1. RETRAINING SPECIALISTS IN FAMILY MEDICINE The Brazilian Experience Marcelo R. Levites, MD Maria Auxiliadora C. De Benedetto, MD Marco Aurélio Janaudis, MD Idblan C. de Albuquerque, MD

2. I) INTRODUCTION

3. B) WHO ARE WE? The Brazilian Society of Family Medicine (SOBRAMFA) was founded in 1992. SOBRAMFA’s aim is “to promote Family Medicine and to establish the proper basis and scientific methodology for family practice”. SOBRAMFA is not attached to any medical school. Students and doctors interested in Family Medicine come voluntarily to take part of its meetings, courses and other activities in which Family Medicine philosophy and practice are taught by SOBRAMFA.

4. C) THE PROBLEM Before SOBRAMFA’s existence many medical students had chosen other specialties because they had no opportunity to consider Family Medicine as a career. Family Medicine core values provide useful principles for improving the skills and enhancing the relationship doctor-patient to any doctor acting in any specialty. Nevertheless, these core values are not taught in current didactic settings.

5. D) WHAT’S HAPPENED? Realizing that the core values and principles of Family Medicine could be applied to the formation and daily practice of any doctor, physicians acting in other specialties became interested in Family Medicine as taught by SOBRAMFA. They started taking part in SOBRAMFA’s open activities and then they asked for guidance to go deeper into Family Medicine.

6. F) FITNESS SENIOR PROGRAM 1) Context Responding to the claim of these doctors and their own needs, SOBRAMFA created a new program, addressed to doctors with ten or more years of profession and know-how in their specialties. The program was called FITNESS SENIOR (in capital letters) and the participants were called simply fitness seniors (in small letters).

7. F) FITNESS SENIOR PROGRAM 2) Objectives of the Program a) To develop skills in Family Medicine (FM). b) To promote the apprenticeship of the FM core values and the practice of Patient-Centered Medicine. c) To awake interest for the teaching of FM and to form FM teachers, with the improvement of communication skills. d) To promote the Reflective Practice and to implement leaderships in FM. e) To update in Primary Care issues and themes that represent the daily practice of a Family Physician. f) To provide skills for the management of medical information.

8. F) FITNESS SENIOR PROGRAM 3) Program Features Duration – one year – half time (20 hours per week). So, the fitness senior can keep his/her usual job. Payment resident bursary. The basic activities are: scientific meetings with technical and philosophical contents and the fitness senior is also trained in practical settings where he/she interacts with students and residents since the beginning of the traineeship. The educational skills are stimulated through the practice of case-based teaching and the constant contact with students and residents in theoretical and practical activities. The guided reading of medical and philosophical texts is oriented according to the objectives of the program.

9. F) FITNESS SENIOR PROGRAM 4) Activities Monthly Family Medicine Educational class and reflexive training – called constructive “pacemaker” – an opportunity to share experience and doubts in order to understand how Family Medicine Department thinks about medicine training and life. The understanding about feedback, methodological evaluation and students based learning are essential objectives of this activity.

10. F) FITNESS SENIOR PROGRAM 4) Activities Weekly Scientific meeting – called “scientific pacemaker” – an opportunity to discuss, in a learning environment, the main themes that represent the day to day of a family doctor in a holistic approach and with focus in patient histories. SOBRAMFA board retreat – bi-annual meeting with the SOBRAMFA’s staff – an opportunity to share the vision and mission of the family doctors.

11. “PACEMAKER”

12. RETREAT

13. F) FITNESS SENIOR PROGRAM 4) Activities Monthly meeting – called Pizza in the Tower – when an extraordinary person is invited to talk about his/her experience of life. The guest is not necessarily a doctor and the subjects discussed could be about ethics, marketing, philosophy, journalism, education, advocacy. In such a meeting one shares experiences, a special pizza and a good wine.

14. F) FITNESS SENIOR PROGRAM 4) Activities The Monthly Meetings of APM (Paulista Medical Association) Family Medicine Department – usually coordinated and led by medical students - shows to the fitness senior fellows a method that provides high impact results: students teaching students. Students present international or Brazilian reference texts that are the basis of subsequent discussions. Several chapters are assigned to the most experienced students, who, by turn, recruit the youngest ones and guide them for the presentation and conduction of the discussion that follows.

15. APM

16. F) FITNESS SENIOR PROGRAM Acting in practical settings - ambulatories (primary care, palliative care, high complexity patients and patients bearing co-morbidities), homecare, nursing homes, management of Preventive Medicine patients. First month - under a SOBRAMFA’s doctor supervision. After - under indirect supervision. Contact with students and residents since the beginning as a way to stimulate and develop educational skills.

18. II) OBJECTIVES OF THE STUDY The main objective is to investigate, in a qualitative way, the impact exerted by the participation in FITNESS SENIOR, considering the motivations, longings and expectations of the doctors in training. The secondary objective is to investigate, in a qualitative way, the benefits of including the FITNESS SENIOR Program in SOBRAMFA’s curriculum, considering the vision and mission of the society.

19. III) METHODOLOGY The data were assembled by the application of a questionnaire to the fitness seniors at the end of the training. The questionnaire, with six questions (table I), was conceived by the members of SOBRAMFA’s team that had organized and participated in the training. As participant observers, all the members of SOBRAMFA’s team were oriented to register their impressions about the fitness seniors performance and the training. Spontaneous opinions, considerations and everything that could be considered relevant should be noted down for future analyses.

20. III) METHODOLOGY The interpretation of the data was done through edition and crystallization/immersion styles as described by Crabtree and Miller (1999). So, the data were assembled in categories that evidenced predominant themes. The validation of the results was done through the revision of the interpretations, of which all participants in the study – members of SOBRAMFA’s staff and fitness seniors – took part.

21. IV) RESULTS A) Educational capacity improvement LOVE TO TEACH B) Better understanding about Family Medicine core values C) Working in a team D) Performance improvement through the application of specific methodology (POEMs, Narrative Medicine and Patient Centered Medicine)

22. IV) RESULTS Each theme was illustrated with fitness seniors and/or participant observers’ phrases. Fitness seniors’ phrases are in italic. Participant observers’ phases are in black.

23. A) EDUCATIONAL CAPACITY IMPROVEMENT “ Before starting the training I wasn’t having contact with students and residents and I was missing it. The work with them shows me how stimulating are the didactic activities. I realized that more we take great care in teaching, more we learn.” “ The environment created by SOBRAMFA is a stimulus to share knowledge, to teach and learn all the time. Students and residents’ presence demands our continuous improvement in order to respond to their needs.”

24. C) WORKING IN A TEAM “ Patients don’t look to worry about being saw by a teacher and a student together or by a student under teacher supervision. The teams formed during the training allow the apprenticeship about the importance of continuity and creation of links between patients /doctors and doctors/students.” “ FITNESS SENIOR is a program very appropriate to doctors who don’t work in academic settings such as Medical Schools but like to work in a team in order to share knowledge and experience.”

25. D) PERFORMANCE IMPROVEMENT THROUGH THE APPLICATION OF SPECIFIC METHODOLOGIES “ During the ‘scientific pacemaker’ it is possible the updating concerned the issues that represent the most common situations the family physicians faces in their daily practice. This allows the resolution of the clinical questions according to the principles of the Evidence–based Medicine. The POEMs methodology was very important for such a task.” “I was stimulated to apply Patient-centered Medicine and Narrative Medicine in my practice. Such methodologies are fundamental for a holistic approach and complement the technical and scientific knowledge.”

26. V) OUTCOMES Fitness seniors improved doctoring skills and more reflexive practice. Fitness seniors used a patient-centered approach to teach. Students and residents enjoyed learning from specialists who practiced in a Family Medicine perspective. At the end of the training, fitness seniors were capable to work as family physicians. Fitness seniors spread word in Medical Schools about Family Medicine as a specialty.

27. VI) CONCLUSION FITNESS SENIOR Program reached the aimed objectives and became a useful tool for the required expansion of SOBRAMFA’s educational activities. Now, the program is keeping according to the initial orientation and the participants are chosen for their alignment with SOBRAMFA’s mission and vision. It is not an open program to any doctor, but it’s only addressed to the doctors are willing to share SOBRAMFA’s dream.

28. VII) GROUP DISCUSSION QUESTIONS AND ANSWERS What do you suggest for improving the FITNESS SENIOR PROGRAM’ s content and teaching methods? What are the advantages and disadvantages of using specialists to train Family Medicine residents and students?

29. VII) BIBLIOGRAPHY BLASCO, P G. O Médico de Família, hoje. SOBRAMFA, São Paulo, 1997. BLASCO, P G. Medicina de Família e Cinema. Recursos Humanísticos na Educação Médica. SOBRAMFA, São Paulo, 2002. BLASCO, P G; JANAUDIS, M A; LEOTO, R F; LEVITES, M R; MORETO, G; RONCOLETTA, A. Princípios da Medicina de Família. SOBRAMFA, São Paulo, 2003. CRABTREE, B J; MILLER, W L. Doing Qualitative Research. California Sage Publications, Inc, 1999.

30. THANKS FOR YOUR ATTENTION www.sobramfa.com.br