Extensionist experience of undergraduate students in medicine as part of the Mais Médicos para o Brasil [more doctors for Brazil] program

Como citar: Gonçalves Júnior J, Brandão SC, Silva SBF, Sá EQC .Extensionist experience of undergraduate students in medicine as part of the mais médicos para o Brasil [more doctors for brazil] program. Rev Bras Med Fam Comunidade. 2021;16(43):2528. https://doi.org/10.5712/rbmfc16(43)2528 1Faculdade de Medicina, Departamento de Reumatologia Universidade de São Paulo (USP), São Paulo 2Faculdade de Medicina Universidade Federal do Cariri


INTRODUCTION
After 32 years since the creation of the Single Health System (Sistema Único de Saúde -SUS), public health in Brazil is experiencing one of the most challenging periods. Immersed in tensions in the political and economic scenarios, the system has suffered from successive budget cuts and substantial changes in the shaping of health policies. 1 The scarcity and poor distribution of the qualified workforce are global concerns, but developing countries are especially affected. This standard limits the accessibility to health services in rural and remote areas. 2,3 In fact, the qualified construction of SUS requires significant investments not only in the structuring of services and in the distribution of health professionals, but also in their training, valuation and establishment.
Furthermore, there is a historical gap in the training process of health professionals. Thus, it is necessary to deeply reflect on the epistemological assumptions in health, which must be based on social determinants, the needs of the population and the locoregional epidemiological profile. 4 Due to the demand of the health system and users for a more humanized medicine and not focused only on pathology, there is a global collective effort to propose changes in the biomedical, curative health model for a holistic, biopsychosocial and integral approach, evidencing a health education centered not only on technical skills, but also on humanized care. 5,6,7 In Brazil, this reality comes to fruition with the proposal of the new National Curriculum Guidelines for Undergraduate Students of Medicine in Brazil, which proposes a professional with humanized, critical and reflective training, able to work at the SUS. 8 However, despite the new curricular guidelines, practical activities in undergraduate courses still proved to be insufficient for the adequate development of the necessary competences for medical practice.
Consequently, the experiences of university extension come to supply this lack of medical training focused on the biopsychosocial model. 9 Among the government actions to qualify training for SUS, the More Doctors Program for Brazil (Programa Mais Médicos para o Brasil -PMMB) was created. It is a public health policy, supported by Law No. 12,871, as of October 22, 2013, 10 intersectoral, the purpose of which is to expand the practice and the insertion of the doctors in training at the SUS care units at an early stage, in strengthening training-service integration, with academic supervision executed by higher education institutions and in the exchange of knowledge and experiences between professionals and students. 9 This measure was implemented in order to address both the problems of deficit in the supply of professionals for the SUS staff and the change in the current medical training model. Education -preparation of case reports, literature reviews and cross-sectional studies based on the students' experiences in the internships; participation of classes promoted by the PMMB on the main themes of primary care, with medical preceptors / professors from the regulating HEI (III) Management Activities -assistance in the logistical preparation of the PMMB locoregional workshops, as well as participation in meetings with managers of the 34 municipalities linked to the program. This prerogative was thought of when it was perceived that the practice of medicine has changed and demands new professional skills, consequently requiring adjustments to the training process offered by medical schools. [11][12][13] Thus, the purpose was to report the experiences lived by the ProMFC fellows within the scope of the PMMB.

Study design:
Unique qualitative case study, of the experience report type, using lexical and content analysis. Participants were selected for convenience, using the following inclusion criteria: being medical students at a public Higher Education Institution, in the center-south region of the countryside of the state of Ceará; having participated in the ProMFC during the year of 2017. All eight students/fellows accepted to participate in the research.

Data Collection
Data collection took place in December 2017, at the last ProMFC articulation meeting. At the time, students were asked to answer two questions: A. What were the negative points and / or challenges faced during the project's year of operation? B. What were the positive points and / or gains obtained during the project's year of operation?
The discussion was carried out in the Yarning Circle format and recorded in the Minutes of the Meetings.
In the end, the portfolio was indicated with the main conclusions of the activity. The responses of each student were extracted from the portfolio and the Minutes and tabulated into the Microsoft Word® program saved in Rich Text format. To maintain anonymity, each student was designated by the letter "E" followed by a number from 1 to 8 during the analysis of the material. The Text Units were organized in the same textual corpus and submitted to lexical analysis by the Iramuteq software. This software is an Interface of R for Multidimensional Text and Questionnaire Analyzes (Interface of R pour les Analyses Multidimensionnelles de Textes et de Questionnaires -IraMuTeQ) version 0.7 alpha 2 developed by Pierre Ratinaud, which allows to make statistical analyzes about textual corpus and individuals/words tables. 14 The analysis was performed in two stages. Firstly, the students' speeches were organized and (c) Theoretical and Research Activities.
Before starting the analysis in the parameterization of the text segments, only "full" language elements were selected to be considered by the software in the lexical analysis (adjectives, unrecognized forms, nouns and verbs) and those auxiliary nouns and verbs as complementary (supplementary), aiming to value the contents of the evaluated text by means of similarity analysis.

Ethics:
The work followed the ethical precepts agreed to in the declaration of Helsinki and the regulatory standard 510/2016 of the National Health Council (Conselho Nacional de Saúde -CNS), the instance of the SUS with the mission of inspecting, accompanying and monitoring public health policies, 13

RESULTS
In

Speeches about the experiences
• "In addition to following the classes and theoretical activities of the [PMMB] program, we had the opportunity to train the organization and execution of a medium-sized event" (E2) "The symposium was good, because it is a yet little discussed topic" (E3) "In the locoregional workshops, it was also very good for us to be able to talk to city managers, see what they think, how they are considering the program and the extension project, and we even received compliments" (E5) "It was good because we saw the difficulty of working as a team and learning together. [...]" (E6) "The best part is being able to talk to the scholarship doctors and see another view of the ABS that we have in college. Like, it is the view of who is acting now, at the moment" (E8)

Speeches about the experiences
• "In the home visits we made during the internship, we strengthened, as our advisor says a lot, the ties of the teaching-service-community integration" (E6). "There was a great exchange of knowledge and the identification of the customs of the community" (E7) • "Home visits also allowed our doubts to be resolved and we were able to have contact with the reality of the public that we will attend to in the future as health professionals" (E8) • "The activities in the center of Barbalha in the campaign to prevent sexually transmitted diseases allowed us to have more contact with the population of the region. It also allowed us to broaden our view on the subject, as we had to study to inform correctly." (E1) "It was really cool; the elderly were very receptive to the campaign and often approached us to ask for the kits we were distributing" (E2)

Description of the activity performed
• Participation in formative classes with the work process in Basic Attention as the theme, in the same discussion environment with the supervisors. • Collection, tabulation and analysis of data from the Projeto de Pesquisa Guarda-Chuva (Umbrella Research Project), inserted into the PMMB. Presentation of scientific papers at local, regional and national events.

Description of the results achieved
• Strengthening of competences, skills and attitudes about recurrent themes in Primary Care, with a better understanding of the health-disease-care process. • It provided us with the opportunity to participate in research projects; experience the elaboration of works and having contact with other researchers in events with themes aligned with the ProMFC purposes.

Speeches about the experiences
• "It enriched us a lot. Often the doctor needs to be a leader, and, in these cases, he/she needs to know how to organize actions in the health center and must take part in campaigns... This learning with the workshops made us aware of a lot in this sense" (E4) "Training classes focused on Primary Care themes enriched us a lot and made us see the need to learn about recurring and relevant problems for the performance of professionals in a community" (E6) • "In addition, we were able to participate in a large research project, which made us understand some things better, such as the integrating teaching with the service; on the other hand, it was also very difficult to collect the data" (E3) Chart 1. Description of the activities performed, and the results achieved in the view of the fellows of the ProMFC.
In data processing, the corpus consisted of 12 Initial Context Units (ICU) and 16-word segments.
From the analysis of the graph theory (Figure 1), it was possible to identify the occurrences between words, helping to understand the structure of the content of a textual corpus. When analyzing students' speeches about the ProMFC activities, the correlation between the words "event", "planning and learning"; "health and enable", "scholarship and region"; "community", "experience", "to know" and "to perceive".

DISCUSSION
We observed that the evoked words that constitute a correlation of similarity were event, planning and learning (Figure 1). Probably, they refer to the planning practices carried out by the academics in the elaboration of the events, articulation meetings and locoregional workshops of the PMMB, enabling them to entice a different knowledge than the one offered by the teaching staff of the academy. In addition, the academics participating in the Pro-MFC were able to follow changes in the organizational culture, with professional development activities in management and team building.
Universities must prepare students to learn teamwork, community action, agility, leadership and purposeful abilities. Likewise, it is known that the performance of medical activities in complex health systems requires the doctor to have knowledge and skills related to improving quality aimed at the population's health. 17,18 The national curricular guidelines of the undergraduate medical course point out that the medical professional must be able to develop preventive, promotion, protection and rehabilitation health actions, both at the individual and the collective levels. 19 Medical education plays a vital role in the knowledge of medical students and the provision of future health workers. The similarity analysis ( Figure 1) shows a correlation between the words know, perceive and experience; associated with "health", "enable and scholarship"; "theme", "learning and planning"; and all directly correlated to the word "project". The use of the ProMFC inserted into the PMMB as a tool that provides health education, reflects the reality of Extension as an agent capable of complementing medical training 22 as it promotes insertion into the everyday, political, social and economic realities, in addition to the direct participation in the experiences with the community in which it is inserted, creating a cycle of social transformation. 23,24 However, there is an increasing accumulation of scientific knowledge, often not associated with the development of skills that require critical and reflective reasoning and ethical and citizen behavior.
In this context, extension activities created an opportune and fruitful ground for good learning practices in PHC, as they integrated, in the students, the notions of social participation, collective thinking and teamwork. The acting of students participating in the ProMFC encouraged the successful collaboration of the entire team, trained students in skills beyond techniques and improved the usage of relevant and varied resources. In addition, in these practice locations, students faced less competition from other students, playing a more significant role in the evaluation of patients, especially in the early stages of diseases and conditions.
The available evidence allows us to state that the PMMB has achieved a set of important results in changing medical training. In a research that analyzed the impact of the creation of medical courses supported by the PMMB in the countryside, the social representations about the work in the PHC of students were compared in the new courses and in the traditional courses. There was emphasis on the evocation of words such as "responsibility", "bond", "community" and "care". In the traditional courses, the most prominent terms were "devalued" and "precariousness", thus, it is possible to verify that the social representations of medical students in the new schools are more consistent with the PHC guidelines. 25 Therefore, it is possible to notice that the words evoked by the academics of the new courses are consistent with the words evoked by the students participating in the ProMFC.
Furthermore, when the words "to know", "to perceive" and "experience" are evoked in the speeches, associated with "health", "enable" and "scholarship", it is inferred that they refer both to the activities in the The literature states that the choice of the target audience based on local needs, as well as a good understanding of primary care and its functioning, is an integral part in the search for community action with social impact. Strengthening the understanding of primary care is central to improving the health care and health itself. 26 Due to these new processes, the possibility of concrete changes in health practices emerges, with a view to the qualification of the health system, from professionals able to understand and intervene 27 in existing demands and problems, both in primary, secondary and tertiary care. 28 Another relevant factor is the opportunity of establishing contact and exchanging experiences between students and doctors working in the PHC (PMMB fellows, supervisors and tutors) and local managers, which are perceived from the correlation between the words evoked -"planning", "theme" and "event" (Figure 1 and Table 1). Extracurricular activities concur as collaborators of the integration between academy-service and public health. According to Machado and Ximenes 4 , the acting in primary care, especially in the PHC, requires a diversity of knowledge and practices in areas related to management, care, management of social determinations and consequences and the territory of operation. In this sense, the early insertion of academics in health education activities is essential -both to acquire knowledge and to develop the needed skills in the future. 29 Through the evocation of the words "scholarship", "region" and "enable", another aspect to be addressed is the low interest of both academics and professionals in more deprived and remote areas.
The PMMB's proposal has the capacity to train professionals in line with the management and care model recommended by the System, calling for a different way of thinking about medical training.
Exposing medical students to experiences in rural communities, in order to positively influence the attraction to work in these areas after graduation, was an initiative of the World Health Organization (WHO), which in 2010 proposed a series of recommendations in response to the insufficiency of health workers in more remote and underserved areas. 23,30 A large number of medical schools in many countries have implemented the strategy and many students have reported increased interest in working in this areas, thus demonstrating that it is possible to unite curriculum making and social impact. 31,32,33 Research in different countries suggests that interventions with undergraduates can help. There is evidence that when academics are trained in practice fields in these areas, they are more likely to return to work in them. The difficulties in engaging and retaining doctors in these areas compromise the quality and access to healthcare. 34,35,36 In addition, Zhang et al demonstrated in a cross-sectional survey on community health reform in China that students' perceptions of work in communities seem to influence their career choice. 37 Thus, it can be understood that measures such as those offered by the ProMFC presented in this article have positive impacts.
As weaknesses of this work, we can mention the absence of sufficient text segments to carry out the descending Hierarchical Classification and quantitative analysis of the speeches.
The ProMFC, tutored and integrated into an extension project, shows itself as an alternative that, although embryonic, has innumerable potentials, as it gives extension workers an early insertion into the PHC, thus allowing students to experience the daily life of a community, facing real impasses in the elaboration, organization and execution of events/activities; training teamwork, assertive communication and group articulation skills; encouraging scientific research; bringing the university closer to local administrations, promoting a dialogical space of building mutual knowledge and benefits; and fomenting an integral view of the student, guiding their perspectives from a disease-centered care to a person-centered care, thus approaching the medical training of those recommended by international guidelines.

CONCLUSION
The ProFMC, in its first year of operation, provided an opportunity for the academics to apply the knowledge acquired during their undergraduation and the development of skills and fundamental attitudes for professionals working at the SUS. In accordance with the basic principles of the University Extension, the project instigates the integration of the activities of the University -PMMB.
The experiences raised during the ProFMC can be pilot models for improving teaching through active methodologies in Primary Care, since the teaching process needs experiences in real controlled environments that are conducive to learning. This raises a situation favorable to the deepening of teachingservice relationships at the SUS, based on the formulation of competent and active human materials in primary care.