Creative Education
2012. Vol.3, No.4, 595-599
Published Online August 2012 in SciRes (
Copyright © 2012 SciRe s . 595
How to Progress from Discourse to Practice? A New Agenda for
Change in Medical Schools into the Next Decade
José Lúcio Martins Machado1,2, Valéria Menezes P. Machado2, Joaquim Edson Vieira3
1Faculdade de Medicina de Botucatu, Universidade Estadual Paulista (UNESP), Botucatu, Brasil
2Universidade Cidade de São Paul o Medical School, São Pa ulo, Brasil
3Faculdade de Medicina, Center for Development of Medical Educa tion (CEDEM), Universidade de São Paulo,
São Paulo, Brasil
Received June 22nd, 2012; revised July 26th, 2012; ac c e p t ed August 5th, 2012
In the context of medical school instruction, the segmented approach of a focus on specialties and exces-
sive use of technology seem to hamper the development of the professional-patient relationship and an
understanding of the ethics of this relationship. The real world presents complexities that require multiple
approaches. Engagement in the community where health competence is developed allows extending the
usefulness of what is learned. Health services are spaces where the relationship between theory and prac-
tice in health care are real and where the social role of the university can be revealed. Yet some compe-
tencies are still lacking and may require an explicit agenda to enact. Ten topics are presented for focus
here: environmental awareness, involvement of students in medical school, social networks, interprofes-
sional learning, new technologies for the management of care, virtual reality, working with errors, train-
ing in management for results, concept of leadership, and internationalization of schools. Potential barri-
ers to this agenda are an underinvestment in ambulatory care infrastructure and community-based health
care facilities, as well as in information technology offered at these facilities; an inflexible departmental
culture; and an environment centered on a discipline-based medical curriculum.
Keywords: Guidelines; Education, Medical, Undergraduate; Problem-Based Learning; Professional
Modern scientific and technological developments have
brought about deep changes in health practices that have mobi-
lized large financial resources in different professional fields
with train ing foc used on sp ecializ ation. Howev er, th e segmente d
approach of a focus on specialties and excessive use of tech-
nology seem to hamper the development of the professional-
patient relationship and an understanding of the ethics of this
relationship. In parallel, medical schools take the same approach
and promote a curriculum focused on targeting practices in
hospitals of high complexity and multiple specialties. Resisting
this view, int ernation al conferen ces such as the Alma Ata (1978)
and others that followed hav e called for health practi ces that ma y
support primary health care (PHC) inst ead , i nflu enc ing tre nds in
the training of health professionals (World Health Organization,
Issues like technology-driven medical care and hospital- and
specialty-centered medical education are general in scope, likely
affecting societies worldwide. Indeed, if the primary goal of
undergraduate medical education is to produce students skilled
in core medical competencies, then pati e nt-centeredness ne e d s a
focus in parallel with learner-centeredness, and health care
quality should be considered in parallel with educational quality
as metrics of any medical education system (Hirsh et al., 2007).
How do we learn in the workplace? Learning by doing and
reflecting on the work: “… competence consists in attributes
displayed in the context of a carefully chosen set of realistic
occupational tasks, which are of an appropriate level of gener-
ality” (Hager and Gonczi, 1996). The real world presents com-
plexities that require multiple approaches. Engagement in the
community where health competence is developed allows ex-
tending the usefulness of what is learned. A wide range of skills
associated with flexibility allows professionals to develop be-
yond “capability” (Fraser & Greenhalg, 2001).
Knowing how to work as part of a t eam is essential at al l levels
of care, which involves fundamental concepts of interdiscipli-
nary and multidisciplinary interaction. Health promotion and
disease prevention have always been considered of low com-
plexity, but the critical success factors are the combination of
traditional approaches and the complexity of events, especially
regarding their promotion (Feuerwerker, 2003).
The need to train professionals willing to take on the respon-
sibility of caring for a diversity of needs and to use resources
available in communities is imperative. Health services are
privileged places for this purpose wh ere the relat ionship between
theory and practice in health comes to life and may confirm the
social role of the university. The experience of the Brazilian
health system and its reception of medical education present an
interesting opportunity to monitor and learn from the develop-
ment of learning with the practice of health care.
Although the literature in medical education emphasizes the
primary health care and the focus during undergraduate directed
towards patient and quality of care while performing as a team
member, the com plexities of “real wo rl d” health care challeng es
these prescriptions.
The objective of this hypothetic study was to propose an
agenda in the field of medical education from experiences re-
ported and related to the Brazilian experience with a national
health system as well as with the implementation of an educa-
tional guideline for health education.
An Agenda for the Decade
A review of literature in the field of undergraduate medical
education and the evaluation of educational experiences applied
to Brazilian medical schools after the offering of a National
Curriculum Guidelines in that country was applied. The litera-
ture search related to national experiences from those Guide-
lines included Brazilian journals in the field of medical educa-
tion, from 2000 to 2012, and the national health system was
considered as a base for the development of such guidelines.
In Brazil, two associated movements have resulted ultimately
in efforts directed to both patient-centeredness and learner-
centeredness: the organization of the health system and imple-
mentation of a national guideline for medical education. The
first, related to health communitarian movements, is the Na-
tional Health System—the SUS (for the Portuguese “Sistema
Único de Saúde”), which relies on worker and user committee
opinions in addition to those from technicians (Cornwall &
Shankland, 2008). Weaknesses and strengths have emerged in
the process of implementing this system, alternating moments
of significant advances with times of significant setback that
have led to reassessment of its principles (Barnes & Coelho,
The creation of the SUS and the representation of Brazilian
society within it helped to boost the relationship between theory
and practice, i.e., between health care and health education. In
this environment, both governmental and associative initiatives
led to the proposal of the National Curriculum Guidelines—
DCN (Portuguese for “Diretrizes Curriculares Nacionais”) in
the year 2000, with important advances to promote community-
oriented curricula and address community health needs (Re-
solução CNE/CES, 2001). The DCN allowed other methods of
teaching and learning to be used for better incorporation across
the accumulated knowledge. In this environment, new curricu-
lum designs were outlined with active methods: Problem-based
Learning, Projects-based Learning, and Learning Teams, each
with its purposes.
Considering the advances in Brazilian medical schools in the
last 10 years, as guided and encouraged by the DCN, an agenda
for change in medical training for the second decade of the 21st
century can be presented. This agenda prompts a progression
from discourse to practice that could be embraced by under-
graduate medical education institut i o n s .
1) Environmental Awareness. Combines policies of sustain-
ability and preservation of life on the planet with the incorpora-
tion of new habits and health practices, including considera-
tions of waste management, rational use of energy, and carbon
deficits associated with health services and their impact on the
health of the population (Pereira, 2007). Medical schools could
embrace programs like the WHO city health profiles. Experi-
ences already indicate that such programs provide an evidence
base to inform health planning for a city, even though appropri-
ate analyses for identifying inequalities within the city are still
lacking. In these matters of identifying and mapping inequali-
ties, engaged students could make the difference (Webster &
Lipp, 2009).
2) Student Involvement in Medical School: Medical educa-
tors around the world have linked three specific aspects to the
recognition of excellence in education: evaluation (Assessment),
student engagement (Engagement), and social responsibility
and “accountability” to society (Accountability). The current
schedule indicates a global medical education committed to
social development, opening up spaces for the promotion of
talents that unite expertise, training, a critical, reflective, and
humanistic outlook, scientific curiosity, willingness, and the
attitude of a lifelong learner (ASPIRE, 2011). In fact, some
experiences set the stage for medical training, including the
importance of understanding the philosophy of service learning
and time for reflection (Elam et al., 2002).
3) Social Networks produce significant sites of learning,
whether formal school spaces or informal learning experiences.
The “Canadian Council of Learning” defines the multiplicity of
spaces and situations such as mixtures of “unlimited dimen-
sions of learning” and points out the need to register these
situations and access evidence evaluation with qualitative and
quantitative research. The popularity of social networks high-
lights the need to incorporate them as a teaching medium and to
research their educational potential (Marti, 2010). Although
these networks are relatively new, some investigations already
suggest the potential that social networks have for disseminat-
ing innovations in health service delivery and organization
(Jippes et al., 2010).
4) Interprofessional Learning requires integration of experi-
ences among medicine and other professions, right from the
beginning. The “Network towards Unity for Health”
( is a network
that has contributed to this view, using the concept that inter-
professional education occurs when “one or more professions
learn with, for, and about each one, to improve collaboration
and quality of care.” Versatile and flexible curricula are based
on the experience of Bologna’s interdisciplinary bachelor's
process, the medical schools of Canada, and the formation of
the American “College” (Almeida Filho, 2008). However, in-
terprofessional learning is not an easy task, considering the
suggested three levels of action that must be incorporated: indi-
vidual, group (faculty), and institution, all to influence health
and educational practices (Ho et al., 2008).
5) New Technologies for the Management of Care. Devel-
oping technologies for the management of care that include
expanded clinical aspects (patient accountability), construction
of lines of care (organization of work for the integral and hu-
manized assistance—continuity of care, acceptance, commit-
ment, accountability, and problem solving), matrices (enabling
interconnection among care services in primary, secondary, and
tertiary health care), and shared construction of individual
therapeutic projects (a therapeutic single subject or individual’s
involvement in the community as a result of interaction with an
interdisciplinary health team) (Campos et al., 2006).
6) Virtual Reality, Robotics, Artificial Intelligence in tele-
medicine and graduate training in health as a replacement for
the set of practices that may go into disuse. Some examples are
the teaching of anatomy, pathology, and surgical skills in un-
dergraduate medical education, with difficulties that arise from
cadaver availability and the pressure from animal defense and
protection movements (Machado, 2010). These two items are
Copyright © 2012 SciR es .
directly or indirectly related to simulation, and there seems to
be no question of whether medical simulation is a critical com-
ponent of training and certification (Gordon, 2012).
7) Working with Reflection and Error in the evaluations of
medical students by using the tools that encourage reflection on
daily practice. Portfolio narratives from human and personal
experiences during medical education are good examples. The
systematization of recording practical aims makes possible
knowledge assessment, questioning of conflicts, and generation
of reflections. The reflection on errors involves values of ethics,
transparency, autonomy, and responsibility. The school must
provide a “sheltered environment” where error is observed, and
the simulations, of either high or low-fidelity mannequin, have
been gaining ground among the most successful environments
in this field (Aranaz et al., 2008).
8) Training in Management for Results. Regardless of the
chosen specialty, actions must be proactive and direct to resolve
collective as well as individual care. It should include health
promotion, prevention of risks and diseases, and rehabilitation
of patients and the communities. In contrast to the apparent
broad spectrum of competence and performance, it should fo-
cus on primary care and emergency care of low and medium
complexity. Performance evaluations should be promoted not
only for purposes of certification and recertification training but
also to promote institutional self-knowledge and its graduates
(Vecina Neto & Malik, 2011).
9) Developing the Concept of Leadership as a competence
required for a medical professional. Issues include globalization,
climate change, digital literacy, the balance of individualism
and team actions, and finally the ability to manage student di-
versity and the approach of teachers who encounter various
habits, cultures, and languages (Morin, 2000). Even though
leadership is not a task simply related to identifying high-po-
tential individuals, their strengths, and the provision of didactic
and experiential learning (Wolf et al., 2005), it seems that im-
mersion in the community would provide a rich and complex
10) The Internationalization of Schools and Medical Educa-
tion aims at universal characteristics: quality, equity, relevance,
innovation, and appropriate use of resources should be im-
proved at schools and during the practice of medical training. In
this context, the increasing mobility of health professionals and
patients from different countries may present a need for new
training profiles and curricula that provide mobility for students
to experience different environments and contexts. International
certification and accreditation takes on new meaning for social
engagement (AAMC—Association of American Medical Col-
leges, 2011; Biggs, 2010; Snadden et al., 2011; Boelen &
Woollard, 2011). Perhaps even more challenging would be to
consider this engagement as an effort to set up collaboration
between a number of schools in different countries, bringing a
global context rather than the context of a single country to the
medical education teaching and learning environment (Harden,
The health human resources community in Br azil has a h istory
of a partnership between Pan-American Health Organization
(PAHO) and the Ministry of Health that has allowed the devel-
opment of projects such as Teaching Care Integration (IDA, for
Portuguese “Integração Docente-Assistencial”). Its premise was
to develop medical training and health care in the same field,
combining theory and practice. Individual and institutional
resistance within universities and a short maturity period of the
SUS as a field of practice limited these projects (Marsiglia,
1995); however, the IDA paved the way for a new program
supported by the Kellogg Foundation, the “UNI Program—A
New Initiative in the Education of Health Professionals, Union
with the Community” (1991-1997), focused on improving the
training of health professionals. A key differentiator for both
projects was involving the community with leadership training
and participation within its own management (Machado et al.,
In the decade after the DCN was established, medical schools
followed and adapted to the DCN, exposing themselves, in-
structors, and students to the external environments of the real
health s yst em. It seemed they could inde e d engage i n real-world
experience as a way to explore the advancements in science and
technology wit h the intention to achiev e excell ence. But wh at, in
fact, is excellence?
The answer t o th i s que stion li es i n th e “ Agenda de Salud para
las Américas” 2008-2017 from PAHO/World Health Organiza-
tion (WHO), which focuses on promoting the progress of
medical education. This agenda, involving countries of the
Americas and the Caribbean, aims to improve health indicators
by 15% by 2015. The basis for this action is the sharing of new
teaching practices aimed at PHC and the development of col-
laboration and documentation (O rganización Pana mericana de la
Salud, 2007).
All of these efforts indicate the need to train professionals
willing to take on the responsibility of caring for a diversity of
needs and to use resources available in communities. Health
services are privileged places for this purpose where the rela-
tionship between theory and practice in health comes to life and
may confirm the soc ial role of the university. The experience of
the Brazilian health system and its reception of medical educa-
tion present an interesting opportunity to monito r and learn from
the development of learning with the practice of health care.
How to “recognize health as a right, and act to ensure com-
prehensive he alth care” is a responsibili ty th at deman ds complex
educational resources, located beyond the classroom. In the SUS,
the Family Health Teams create fertile ground for the develop-
ment of comprehensive care and for Continuing Education in
Health. To look critically at the contextual situation and be able
to plan health actions are also flagged by the DCN. The profes-
sionalization of teaching is a powerful strategy used by some
schools as well as the continuing education program in place for
health professionals (Machado et al., 2011).
In addition, the objective “to know the principles of scientific
methodology” indicates that the student must be a builder of
critical knowledge of relevant information. The application of
the DCN implies changes in the structure and organization of th e
Brazilian university in its own environment, which asks for the
listening and reflection of qualified peers, institutional partners,
and students (Feuerwerker & Sena, 2002; Bowe et al., 2003).
The Brazilian DCN su ggests th e necessar y ski lls as follows: 1 )
Health care at differe nt levels b ecause these levels are not readily
identified in the work processes; 2) Decision-making because
competence requires prof essional s who hav e skills and work out
systematization and evidence; 3) Communication skills that
involve multidisciplinary knowledge and interactions based on
codes that should be understood and recognized as familiar and
invite participation; 4) Leadership, the commitment to and re-
Copyright © 2012 SciRe s . 597
sponsibility for the skills already described; 5) Administration
and management because they are not equitable for all health
professions; and 6) Continuing education, or the ability to learn
how to learn, which can be achieved through specific teaching
The DCN also established specific skills for scientific and
technical issues: proficiency in medical history, physical ex-
amination, interpretation of laboratory tests, clinical reasoning,
and therapeutics. There are difficulties, however, such as when
to consider the epidemiological criteria for the topics covered in
the training curriculum (Machado et al., 2012).
Some competencies are lacking, and may need the estab-
lishment of a environment where to develop them: the compe-
tence of working in primary care because most medical profes-
sionals/teachers were trained in a hospital-centered model
school; the competence of acting as an agent of social change
because there is limited experience in exercising politics in the
sense of citizenship; and the promotion of a healthy lifestyle,
although it is a skill not so distant from the practice of health
education courses and services, considering that the actions
related to health promotion are more accepted by the health
services as something th at does n ot disturb their routine (Cotta et
al., 2007).
We believe the majority of potential barriers to this agenda
could be related to those of any new educational approach in
general (Hirsh et al., 2007). The two most important barriers
related to health care are probably underinvestment in 1) am-
bulatory care infrastructure as well as in community-based
health care facilities directed to promote a learning environment
and 2) in information technology offered at these facilities
(ambulatory and community). In addition, the almost inflexible
departmental culture, mostly related to an environment where
the medical curriculum is discipline based, could impair pro-
gress toward an improved understanding and compromise for a
patient-centered education process. A simple strategy, like vis-
iting families in underserved areas, has helped medical under-
graduate students to acquire capacities in identifying social and
local health realities and understanding the Family Health Pro-
gram, the PHC structure, and the national health system (Vieira
et al., 2007).
AAMC—Association of American Medical Colleges (2011). Global
health learning opportunities. URL (last checked 28 November 2011).
Almeida Filho, N. (2008). Modelo de educação superior: Modelo norte-
americano. In Santos, B. S., Almeida Filho, N. (Eds.), A universidade
no século XXI: Para uma universidade nova. Coimbra: Almedina.
Aranaz, J. M., Aibar, C., Vitaller, J., & Mira, J. J. (2008). Gestión
sanitária: Calidad y seguridade de los pacientes. Madrid: Diaz de
ASPIRE (2011). Medical school programme for international recogni-
tion of excellence in education. URL (last checked 28 November
Barnes, M., & Coelho, V. S. (2009). Social participation in health in
Brazil and England: Inclusion, representation and authority. Health
Expectations, 12, 226-236. doi:10.1111/j.1369-7625.2009.00563.x
Biggs, J. (2010). La enseñanza de los estudiantes internacionales. In
Biggs, J. (Ed.), Calidad del aprendizaje universitário. Madrid: Nar-
Boelen, C., & Woollard, R. (2011). Consenso global sobre la responsa-
bilidade social de las facultades de medicina. Educación Medica, 14,
Bowe, C. M., Lahey, L., Kegan, R., & Armstrong, E. (2003). Ques-
tioning the “big assumptions”. Part II: Recognizing organizational
contradictions that impede institutional change. Medical Education,
37, 723-733. doi:10.1046/j.1365-2923.2003.01580.x
Campos, G. W. S., Minayo, M. C. S., Akerman, M., Drumond Jr., M.,
& Carvalho, Y. M. (2006). Tratado de saúde coletiva. São Paulo:
Cornwall, A., & Shankland, A. (2008). Engaging citizens: Lessons
from building Brazil’s national health system. Social Science &
Medicine, 66, 2173- 2184. doi:10.1016/j.socscimed.2008.01.038
Cotta, R. M. M., Gomes, A. P., Maia, T. M., Magalhães, K. A.,
Marques, E. S., & Siqueira-Batista, R. (2007). Pobreza, injustiça, e
desigualdade social: Repensando a formação de Profissionais de
Saúde. Revista Bras i l e i r a de Educação Médica, 31 , 278-286.
Elam, C. L., Musick, D. W., Sauer, M. J., & Skelton, J. (2002) . How we
implemented a service-learning elective. Medical Teacher, 24, 249-
253. doi:10.1080/01421590220134079
Feuerwerker, L. C. M. (2003). Educação dos profissionais de Saúde
hoje problemas, desafios, perspectivas e as propostas do ministério
da saúde. Revista da ABENO, 3, 24-27.
Feuerwerker, L. C. M., & Sena, R. R. (2002). A contribuição ao
movimento de mudança na formação profissional em saúde: Uma
avaliação das experiências UNI. Interface—Comunicação, Saúde e
Educação, 6, 37-50. doi:10.1590/S1414-32832002000100004
Fraser, S. W., & Greenhalg, T. (2001). Coping with complexity: Edu-
cating for capability. British Medical Journal, 323, 799-803.
Gordon, J. A. (2012). As accessible as a book on a library shelf: The
imperative of routine simulation in modern health care. Chest, 141,
12-16. doi:10.1378/chest.11-0571
Hager, P., & Gonczi, A. (1996). What is competence? Medical Teacher,
18, 15-18. doi:10.3109/01421599609040255
Harden, R. M. (2006). International medical education and future direc-
tions: A global perspective. Ac a demic Medicine, 81, S22-S29.
Hirsh, D. A., Ogur, B., Thibault, G., & Cox, M. (2007). “Continuity” as
an organizing principle for clinical education reform. The New Eng-
land Journal of Medicine, 35 6, 858-866.
Ho, K., Jarvis-Selinger, S., Borduas, F., Frank, B., Hall, P., Hand-
field-Jones, R., Hardwick, D. F., Lockyer, J., Sinclair, D., Lauscher,
H. N., Ferdinands, L., MacLeod, A., Robitaille, M. A., & Rouleau, M.
(2008). Making interprofessional education work: The strategic roles
of the academy. Academic Medicine, 83, 934- 940.
Jippes, E., Achterkamp, M. C., Bran d, P. L., Kiewiet, D. J., Pols, J., &
Van Engelen, J. M. (2010). Disseminating educational innovations in
health care practice: Training versus social networks. Social Science
& Medicine, 70, 1509-1517. doi:10.1016/j.socscimed.2009.12.035
Machado, J. L., CaldasJr., A. L., & Bertoncello, N. M. F. (1997). Uma
nova inciativa na formação de profissionais de saúde. Interface—
Comunicação, Saúde e Educação, 1, 147-156.
Machado, J. L. M. (2010). Habilidades cirúrgicas no contexto da edu-
cação médica inovadora. Manual de habilidades cirúrgicas na
graduação em medicina. Be lo Hori zonte: Medvance.
Machado, J. L. M., Machado, V. M., & Vieira, J. E. (2011). Formação e
seleção de docentes para currículos inovadores na graduação em
saúde. Revista Brasileira de Educação Médica, 35, 326-333.
Machado, J. L. M., Souza, S. R. P., Brenna, S. M. F., Pose, R. A.,
Bollela, V. R., & Vieira, J. E. (2012). Use of epidemiological data as
the basis for developing a medical curriculum. São Paulo Medical
Journal, 130, 109-114. doi:10.1590/S1516-31802012000200007
Marsiglia, R. G. (1995). Relação ensino/serviços: dez anos de integra-
ção docente—Assisten cial (IDA) no Brasil. São Paulo: Hucitec.
Martí, M. C. (2010). Las redes sociales para enseñar y aprender. Re-
flexiones pedagógicas básicas. In: L. C. Quintero, & J. C. Almenara
(Eds.), Aprendizaje con redes sociales. Tejidos educativos para los
nuevos entornos. Sevilla: MAD.
Morin, E. (2000). Saberes globais e saberes locais: O olhar transdisci-
Copyright © 2012 SciR es .
Copyright © 2012 SciRe s . 599
plinar. Rio de Janeiro: Garamond.
Organización Panamericana de la Salud (2007). Agenda de Salud para
las Americas—2008-2017. URL (last checked 28 November 2011).
Pereira, D. C. P. (2007). Nova educação na nova ciência para a nova
sociedade. Fundamentos de uma pedagogia científica contem-
porânea. Porto: Ed. UP.
Resolução CNE/CES (2001). Institui diretrizes curriculares nacionais
do curso de graduação em medicina. URL (last checked 28 Novem-
ber 2011).
Snadden, D., Bates, J., Burns, P., Casiro, O., Hays, R., Hunt, D., &
Towle, A. (2011). Developing a medical school: Expansion of medi-
cal student capacity in new locations: AMEE guide no. 55. Medical
Teacher, 33, 518-529. doi:10.3109/0142159X.2011.564681
Vecina Neto, G., & Malik, A. M. (2011). Gestão em saúde. Rio de
Janeiro: Guanabara Koogan.
Vieira, J. E., Elias, P. E. M., Benseñor, I. J. M., & Grisi, S. J. E. (2007).
Implementation of the discipline basic care at the Faculty of Medi-
cine of the University of São Paulo [Portuguese]. Revista Brasileira
de Educação Médica, 31, 236-244.
Webster, P., & Lipp, A. (2009). The evolution of the WHO city health
profiles: A content review. Health Promotion International, 24, i56-
i63. doi:10.1093/heapro/dap055
Wolf, G., Bradle, J., & Nelson, G. (2005). Bridging the strategic lead-
ership gap: A model program for transformational change. Journal of
Nursing Administration, 3 5 , 54-60.
World Health Organization (1978). Declaration of Alma-Ata. URL (last
checked 28 Novem ber 201 1).