Pesquisa científica, atenção primária e medicina de família: três ingredientes indispensáveis para a melhoria da qualidade do cuidado em saúde

Adelson Guaraci Jantsch

doi:10.5712/rbmfc15(42)2466

Autores/as

Adelson Guaraci Jantsch Secretaria Municipal de Saúde do Rio de Janeiro (SMS-RJ) https://orcid.org/0000-0002-3012-5619

DOI:

https://doi.org/10.5712/rbmfc15(42)2466

Palabras clave:

Atención Primaria, Medicina Famíliar, Capacitación.

Resumen

A pesar del gran crecimiento de nuestra especialidad en los últimos 30 años, todavía estamos lejos de satisfacer la demanda brasileña de médicos de familia. Actualmente representamos solo el 1.4% del número total de médicos especialistas en Brasil y menos del 5% del número total de plazas de residencia en el país se asignan a medicina familiar y comunitaria (MFC). Con el 70% de nuestra población cubierta por la Estrategia de Salud Familiar, solo una pequeña parte tiene un médico de familia capacitado por un programa de residencia de MFC. Desgraciadamente, tenemos poca evidencia que muestre el impacto de la capacitación en MFC en el cuidado de las personas, y gran parte de lo que sustentamos como diferencial de nuestra práctica, carece de evidencia científica. Esto perpetúa una noción común entre los formuladores de políticas y los gerentes de que la atención primaria a la salud (APS) es una área de acción carente de desafíos, sin complejidades y que puede ser realizada por cualquier médico sin capacitación especializada. Si la MFC tiene la intención de establecerse como la especialidad médica responsable por la APS en Brasil, necesita avanzar en el desarrollo de habilidades de investigación para estudiar el universo de la MFC y de la APS con la profundidad y rigor que la complejidad de estos disciplinas demandan. El desarrollo de potencial para la investigación representa un paso importante en el proyecto profesional de nuestra especialidad y en la maduración de la APS. Al cuestionar nuestra práctica y preguntarnos si hacemos realmente la diferencia en el cuidado de nuestros pacientes, ampliaremos la base de evidencias de nuestra especialidad y demostraremos cuánto la APS adquire mayor calidad y competencia por tener un médico especialista en MFC. Este ensayo aborda las dificultades de la MFC para mostrar su valor y su importancia para los sistemas de salud y presenta el papel vital que debe desempeñar la investigación científica para enfrentar estos desafíos.

Descargas

Los datos de descargas todavía no están disponibles.

Métricas

Cargando métricas ...

Citas

(1) Fontenelle LF, Sarti TD. Pesquisar para quê? Rev Bras Med Fam e Comunidade. 2020;15(42):13-16. https://rbmfc.org.br/rbmfc/article/view/2369/1515. DOI: https://doi.org/10.5712/rbmfc15(42)2369

(2) De Maeseneer JM, Sutter A De. Why Research in Family Medicine? A superfluous Question. Ann Fam Med. 2004;2(2):17-22. doi:10.1370/afm.148.INTRODUCTION

(3) Rosser WW, Weel C van. Research in Family/General Practice is Essential for Improving Health Globally. Ann Fam Med. 2004;2(2):2-4. doi:10.1370/afm.145.uring

(4) Weel C Van, Rosser WW. Improving Health Care Globally: Medicine Research and Recommendations. Ann Fam Med. 2004;2(2):5-16. doi:10.1370/afm.194.Department

(5) The Lancet. Is primary-care research a lost cause? Lancet. 2003;361(9362):9362. DOI: https://doi.org/10.1016/S0140-6736(03)12837-1

(6) Howe A. Is primary care research a lost cause? [letter to the editor]. Lancet. 2003;361:1473-1474. DOI: https://doi.org/10.1016/S0140-6736(03)13116-9

(7) Andrade HS De, Alves MG de M, Carvalho SR, da Silva Júnior AG. A formação discursiva da Medicina de Família e Comunidade no Brasil. Physis Rev Saúde Coletiva. 2018;28(3):1-18. https://scielosp.org/pdf/physis/2018.v28n3/e280311/pt. DOI: https://doi.org/10.1590/s0103-73312018280311

(8) Horton R. Evidence and primary care. Lancet. 1999;353:609-610. doi:10.1016/S0140-6736(99)00056-2 DOI: https://doi.org/10.1016/S0140-6736(99)00056-2

(9) Starfield B. Atenção Primária - Equilíbrio entre necessidades de saúde, serviços e tecnologia. Porto Alegre. 2002:726p.

10 Greenhalgh T. Primary Health Care: Theory and Practice. 1st edition. Wiley; 2007. DOI: https://doi.org/10.1002/9780470691779

(10) McWhinney IR, Freeman T. Textbook of Family Medicine. OXFORD UNIVERSITY PRESS; 2009.

(11) Sociedade Brasileira de Medicina de Família e Comunidade - SBMFC. Currículo Baseado em Competências para Medicina de Família e Comunidade. http://www.sbmfc.org.br/wp-content/uploads/media/Curriculo Baseado em Competencias(1).pdf. Published 2015. Accessed February 27, 2020.

(12) European Academy of Teachers in General Practice (Network within WONCA Europe). THE EUROPEAN DEFINITION OF GENERAL PRACTICE / FAMILY MEDICINE.; 2011. https://www.woncaeurope.org/sites/default/files/documents/Definition EURACTshort version revised 2011.pdf.

(13) Stewart M, Brown JB, Weston W, McWhinney IR, McWilliam CL, Freeman T. Patient-Centered Medicine: Transforming the Clinical Method. 3rd Ed. Radcliffe Medical Press; 2014. DOI: https://doi.org/10.1201/b20740-1

(14) Stange KC. The Generalist Approach. Ann Fam Med. 2009:198-203. doi:10.1370/afm.1003.T

(15) Heath I. ‘Uncertain clarity’: contradiction, meaning, and hope. Br J Gen Pract. 1999;49(August):651-657. https://bjgp.org/content/bjgp/49/445/651.full.pdf.

(16) Starfield B. Primary Care and Health: A Cross-National Comparison. JAMA J Am Med Assoc. 1991. doi:10.1001/jama.1991.03470160100040 DOI: https://doi.org/10.1001/jama.1991.03470160100040

(17) Starfield B, Shi L, Macinko J. Contribution of Primary Care to Health Systems and Health. Milbank Q. 2005;83(3):457–502. doi:10.1111/j.1468-0009.2005.00409.x DOI: https://doi.org/10.1111/j.1468-0009.2005.00409.x

(18) Macinko J, Starfield B, Shi L. The contribution of primary care systems to health outcomes within Organization for Economic Cooperation and Development (OECD) countries, 1970-1998. Heal Serv Res. 2003;38(0017-9124 (Print)):831-865. doi:10.1111/1475-6773.00149 DOI: https://doi.org/10.1111/1475-6773.00149

(19) WHO-Unicef. Declaration of Alma-Ata. Int Conf Prim Heal Care. 1978. https://www.who.int/publications/almaata_declaration_en.pdf.

(20) WHO & UNICEF. Declaration of Astana.; 2018.

(21) WHO. The World Health Report 2008 - Primary Health Care: Now More Than Ever.; 2008. doi:10.12927/hcpol.2013.22778 DOI: https://doi.org/10.12927/hcpol.2013.22778

(22) Macinko J, Harris MJ. Brazil’s Family Health Strategy — Delivering Community-Based Primary Care in a Universal Health System. N Engl J Med. 2015;372(23):2177-2181. doi:10.1056/NEJMp1501140 DOI: https://doi.org/10.1056/NEJMp1501140

(23) Dourado I, Oliveira VB, Aquino R, et al. Trends in Primary Health Care-sensitive Conditions in Brazil. Med Care. 2011;49(6):577-584. doi:10.1097/MLR.0b013e31820fc39f DOI: https://doi.org/10.1097/MLR.0b013e31820fc39f

(24) Pinto LF, Giovanella L. The Family Health Strategy: expanding access and reducing hospitalizations due to ambulatory care sensitive conditions. Cien Saude Colet. 2018;23(6):1903-1914. doi:10.1590/1413-81232018236.05592018 DOI: https://doi.org/10.1590/1413-81232018236.05592018

(25) Mendonça CS, Harzheim E, Duncan BB, Nunes LN, Leyh W. Trends in hospitalizations for primary care sensitive conditions following the implementation of Family Health Teams in Belo Horizonte, Brazil. Health Policy Plan. 2012;27(4):348-355. doi:10.1093/heapol/czr043 DOI: https://doi.org/10.1093/heapol/czr043

(26) Rasella D, Harhay MO, Pamponet ML, Aquino R, Barreto ML. Impact of primary health care on mortality from heart and cerebrovascular diseases in Brazil: A nationwide analysis of longitudinal data. BMJ. 2014. doi:10.1136/bmj.g4014 DOI: https://doi.org/10.1136/bmj.g4014

(27) Rasella D, Aquino R, Barreto ML. Reducing Childhood Mortality From Diarrhea and Lower Respiratory Tract Infections in Brazil. Pediatrics. 2010;126(3). doi:10.1542/peds.2009-3197 DOI: https://doi.org/10.1542/peds.2009-3197

(28) Anderson MIP, Rodrigues RD. Formação de especialistas em Medicina de Família e Comunidade no Brasil: dilemas e perspectivas. Rev Bras Med Fam e Comunidade. 2011;6(18):19-20. https://www.rbmfc.org.br/rbmfc/article/view/246/pdf. DOI: https://doi.org/10.5327/Z1809-59092011001800005

(29) Jaturapatporn D, Hathirat S. Specialists’ perception of referrals from general doctors and family physicians working as primary care doctors in Thailand. Qual Prim Care. 2006;14:41-48.

(30) Pongsupap Y, Lerberghe WVAN. Patient experience with self-styled family practices and conventional primary care in Thailand. Asia Pacific J Fam Med. 2006;5(1). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1466579/pdf/0010144.pdf.

(31) Pressentin KB Von, Mash RJ, Baldwin-ragaven L, et al. The perceived impact of family physicians on the district health system in South Africa: a cross-sectional survey. BMC Fam Pract. 2018;19(24):1-10. doi:10.1186/s12875-018-0710-0 DOI: https://doi.org/10.1186/s12875-018-0710-0

(32) Afonso MPD, Shimizu HE, Merchan-Hamann E, Ramalho WM, Afonso T. Association between hospitalisation for ambulatory care-sensitive conditions and primary health care physician specialisation: A cross-sectional ecological study in Curitiba (Brazil). BMJ Open. 2017. doi:10.1136/bmjopen-2016-015322 DOI: https://doi.org/10.1136/bmjopen-2016-015322

(33) Glazier RH, Hutchison B, Kopp A. Comparison of Family Health Teams to Other Ontario Primary Care Models, 2004/05 to 2011/12.; 2015. http://www.ices.on.ca/~/media/Files/Atlases-Reports/2015/Comparison-of-Family-Health-Teams/ICES-083-Ontario-Primary-Care-Model-Report_mk06B_CC.ashx.

(34) Macdonald SE, Voaklander K, Birtwhisde R V. A Comparison of Family Physicians’ and Obstetricians’ Intrapartum Management of Low-Risk Pregnancies. J Fam Pract. 1993;37(5):457-462. https://mdedge-files-live.s3.us-east-2.amazonaws.com/files/s3fs-public/jfp-archived-issues/1993-volume_36-37/JFP_1993-11_v37_i5_a-comparison-of-family-physicians-and-o.pdf.

(35) Grunfeld EVA, Fitzpatrick RAY, Mant D, Yudkin P, Adewuyi-dalton R, Stewart J. Comparison of breast cancer patient satisfaction with follow-up in primary care versus specialist care: results from a randomized controlled trial. Br J Gen Pract. 1999;49(September):705-710.

(36) Tamblyn R, Abrahamowicz M, Brailovsky C, et al. Association Between Licensing Examination Scores and Resource Use and Quality of Care in Primary Care Practice. JAMA. 1998;280(11):989-996. DOI: https://doi.org/10.1001/jama.280.11.989

(37) Miller G, Britt H, Pan Y, Knox S. Relationship between general practitioner certification and characteristics of care. Med Care. 2004;42(8):770-778. doi:10.1097/01.mlr.0000132369.13832.10 DOI: https://doi.org/10.1097/01.mlr.0000132369.13832.10

(38) Anderson MIP. Médicos pelo Brasil e as políticas de saúde para a Estratégia Saúde da Família de 1994 a 2019: caminhos e descaminhos da Atenção Primária no Brasil. Rev Bras Med Fam e Comunidade. 2019;14(41):1-16. DOI: https://doi.org/10.5712/rbmfc14(41)2180

(39) Greenhalgh T. Uncertainty and Clinical Method. In: Sommers LS, Launer J, eds. Clinical Uncertainty in Primary Care: The Challenge of Collaborative Engagement. New York: Springer; 2013. doi:10.1007/978-1-4614-6812-7 DOI: https://doi.org/10.1007/978-1-4614-6812-7

(40) Storti MMT, de Oliveira FP, Xavier AL. A expansão de vagas de residência de Medicina de Família e Comunidade por municípios e o Programa Mais Médicos. Interface Commun Heal Educ. 2017;21:1301-1313. doi:10.1590/1807-57622016.0511 DOI: https://doi.org/10.1590/1807-57622016.0511

(41) Prado Junior JC. Desafios para a expansão de programas de residência em Medicina de Família e Comunidade: a experiência carioca. Rev Bras Med Família e Comunidade. 2015;10(34):1-9. http://www.rbmfc.org.br/rbmfc/article/view/1105. DOI: https://doi.org/10.5712/rbmfc10(34)1105

(42) Mário Scheffer. DEMOGRAFIA MÉDICA NO BRASIL 2018. São Paulo; 2018.

(43) Wollmann L, D’Avila OP, Harzheim E. Programa Médicos pelo Brasil: mérito e equidade. Rev Bras Med Família e Comunidade. 2019;15(42):1-6.

(44) Hodges BD, Lingard L. The Question of Competence: Reconsidering Medical Education in the Twenty-First Century. ILR Press; 2012.

(45) Arya N, Gibson C, Ponka D, et al. Family medicine around the world: overview by region. Can Fam Physician. 2017;63(June 2017):436-441. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5471080/pdf/0630436.pdf.

(46) Ponka D, Rouleau K, Arya N, et al. Developing the evidentiary basis for family medicine in the global context. Can Fam physician Médecin Fam Can. 2015;61(7):596-600. http://www.ncbi.nlm.nih.gov/pubmed/26380849%5Cnhttp://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=PMC4501601.

(47) Ponka D. The Besrour Papers: Seeking evidence for family medicine. Afr J Prim Heal Care Fam Med. 2017:1-2. doi:10.4102/phcfm.v9i1.1559 DOI: https://doi.org/10.4102/phcfm.v9i1.1559

(48) Stange KC, Etz RS, Gullett H, et al. Metrics for Assessing Improvements in Primary Health Care. Annu Rev Public Health. 2014;35:423-442. doi:10.1146/annurev-publhealth-032013-182438.Metrics

(49) Wisner B. GOBI VERSUS PHC? SOME DANGERS OF SELECTIVE PRIMARY HEALTH CARE. Soc Sci Med. 1988;26(9):963-969. DOI: https://doi.org/10.1016/0277-9536(88)90417-0

(50) Duarte EC, Barreto SM. Transição demográfica e epidemiológica: a Epidemiologia e Serviços de Saúde revisita e atualiza o tema. Epidemiol e Serviços Saúde. 2012;21(4):529-532. doi:10.5123/S1679-49742012000400001 DOI: https://doi.org/10.5123/S1679-49742012000400001

(51) Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Qualificação Dos Indicadores Do Manual Instrutivo Para as Equipes de Atenção Básica (Saúde Da Família, Saúde Bucal e Equipes Parametrizadas) e NASF. Brasília; 2015. http://bvsms.saude.gov.br/bvs/publicacoes/qualificacao_indicadores_manual_instrutivo_equipes.pdf.

(52) World Bank. Primary Health Care Performance Initiative (PHCPI). https://improvingphc.org/. Published 2018. Accessed January 1, 2020.

(53) Donabedian A. The Quality of Care: How Can It Be Assessed? JAMA J Am Med Assoc. 1988. doi:10.1001/jama.1988.03410120089033 DOI: https://doi.org/10.1001/jama.1988.03410120089033

(54) Ratcliffe HL, Schwarz D, Hirschhorn LR, et al. PHC Progression Model: a novel mixed-methods tool for measuring primary health care system capacity. BMJ Glob Heal. 2019;4. doi:10.1136/bmjgh-2019-001822 DOI: https://doi.org/10.1136/bmjgh-2019-001822

(55) Moosa S, Peersman W, Derese A, et al. Emerging role of family medicine in South Africa. BMJ Glob Heal. 2018:2-4. doi:10.1136/bmjgh-2018-000736 DOI: https://doi.org/10.1136/bmjgh-2018-000736

(56) Mash R, Downing R, Moosa S, Maeseneer J De. Exploring the key principles of Family Medicine in sub-Saharan Africa: international Delphi consensus process. South African Fam Pract. 2008;50(3). doi:10.1080/20786204.2008.10873720 DOI: https://doi.org/10.1080/20786204.2008.10873720

(57) Willcox ML, Peersman W, Daou P, et al. Human resources for primary health care in sub-Saharan Africa: progress or stagnation? Hum Resour Health. 2015;13(76). doi:10.1186/s12960-015-0073-8 DOI: https://doi.org/10.1186/s12960-015-0073-8

(58) Hulley SB, Cummings SR, Browner WS, Grady DG, Newman TB. Designing Clinical Research. Lippincott Williams & Wilkins; 2013.

(59) Ponka D, Coffman M, Fraser- KE, et al. Fostering global primary care research: a capacity- building approach. BMJ Glob Heal. 2020;5:1-7. doi:10.1136/bmjgh-2020-002470 DOI: https://doi.org/10.1136/bmjgh-2020-002470

(60) Hesse-Biber SN. Mixed Methods Research: Merging Theory with Practice. The Guilford Press; 2010.

(61) Christopher Dye, Ties Boerma, David Evans, Anthony Harries, Christian Lienhardt J, McManus, Tikki Pang, Robert Terry RZ. The World Health Report 2013: Research for Universal Health Coverage.; 2014.

(62) Kidd M. The Contribution of Family Medicine to Improving Health Systems: A Guidebook from the World Organization of Family Doctors. CRC Press; 2013.

(63) Gotler RS. Unfinished Business: The Role of Research in Family Medicine. Ann Fam Med. 2019;17(1):70-76. http://www.annfammed.org/content/17/1/70.full.pdf+html. DOI: https://doi.org/10.1370/afm.2323

(64) Sullivan F, Hinds A, Pitkethly M, et al. Primary care research network progress in Scotland. Eur J Gen Pract. 2014;20:337-342. doi:10.3109/13814788.2013.879116 DOI: https://doi.org/10.3109/13814788.2013.879116

(65) UTOPIAN. University of Toronto Practice-Based Research Network (UTOPIAN). https://www.dfcm.utoronto.ca/about-utopian. Published 2019.

(66) Koskela TH. Building a primary care research network – lessons to learn. Scand J Prim Health Care. 2017;35(3):229-230. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5592348/pdf/ipri-35-229.pdf. DOI: https://doi.org/10.1080/02813432.2017.1358439

(67) NAPCRG. North American Primary Care Research Group. https://www.napcrg.org/.

(68) Wood M. THE GENESIS OF THE NORTH AMERICAN PRIMARY CARE RESEARCH GROUP. Ann Fam Med. 2003;1(4):2003.

(69) EGPRN. European General Practice Research Network. https://www.egprn.org/.

(70) Thomas P. The research needs of primary care. BMJ. 2000;321(July):2-3. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1127682/pdf/2.pdf. DOI: https://doi.org/10.1136/bmj.321.7252.2

(71) Guimarães Rosa J. A hora e a vez de Augusto Matraga. In: Sagarana.