Set of meanings 1.: University Extension as a counter-hegemonic space of medical training

“Here is a place that is exactly for you to open that closed mind of yours”.

In this first set of meanings, students’ speeches are presented in a reflection on university extension as a counter-hegemony strategy in medical education. The current paradigm in most medical courses is the biomedical one, based on the Cartesian model of science, conceiving the body in a biomechanical way, with intense specialization and separation between normal and pathological, biological and social²².

In medical education, the biomedical model considers the clinical aspects as the most important to produce a good professional, with the mastery of other skills considered less relevant, such as sociocultural skills. At this point, it is important to highlight the challenge when meeting this dominant paradigm while addressing social issues, as they operate from different epistemological principles. While the first works in an exclusive logic, where a new technique, procedure or product must replace the previous one, Social Sciences operate with distinct and complementary schools of thought, so as not to be excluded and thus, persist²³. The extensionists’ speeches showed that the university extension allowed the approximation of these two fields:

I came looking for something different in terms of dealing with the patient.

We are going to be doctors. We will experience the most varied types of culture. And doctors are not prepared for this. We need to see beyond that.

Here we can get to know, experiment the different.

The extensionists stressed that it is important to experience dealing with different people and that the social reality is related to the extended conception of health. In the community, the experience of daily life and health conditions required a dialogue of knowledge that goes beyond the technical training in health²⁴, including political and social perspectives¹¹. They also brought in their speeches the resistance by other college students when talking about this experience, which reinforces the hegemony of the biomedical model in training:

In our class, the people are very resistant! They are always ‘mocking’ us. You have a test tomorrow and are going to travel to that ‘thing’ of the Indians?

“The people who are not from the project always say: I only see that as interesting as it adds hours to the curriculum.

The biomedical model admires the homogeneity between the diseases and also the ways the students think, dress and act, with attitudes that are different from the majority being little accepted. In contrast, popular extension values diversity and demonstrates that its protagonists are open to changes based on the experiences they have had⁴, while the traditional model tends to suppress these practices.

In popular extension, there is a contribution to the formation of health professionals who are more empathetic, ethical and committed. This approximation between academia and social reality generates mutual strangeness, restlessness and leads those involved to a critical reflection on their position in the world²⁵.

In the statements below, the students reflected on the space of extension as a possibility to produce diversity:

There is not just any group in college that is so mixed, so full of different people.

Who would have thought that I would be here? The people in my class would say: This crazy guy was on an indigenous extension project? This guy must be the most ignorant person on Earth with patients.

The difference regarding this group is that they are people who are here and accept changes.

Îandé Gûatá has transformed other areas of my life as well. Not only academically.

The university extension was associated with expressions such as: local reality, knowing, living with the different, life enrichment, a differentiated look, dealing with the patient, opening your closed mind, mixed group, countless learnings. When referring to students who had no contact with the extension, they associated them with expressions such as: not prepared to live with the different, resistant to the new, focus on workload. In this comparison, the impact of popular extension on the creation of criticism was evident, beyond the biomechanical and technical training^{11), (22}.

Taking a university extension while attending a Medical course with its strenuous workload was considered a challenge, requiring effort from students and teachers. Thus, horizontal relationships and the exercise of understanding were necessary for the group to be able to grow together, in a relationship between educator and students, in which everyone taught and everyone learned¹⁷.

We didn’t always have time for the extension.

Even when I was tired, going to the indigenous village on Saturday brought me a lot of learning.

For me, one thing that was very important was the integration with the teachers.

For me it was a new thing. I never had this issue of having this bond with teachers, of being able to joke, being more informal, because I never allowed myself to do it.

I had the opportunity to have a conversation with the teacher that helped me. If I had not joined the extension project, we might not have had the opportunity and the freedom to talk.

The understanding of the extension project as a space for exchange and, above all, the construction of knowledge, was only possible due to the stimulus to the extensionists as protagonists. In this case, teachers acted as triggers for an identity learning process, where students had an active production. This was evident in terms as: working with autonomy; do different; take over; have faith in yourself; motivate you; light the fire. After that, the students brought elements to their speeches that denote the achieved autonomy:

It was the time with the most mobilization.

I thought it was cool that we were open to talk about the project.

If we want this to work, we will have to do it in a different manner.

I put in my two cents’ worth.

Along this path, an aspect highlighted in the speeches is the fact that the project’s administration was carried out through shared management, using the talking circle method²³. They addressed the division of tasks, but also the camaraderie between colleagues and the energy of new members in moments of extension fragility, along the path of the collective construction:

I learned here to fully share the roles.

When someone was discouraged, someone did something.

Because everyone has to want it, let’s make this thing work.

Thus, the extensionists showed in their speeches that, through the dialogue in the talking circle, the closure of the extension cycle was a natural process, with movements constructed by themselves and the mediation carried out by the teachers.

Set of meanings 2.: The development of general competences for the future health professional

“I am not going to be that kind of doctor who will have a careless attitude with everyone.”

The students elucidated the educational leaps they achieved with the university extension. We used the concept of inclusive and dialogic competence^{26), (27), (28} as a reference for presenting and discussing the results of this set of meanings.

Professional competence is the habitual and judicious use of communication, knowledge, technical skills, clinical reasoning, emotions, values and reflection in daily practice for the benefit of the individual and the community^{25), (29}. The perspective of the dialogic approach works based on two ideas that complement each other: the combined development of attributes/performances (cognitive, psychomotor and affective) that follow different ways of performing essential tasks and characteristics of professional practice; recognizes and considers the history of people and societies that legitimize the attributes and expected results in that particular professional area²⁸.

In this sense, the students brought in words that were repeated or emphasized, such as: growing up, looking, learning from mistakes, opinion, more open mind, (towards the different and to criticism), adaptation, learning:

I think everyone here will have a much more comprehensive look in relation to anyone who arrives.

You will know that behind that person there is a history and a whole life and context.

The speeches pointed to the constant need to practice reflection for the professional future, since they need to be open to criticism, to different opinions and to have a sensitive look for the integral care of people. These aspects corroborate the idea that competence is context-dependent, being a statement of the relationship between a skill, a task (in the world, service or health system) and the context in which these tasks occur²⁷.

This explanation allows a more open process of exploring the different conceptions, interests, values and ideologies that invariably rule and determine the intentionality of educational processes²⁸. Therefore, the use of problematization as a methodological strategy made it possible for students to be in the real-life spaces of indigenous people and, in the following stages, to reflect on the practice and return to reality with a more grounded and debated reading of the world¹⁷.

The students assessed that the university extension organization model favored the members’ autonomy and teamwork. The group showed strength in being open to discussions in the perspective of growth and continuous and active learning:

This is a group where I think everyone knew how to respect the other.

Shared management, this equity made all the difference, because that way I felt that everyone there was responsible.

The evaluation of students in relation to the shared management of the project stimulated performances, from three perspectives: 1. collaborative learning perceived by the group’s cohesion, while respecting the different opinions and feeling of belonging; 2. acquisition of an attitudinal attribute of teamwork; 3. meaningful learning.

Working in small groups and investing in an extension format in which management is everyone’s responsibility and task facilitated the interaction and made collaborative learning possible. Moreover, learning through practice allowed the acquisition of knowledge, skills and the development of attitudinal attributes essential for adequate future professional performance³⁰.

When the learning process is triggered by everyday life, meaning is built according to your motivation to learn and the potential value that new knowledge has in relation to its use in personal and professional life. Therefore, the process that favors meaningful learning requires an active and critical posture, on the part of those involved in learning³¹.

The group thought it was noteworthy the development of scientific works and their presentations, which allowed the development of other potentials by the extensionists. They described an improvement in the capacity to write, to use the tools available for that purpose, of communication in oral presentations and expressing themselves on a daily basis.

A lot of things that I had never seen! I did not know they existed. The teacher showed them to us. So, it opened my mind!

I was always anxious, very nervous to speak in public. I’m still anxious, but I’ve improved.

I had difficulty in writing. I always thought that I write very poorly. Nowadays I feel more confident.

The distance between the practices that a person already masters and the new ones acquired can be reduced by the interaction of different people and skills, named by Vygotsky³² as a zone of proximal development.

In the students’ evaluation, the challenge of breaking the excessive fragmentation of knowledge and expanding ethical awareness in the production of new knowledge³³ was important to build a better performance in the cognitive field and in written and spoken communication skills.

Moreover, meeting the learning needs of everyone involved in an educational initiative guarantees respect, acceptance, inclusion and commitment³⁴. Without a doubt, this is not a simple and romantic process, so it is essential to highlight that the teachers’ mediation was a critical success factor. This analysis was made by the students themselves and reflected in the research talking circle: they understood that the teachers, even though they were not the center of the process, had a fundamental role in the intentionalities, in the articulation of different points of view and as a support in times of group crisis.

This set of meanings allowed a glimpse of competence gains, in a dialogic perspective, for the construction of students’ identity and role in a future professional life. As a complement, it reinforced the role of university extension, based on adult learning and education as the practice of freedom and autonomy¹⁷, especially built through the development of the students’ critical awareness.

Set of meanings 3.: The encounter between different cultures in the extension experiences

“I learned another way to see the world. It is something you didn’t even know it existed”.

In this last set of meanings, we present, based on the extensionists’ speeches, the encounter between different cultures in the approximation between Medical students and Potiguara indigenous people. Thus, it is necessary to understand that, at the same time, an evolutionary understanding, with a strong Eurocentric character still persists, which influences Brazilian society, favoring the imaginary that the native peoples are primitive and little evolved. The fact is that the historical process about the concept of culture in Europe during the Illuminist period, with the description that each society would go through the same stages until it became a more developed society, still favors the understanding that to be evolved is to be closer to the European society³⁵. The students’ speeches brought what echoes in the voice of society:

One day, I was there at the hospital, then a Potiguara shaman arrived to see his brother who had had a stroke, or something like that. Then I heard one of the surgeons saying: ‘Ah, these indigenous people, they are primitive, I don’t know what else,

This posture had an impact on the initial contact relations between the indigenous people and the students, who were uninformed and insecure when they first arrived at the village, which was deconstructed over time:

You fall into a place while you are wearing a blindfold and you don’t know what you’re doing. Then, with the visits, we have learned.

In their speeches, they demonstrated a surprise that the reality did not correspond to the initial expectation about the villages - closely related to the romantic view of the generic indigenous individual - when faced with customs and practices similar to those of their own daily lives:

We immediately lose that illusion that we had, that we would find them dressed in the characteristic way, wearing a headdress.

We were very surprised with the history of pay-TV packages that were sold in the village. We still had that idea of an indigenous individual closed to the world.

In this context, it is clear that ruptures occurred, in a construction of learning based on what is lived, while being open to be transformed by experience and the affections caused by it, in a direct relationship between knowledge and human life³⁶. Thus, the extensionists began to question their own ethnocentric viewpoint through cultural relativism, considering the diversity of forms of community and family organization, and overcoming the evolutionary nature of culture by incorporating the idea that it is dynamic, and not static³⁵.

I remember that leader, on that first visit, who sat there at the foot of the stairs at his house and surprised us with such intelligence, that we could never imagine.

We found out that the flour mill house had a community function and that you paid for it. It showed us a vision that we had not been able to have.

The students’ speeches focused on the process of experiencing and overcoming prejudices, which was made possible through the experience with the different, in a process of recognizing the conflict and making it into a strength in the relationship.

Most of us painted ourselves and when we came back to the medical school, the others were very surprised. There were people who found it strange, people who liked it, people who didn’t like it. There were people who didn’t really disguise it.

The question of the meaning of body painting is incredible, I think it really touches you! Because my painting meant being a warrior, it was strong. And I thought it was great!

In the students’ speeches, having their skin painted with indigenous drawings was repeatedly disclosed as an experience that generated conflicts and disagreements, but also knowledge. Consequently, they built new understandings that could not be developed based on activities that were strictly planned and that would prevent something unforeseen and spontaneous from happening³⁶.

In the approximation between the different cultures, the students’ speeches demonstrated the respect and tolerance made possible by the recognition of specificities related to habits, customs and beliefs. They also emphasized the understanding that they come from a different culture, but not a hierarchically inferior one³⁷. In an indigenous assembly in which they were able to participate, they recognized differences regarding the organization and the relationships between people:

One of the most interesting things I saw was that they kept shaking the maraca so that the person would not stray from the subject. But this is different when you are an elder. They respected the elder and did not shake the maraca. He had the preference. It was the respect he had, that a lot of people don’t have in the city!

There was the general population that did not have any specific position and they were there! Also fighting and saying that they were following, that they wanted to go to Brasilia when they went to fight. I found it very organized. If it were me, I wouldn’t even know what that was about.

I used to see it as if they were taking advantage of their historical condition to get everything. And I realized that this is not it, understand? They have their own ways when they fight. It is one of their strengths, they are not just oppressed people.

Therefore, the possibility of recognizing that a culture is different from yours and that it must be respected appeared in the speeches, bringing an important learning: cultural competence. Cultural competence means the capacity to understand and effectively respond to the cultural needs brought by patients, horizontally, without hierarchizing values and practices, overcoming prejudices³⁸.

I always saw them saying that they had to show their culture and that they didn’t have to feel ashamed, that they had already acquired a lot, but they should never be ashamed of dancing the toré. I thought that was beautiful.

We share this desire to be open to new ideas, to want to know other things. This is what allows us to be close, because we arrive here without any preconceptions. Wanting to acquire other concepts, like that.

When identifying and working with a different culture in the health field, it is possible to recognize it as a set of symbols and meanings that allow individuals from a group to interpret the experience and direct their actions. This definition of culture as intertwined systems of interpretable symbols, within which social events, behaviors and institutions can be intelligibly described, makes it possible to understand health (and, moreover, illness) as a system that is social and cultural in its origin, structure, function and meaning³⁹.

Therefore, similarly to other studies, it is clear that medical education must address the needs of patients from culturally heterogeneous populations and, for that, it is necessary to take Medical students to these different scenarios, including remote and indigenous areas, and that the university extension can be one of these spaces in the path of the training of doctors that are more aware of the different socioeconomic and cultural realities of Brazil^40,41.