INTRODUCTION

The object of this report was the experience of the systematization of the Therapeutic Itineraries (TI) and production of Singular Therapeutic Projects (STP) of users of the Brazilian Unified Health System (SUS, Sistema Único de Saúde) by the students, as a pedagogical tool of the Collective Health II (DSCII) discipline, of the second year of the Medical course of Universidade Federal de Santa Maria (UFSM), state of Rio Grande do Sul (RS), Brazil. It is a production of the teachers and monitors of the discipline, authors of this study and involved with the creation and implementation of the proposal from 2017 to 2019.

Changes in the training of health professionals, in general, and in medical education, in particular, comprise the agenda of the Brazilian health system, with more emphasis since the Federal Constitution of 1988, which established the SUS. The legal proposition that establishes that the SUS is responsible for establishing the professional training in health, as well as the recognition of social determinations as guidelines for care policies and practices, are markers of proposals for the transformation of medical training^1),(2.

The current National Curriculum Guidelines for Medicine² indicate greater consistency in medical training with the Health Care Model proposed for the SUS and its needs^2),(3. However, the proposed transformations in medical education are in dispute and under construction in the daily life of educational institutions⁴. Producing innovations towards the desired changes is a challenge for teachers and students. In this experience, the proposition was to articulate the contents of the discipline, especially the TI studies, the construction and reflection on the STPs, the Health Care Networks (HCNs) and the lines of comprehensive care (LCC).

For the work proposed in the discipline, the TIs express the users’ trajectories in search of answers to their health needs⁵, more specifically the ones in search of treatment to identify “(a) past behaviors (actions that have been previously carried out); and (b) the difficulties through which individuals and social groups arrived at a therapeutic modality (“problematic situations”)”(p.134)⁶. In the case of this experience, the first systematization exercise considers the TI as an instrument for the practical analysis of the HCN organization, of the access and flows of the user through health services. Subsequently, when revisiting the initial systematization of the TI, it is sought to reinforce it as a tool to interpret the relationship between the social structure, the individuality of the users’ experience and the health concepts that cross them. The understanding of this relationship is considered crucial for the construction of STP and LCC⁵.

The STP was proposed as a care tool that considers economic, social, family, cultural and geographic dimensions, among others; that is, the singular existence of individuals⁷, but also a tool whose centrality is the care that “helps to continue to live in the most powerful and pleasant way possible, despite the problem/disease/suffering” that is, “that expands the power of life, truly at the service of better coping with situations”(p.78)⁸.

The LCC, whose pedagogical intention is to reflect on the functionality of the processes and the practical success of care, were addressed as arrangements, strategies and tools that reorganize the work processes of teams and services that are characterized by dynamicity, by the contexts and decisions that are produced from meetings involving managers, workers and users. It is the image that expresses the flows and work processes whose centrality is the guarantee of safe and qualified pathways in response to individual and colective health needs^5),(9.

This report initially presents a description of the experience and, subsequently, reflections and analysis about the initial questions that guided the systematization of this experience, which are: what is the effect of the TI and STP construction tools to connect the theoretical and practical moments provided in the discipline of Public Health II? Are they tools that allow meeting the discipline objective and the proposed syllabus? Are they viable pedagogical strategies for the actual conditions of the discipline offer?

EXPERIENCE REPORT

The UFSM is located in the municipality of Santa Maria, which has 283,677 inhabitants and is located in the central region of the state of Rio Grande do Sul (RS), Brazil. It had, in 2018, approximately 40% of Primary Health Care (PHC) population coverage, either in the Family Health Strategy or traditional Basic Health Units¹⁰. Almost all of the practical activities of the medical course, whether in the basic, clinical or internship cycles, are guided by hospital services, especially the University Hospital of Santa Maria/Empresa Brasileira de Serviços Hospitalares (HUSM/EBSERH), a large, tertiary hospital that belongs 100% to SUS, which is a referral service for approximately one million and one hundred thousand inhabitants of the Midwest Macroregion of RS.

Medical training in Santa Maria began in 1954 and predates the foundation of UFSM¹¹. It is a traditional medical course, strongly influenced by the biomedical and hospital-centric model. The Public Health, which includes Epidemiology, Policies, Planning and Management, Social Sciences in Health, Occupational Health and internship in Public Health, has 390 hours of the 8815 hours planned for the medical course, which represents 4.4% of the total workload. These numbers of hours and percentage of the total course load are lower than the national median, which were, respectively, 440 and 5.4%¹². The PHC disciplines and internship total 855 hours, 9.7% of the total workload. Therefore, the sum of these two areas does not even reach 15% of the offered workload, explaining the traditional emphasis of training in hospital specialties and services¹³.

The DSCII has 45 programmed hours and it is offered in the fourth semester of the undergraduate medical course, a moment when the contact between the students and the users is also initiated, in the perspective of the “individual clinic”, from the inclusion in the hospital environment through the Medical Semiology discipline. The programmatic contents provided in the DSCII menu are: governance of the health sector; regionalization of health; instruments and tools for SUS management; collaborative work in health teams; management of health care and health and environment¹⁴.

In the first meetings, the teaching plan of the discipline was presented, and the theoretical-methodological proposal that guided them to describe, reflect on and produce analyses on the TI of the interviewed users and the contents related to HCN, SUS management and regionalization of health was addressed. This first TI systematization exercise considered “the possibilities of articulating knowledge about the therapeutic itineraries and the health care management, whether in the organization of services, in the interactions between professionals and patients or even in the access to health care”(p.848)⁵. Based on an initial semi-structured script (Chart 1), the students, organized in trios, carried out the interviews and produced the first TI report, which was presented to the large group in two classes.

Based on the groups’ presentations, the strategy adopted by the teachers was to connect them with the reports of the users’ actual experiences, problematizing the existence of spaces, initiatives, conditions for experimenting the therapeutic projects in a singular, interdisciplinary and care management perspective. Subsequently, the contents provided in the discipline related to interprofessional, teamwork, horizontal, shared relationships, LCC and the development of STP were addressed. The production of the STP by the group of students and for the same interviewed user was proposed as an approximation exercise to identify the social, economic and family contexts and the dynamic relationships for the construction of care as a practical success that is not restricted to the clinic with a technical purpose^5),(8.

Guided by the topics addressed throughout the semester in Public Health II, specifically the LCC and STP, the students carried out a second interview in the final weeks of the academic semester, which was the basis for formulating the term paper for the discipline, in the format of scientific article. This second TI systematization was characterized based on the reflection provided by the debate on the arrangements of the LCC, the STP and, above all, the dialogic and intersubjective dimension that confer the dynamics of the care processes⁵. Finally, the articles were presented to the large group and discussed between the students, teachers and monitors.

The interviewee was a user, hospitalized at the HUSM, preferably the same person who would be invited to undergo the anamnesis and physical examination, scheduled for the Medical Semiology course. Two classes were offered per semester, each with 30 vacancies and one teacher. This design, even though it allows dividing the groups for the presentation of the TI, is still insufficient to allow time for the debate, as well as hindering the singularization of the students’ formative itineraries. However, it allows the teacher to grasp the information from the described itineraries that are triggers for the debate of the presented contents. Between 2017 and 2019, around one hundred and sixty TI were systematized by the students.

DISCUSSION

The articulation between practice and theory was possible from the conduction of the interview, the TI systematization, the production of the STP and the correlation of these activities with the theoretical “tool concepts”¹⁵, predicted in the contents, especially in the HCN, teamwork and LCC. In the first exercise of TI systematization, it was possible to reflect on the care networks that “refer to institutionalized structures and services and, in general, strongly normatized”(p.11)⁹. The second systematized TI was qualified based on the formulation of the STP and the debates on the LCC as arrangements that “are immanent, produced in each context and instituting practices and articulations between services and workers that allow possible and viable care itineraries, agreed upon and effective to meet the health needs”(p.11)⁹.

The socialization of the TI and STP of several users, from different municipalities that access the HUSM, with different sufferings and different life and care histories, allowed reflecting on the particularity of the HCN territories and the immanence of the LCC and the singularity of individual care. The “successful” experiences were also correlated with more structured regions and HCNs, lines of care produced in and by the relationship between workers and users, singularized therapeutic projects, teamwork, user protagonism, support networks and varied strategies to face suffering, just as the opposite was evidenced in experiences in which access, comprehensiveness, quality and effectiveness were compromised.

As mentioned above, the experience took place at a Federal University with a traditional, biomedical curriculum and at a large University Hospital, located in a city with low PHC coverage of the population. This allowed the students to identify the consequences of a fragmented HCN and without an intense presence of PHC, in contrast to the TI of people in which the territories have strengthened primary care and, therefore, the bond between workers and users. The differences and similarities of the presented TIs, the debate and reflection carried out in the meetings made it possible to recognize the diversity of the SUS, the care practices and health work processes.

Hence, when the focus for the construction of learning was the itinerary experienced by the user in search of care and the exercise of proposing an STP, it became possible to articulate the different proposed topics and the approach of the contents that mobilized both the previous learning and interest in learning, a central condition for meaningful learning.

From this experience, it was possible to identify that the biomedical and content logic is still predominant in the students’ perspective and it was the “initial resource” used by them for the TI systematization. The more the students’ production and the debates allowed having a sensitive look at the relationships that imply the structures - both of the care networks and of the social, economic and family dimensions - the conceptions of health and the singularities of the individuals’ life experiences, the more it was possible to articulate the knowledge of the TI with the construction of the STP and the LCC⁵.

Developing competencies and skills for the critical analysis of reality and for the emancipatory action of the limits of technicism, of bureaucratism, norms and standardizations, was the aim of the action-reflection-action strategy (first version of the TI - the debate, contents and production of the STPs - the second version of the TI) that acknowledges the historical and life contexts of the involved actors and that stimulates curiosity, an active posture and experimentation in which everyone learns, teaches and transforms based the dialogue^16),(17.

A pressing issue for the teaching of Collective Health in the formation of health, in general and in Medicine, specifically, is how much this is considered peripheral and marginalized as an area of ​​knowledge and in resources. The time available for teaching, the conditions for carrying out the practices, the availability of corresponding teachers are often insufficient, which is also observed in the reported experience (considering that, for the other practical activities of the medical courses, in general, one teacher is assigned up to 10 students). It is worth noting that, even if it is possible to invent strategies that enhance Public Health, as in the case of this experience, the conditions related to the offer of the disciplines hinder the possibility of problematizing and supporting the production of meaning by students and, therefore, the learning. This context contributes to the students’ critical assessment of the area of ​​Public Health and its teachers.

However, considering the available conditions, TI and STP tools made it possible, based on real cases of daily life, to go through the region’s health system, the different points of care, whether or not in the health sector, the practices of care within the services, the users’ life histories and networks of affection that contextualize the demands and deliveries of care, as designed based on the singularities of their existences.

The systematization and analysis of the TI allowed experiencing the power of the encounter between users, students and teachers in the production of knowledge. Recognizing learning as “something that is experienced, something that is tried, which comes from the encounter and not from the more experienced individual passing on teachings to the less experienced”(p.19)¹⁸, listening to how users build their itineraries of care and the experimentation by students, monitors and teachers was valued.