing the focus of welfare actions and understand that care, rather than assistance, should combine actions of disease prevention, health promotion, beyond cure and rehabilitation - all requiring plurality of knowledge, and also interdisciplinary and multiprofessional teamwork , preferably network.

However, these actions do not occur by themselves, they involve a number of procedures and decisions that depend on the government, managers of services, the community and in particular, the academic world. How can the courses organize themselves to form a professional capable of working under this new paradigm in the health area?

The National Curriculum Guidelines (NCG) [1] for the courses in the area of health, approved in 2001 and resulting from a process of discussion between government representatives, professors, students, pro-deans and principals of schools, among others, are designed to guide their training, based on general knowledge and emphasis on social commitment. This means rethinking the role of the school that, until then, would never interact with society.

If taken as a benchmark for innovation, these guidelines represent undoubtedly a major task for the institutions of higher education, by introducing new elements, which show forms of organization and management of teaching that have never been used in Brazil's academic levels. It is proposed to guide the medical courses, among others, to innovate their curricula so that they are linked to the needs of Brazilian society, seeking "dialogue" of the curriculum projects with the social context in which the university is a part; guiding the training of professionals who are able to act at different levels of health care, being competent to work, especially in primary care and social responsibility. This is a new fact that requires a high level of technical complexity.

However, there is a long way to go, in which universities play an important role as agents of this process. Medical schools are, mostly, playing a dichotomized training, disciplinary expressed in the curriculum, fragmented and focused on specialties, with the prevailing field of practice the university hospital, emphasizing the procedurecentered health practices disregarding the user- centered ones.

Approaching the guidelines of UHS, it is not hard to see that the project of transforming the health care of the Brazilian population has been designed without taking into account the actors who would make the system work. By using an analogy: a machine with high technology and high complexity does not work if there is someone able to operate it. This can be transcribed to the current policy of Public Health, created a Unified Health System, but those involved in its implementation, operation and maintenance are not committed or prepared to act in this system, since the training institutions did not follow the changes resulting from this new orientation. In theory, it is attributed to the UHS the authority to order the formation of human resources in health, based on a new model that integrates the theoretical with the practical services. It is necessary and urgent to the relationship that the university should establish with the UHS, using inclusive public policies that are being implemented to ensure this integration.

The debate on the formation and development in the health area as a strategic move to drive the agenda of renewal and reform in the health sector, therefore, of a deep understanding that health sector reform as profound renewal of health organizations, does not happen without an education policy in the sector. [...] Although there is no doubt that a thorough reform process cannot be done without major changes in the ethical, technical and institutional personnel profile [...], no reform will be done without changing the quality relations of health care, failing to improve the technical organization of the system and which does not generate, in the actions of users and services or the population, the sense of caution.

In our view, the curricular innovation correspond to the changes that seek to build new processes for training of professionals in their relations with the socioeconomic structure, involving those relationships, others for the content, processes and methods of teaching / learning. Therefore, it includes significant changes in the curriculum, which can become the embryo of major changes in university-school-community.

In the text of the NCG, for example, out of the 22 skills and abilities listed for the graduates of medical school, most of them indicate an action, behavior, a result that the professional must meet, which we briefly removed from the official text:

[...] To communicate adequately with their colleagues, patients and families, performing with proficiency anamnesis [...]; properly diagnosing and treating major diseases of human beings [...]; properly utilizing semiological and therapeutic resources [...], performing medical and surgical procedures necessary for outpatient care and for the initial care of emergency care at all stages of life cycle [...] Translated into English. Original text in Portuguese.

Few of these skills relate to attitudes and values, as can be seen in those who identify also the text of the NCG:

[...] Dealing critically with the dynamics of the market and health policies, recognizing their limitations and refer appropriately, patients with problems that escape the reach of their general education, work in interdisciplinary team [1]. Translated into English. Original Text in Portuguese.

However, we must recognize the importance of this document; it clearly demonstrates the intention to emphasize the social role of egress and approximate the medical education needs to the population, political issues, the interdisciplinary work in prevention and health promotion. Even if it is still not extensive, its formulation suggests a breakthrough in terms of innovations in the curriculum of health professionals.

In this context, the choice of the theme "Fraternity and Public Health" further strengthens the need for a Medicine in the country aimed to promote health without distinction of social class, with actions that humanize the performance of professionals and students aware of their importance as agents of transformation.

The most attentive and competent doctors have concluded that we cannot measure the patients' affliction only by the answers given by the diagnosis machines. Human beings, first of all want to be treated like people. They need sympathy, attention for their ego weakened by the disease, and drug prescriptions and medical procedures itself. The cause-effect relationship, which prints the scientific medicine, needs to read between the lines that inhabit the person that is sick.

The United Nations Educational, Scientific and Cultural Organization (UNESCO) proclaimed four guiding principles of Education for this century [2]:

a) Learning to know, joining theory and practice, practice and theory that is taught at all;

b) Learning to do all that what is taught;

c) Learning to live with others;

d) Learning to be.

In this first decade of this century, we find that citizens are already concerned about "learning to live." It explains the large volume of information on health and life in the publications [3-5]. The quest for longevity has become universal concern.

The medical knowledge loses power if not applied with art. Hippocrates, nearly 2500 years ago, taught that "Medicine is science and art." Art of scrutinizing the sufferings and aspirations of those who want to heal. Antonio Murri gives us a terse statement about the role of the physician:

"If you can heal, heal it, if you cannot heal, alleviate it, if you cannot soothe, console."


1. Brasil. Ministério da Educação. Diretrizes Curriculares Nacionais (DCN). Resolução CNE/CES Nº 4, de 7 de novembro de 2001. Disponível em:

2. Werthein J, Cunha C. Fundamentos da nova educação. Brasília: UNESCO; 2000. 84p.

3. Saadia A. Temas para discussão e discordância. Rev Bras Cir Cardiovasc. 2005;20(3):II-IV. View article

4. Braile D. O futuro da cirurgia cardiovascular. Rev Bras Cir Cardiovasc. 2006;21(2):I-II. View article

5. Barbosa GV. Um novo programa de residência médica em cirurgia cardiovascular com acesso direto. Rev Bras Cir Cardiovasc. 2006;21(4):XII-XIV. View article

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