INTRODUCTION

The word “communicate” derives from the Latin word communicare and means to share, to make public, to relate to, from which the word “commune” also originated, which means to share with everyone, to participate, to do something in common, to tune into feelings, thoughts and actions¹. Thus, communication is relational and, as Araújo and Cardoso state, it is a “social practice”². For Paulo Freire, communication is an essential condition of human beings, and without it, human knowledge would be impossible, as the cultural and historical construction of human reality requires “intercommunication” and “intersubjectivity” based on dialogicity³. Therefore, the educator, who aims to expand the perspectives and possibilities for the student’s assertion as a person in the society, through reflection and action on reality, must problematize the world, in a dialogic and solidary way^3),(4.

Therefore, the importance of dialogue should always be taken into account by educators/teachers of the medical course and physicians. In the past, however, teaching was teacher-centered and the clinical encounter was physician-centered and based on the biomedical model, focused on the disease, limiting the active participation of the students and those under medical care. In the teaching process, in clinical reasoning and in decision making, their knowledge, experiences, perspectives and practices, as well as their values, ​were not taken into account^5),(6.

In health care, this reality started to change in the 1970s, when studies demonstrated that the biopsychosocial model⁷, encouraging the active participation of the person under care and attentive listening and empathy⁸ generated better health outcomes. Some proven outcomes were: decrease of uncertainties in people under care and increase in their trust, security, adherence to the therapeutic plan, autonomy and responsibility for self-care, as well as better control of chronic diseases, including hypertension and diabetes and less stress, anxiety and depression. Family members also felt less anxious and stressed, and physicians achieved greater diagnostic accuracy and effectiveness in their care. As a result, everyone was more satisfied^9)-(17.

The importance of communication in interdisciplinary and interprofessional teamwork was also verified - considering the person under care and their family members / caregivers as part of the team - for the prevention of avoidable harm in health care and, therefore, to ensure the safety of the person under care^18)-(25. It was demonstrated that the greater effectiveness of collaborative work required a shared leadership, respect for all involved, with their listening, recognition and appreciation of their contribution to the team’s mission, and through frequent, assertive and conciliatory dialogue, would provide the fast and effective flow of information, the construction and maintenance of relations, clarity of roles and functions of each participant and the management of uncertainties, conflicts, adverse events and errors^18)-(27. As a result, the person under care accepts the treatment better, has better health outcomes, takes less risks and feels more satisfied; team members work more effectively and feel greater well-being; and, there is greater efficiency in the services provided by the team and access to care, and the hospital length of stay, unplanned hospitalizations and institutional costs are reduced^18)-(27.

On the other hand, it was found that when communication in teamwork was ineffective, there were more errors in health care, including delays in diagnosis and treatment and an increase in medication and procedural errors^19)-(22. Their most frequent causes were the omission of important clinical information, verbal prescription, illegible writing in medical records and files and/or the absence of the name, signature and stamp/digital certification of the professional responsible for the care. These problems occurred more frequently during the transition of care between shifts, in transfers between sectors and between health institutions, and in emergency situations. Proven barriers to communication in teamwork include hierarchy, little regard for the opinion of its members, failure to include the person under care and their family members/caregivers as part of the team, and little clarity about the role and functions of the team member, which are corroborated by the instability of the teams and/or transitoriness of its members and the assignment of tasks to new members, without support and prior qualification, among others^18)-(25.

As for the qualification for teamwork, a recent systematic review of the resources in the literature on communication for health professionals during the Covid-19 pandemic concluded that most articles and documents were directed at the physicians, and there was a gap related to the resources for non-medical professionals. Topics that required greater consideration, indicated by the authors, included: communication strategies in telehealth, cultural sensitivity, empathy, compassion, loss, grief and moral distress²⁸ caused by the witnessing of inappropriate attitudes and actions or the need to make decisions that go against one’s own moral values, often due to the scarcity of resources²⁹.

The importance of training health professionals for the 21^st century, so they can effectively communicate in collaborative interdisciplinary/interprofessional, intersectoral and transnational teamwork, in health leadership and in local, regional, national and global politics has been highlighted. This competence is necessary so that teams can act in a responsive way to the constant changes in local, national and global health needs, favoring the transformation of reality (transformational education), and to improve “health systems in an interdependent world”, promoting the health of populations, universal equity in health, social justice, global socioeconomic development and human security³⁰. In this context, human health must be understood as part of a web of interdependent relationships with life in a broader sense, dependent on the consolidation of relationships of solidarity and individual, collective and environmental care³¹, without territorial boundaries. As stated in the National Curriculum Guidelines (DCN, Diretrizes Curriculares Nacionais) for the undergraduate medical course, health care must preserve “biodiversity with sustainability”, respecting the relationships between “human beings, the environment, society and technologies”³².

Since the 1990s, the model of care centered on relationships has emerged³³, recognizing that, in addition to the relationship with the person under care, all the relationships created at each moment and in each space of health care influence each other and that care is interdependent on these relationships. This means that each person involved in this care influences its results, bringing to this encounter their subjectivity, with a personality and life story and their relationships with themselves, their emotions, interpretations, perspectives, needs, expectations and choices, and their own knowledge and values. Thus, the physician must be aware of how they, their emotions and all of their subjectivity, as well as those of other people involved in care, contribute to the care outcomes^33)-(36.

The knowledge built on effective communication processes and components and on the effectiveness of their teaching³⁷ contributed to the development of models to construct the clinical encounter and, among them, the method centered on the person under care³⁸, the SEGUE (Set the stage, Elicit information, Give information, Understand the patient’s perspective, and End the encounter) method³⁹, the Calgary-Cambridge guide^40,41 and the Four Habits Model⁴². Moreover, consensuses were created for the teaching of communication in undergraduate medical courses^43)-(52. As professionalism is a construct, whose components are essential to medical practice^52)-(56 (as well as to the practice of other professional categories), it is one of the bases of communication in some consensuses, such as in the ones from the United Kingdom^46),(51. The security of the person under care, while part of professionalism, is another basis of communication in the most recent UK consensus⁵¹.

Several books have also been published to support the teaching of medical communication in general and in the clinical encounter. Some of them are mentioned here to provide greater familiarity to those interested in the topic^{2),(38),(57)-(62}, but they are just the “tip of the iceberg” amidst the existing vastness.

The international consensuses for the teaching of communication partially meet the needs of medical training in Brazil, considering that its population exceeds 200 million inhabitants, which has different intra and inter-regional characteristics and needs⁶³, and that its public health system - the Brazilian Unified Health System (SUS, Sistema Único de Saúde) - has as principles the universality (egalitarian access to health services for all individuals^64),(65), integrality (integral vision of the human being, with comprehensive and effective actions in health^64),(65) and equity (respect for the uniqueness and subjectivity of each person, considering their individual and collective characteristics and needs, without any kind of prejudice or privilege, prioritizing vulnerable and at-risk groups or categories, to defend dignified treatment and guarantee social justice^64),(65). The SUS also includes the social control guideline, which presupposes the active and daily participation of the population in discussions to direct health services and actions in all of their instances, so that the system meets their needs and interests ⁶⁴. Embracement, which includes listening to the users of the Unified Health System (SUS) and other Brazilian citizens, is part of the national humanization policy to increase social participation and meet the health needs of the population^64),(66.

The DCNs, introduced in 2001, aimed to align medical education with the learning needs of the students and with the health needs of the population according to the SUS. In the DCNs, communication was one of the six skills to be achieved by medical school graduates⁶⁷. After the “More Doctors Program” (PMM, Programa Mais Médicos) in 2013⁶⁸, the guidelines were revised, resulting in the 2014 version of the DCNs³². The previous focus on six competencies to be achieved changed to competencies in relation to the areas of health care, health management and health education. Communication permeates most processes in these three areas of competence.

Being aware of the importance of training Brazilian physicians to effectively communicate when attending to the Brazilian population, while following the principles of the SUS, ABEM developed a communication project, containing among its objectives the construction of a consensus for its teaching in Brazilian medical courses^69),(70. The aim of this manuscript is to present the consensus for the teaching of communication in Brazilian medical schools.

METHOD

The creation of the consensus started in 2014⁶⁹. Its construction was carried out in a collective and collaborative manner. According to Innes and Booher⁷¹ and Innes⁷², a collaboratively constructed consensus constitutes “a set of practices” in which people representing different interests meet for a long-term dialogue, mediated by a facilitator, to address an issue or concern and arrive at a joint proposal. Its construction process must contain the following criteria: include representatives with different levels of interest; be guided by goals, tasks and practices shared by the group; allow participants to actively interact throughout the process, encouraging creative thinking; incorporate high quality information and evidence; reach an agreement on their meanings; and seek consensus by agreement, after broadly exploring the answers to the differences, through discussions^65)-(66.

To ensure the participation of as many representatives as possible and their diversity, the discussions took place in person between 2014 and 2018 in six workshops held at the Brazilian Congresses of Medical Education promoted by ABEM, and three specific events on communication. The total number of participants was 276, including communication experts and teachers, students and other professionals interested in the area, from 126 higher education institutions in the medical and health area, four Health Secretariats and one Health foundation. One group met virtually, every two weeks or monthly, after the first in-person workshop.

Each in-person meeting lasted from four to eight hours and its dynamic consisted of sharing experiences in the teaching of communication and bibliographic material brought by experts, in addition to international consensuses, as they were being published^40)-(50 and the presentation of the version under construction of the Brazilian consensus offered by the organizers. New knowledge, skills and attitudes that should be part of the consensus were then discussed in small groups, which were subsequently presented to all the participants, with debates and agreement on the content to remain, confirmed by voting. As several components of professionalism were listed in the construction process, one of the workshops was aimed to discuss which components should be included in the consensus. The decision was unanimous to keep all of them and to consider professionalism as one of the bases of communication. The virtual meetings followed the same dynamics as the in-person meetings but lasted from one and a half to two hours.

The consensus was finalized in 2020 by the virtual group. However, the new communication challenges highlighted throughout the Covid-19⁷³ pandemic required its review.

The semifinal version of the consensus was presented in July 2021 at a meeting held on ABEM’s virtual platform, with an invitation being sent to its directors and all those who had participated at some point in its construction process, when changes were suggested to be included in its final version, which was unanimously approved. After being submitted to the present journal, one of the opinions demanded new virtual meetings to consider the listed recommendations. The new final version was approved in a virtual meeting with an invitation being sent to all the participants of the consensus at the end of February 2022.

Considering the importance of the material shared by the participants throughout the consensus construction process and also the lack of familiarity that some readers might have in relation to some of the mentioned aspects, unlike other consensuses, this one contains bibliographic references in some of its specific objectives. We would like to clarify that articles and books cited as references were selected according to their relevance, aiming to support educators in the teaching of communication; however, without the intention of exhausting the literature. The explanation of some concepts and terms are also provided in a separate table, to facilitate their understanding by readers who may not know them.

RESULTS AND DISCUSSION: THE CONSENSUS

The teaching of communication in medical schools should have the overall objective of developing knowledge, skills and attitudes in the medical student, so that, when they graduate from the course, they can demonstrate competence when communicating with the people involved in the academic-scientific environment, in health care and health management.

The people involved include students, faculty, physicians, professionals in the healthcare area and other areas of knowledge, members of the interdisciplinary and interprofessional team, employees, researchers, managers, people under care, their family members, caregivers, guardians, loved ones, interpreters, people who respond for them, families, social groups, the community and its representatives and other people with whom the physician has a relationship in their professional performance.

Communication must be based on relationships, being grounded on professionalism, on the principles of the SUS and on social participation. Medical training must be guided by the DCNs and be based on theoretical references and scientific evidence. The DCNs establish that the medical course must provide a “humanistic, critical, reflective and ethical” training, and that it should develop in the student the

Capacity to act at the different levels of health care, with actions to promote, prevent, recover and rehabilitate health at the individual and collective levels, with social responsibility and commitment to the defense of citizenship, human dignity, the integral health of the human being and having as transversality in its practice, always, the social determination of the health and disease process³².

The DCNs also establish that, in health care, the student must be trained to act, considering “always the biological, subjective, ethnic-racial, gender, sexual orientation, socioeconomic, political, environmental, cultural, and ethical dimensions, and other aspects that comprise the spectrum of human diversity that make each person or each social group unique”³², which is in line with the principles and guidelines of SUS⁶⁴ and constitutes one of the components of professionalism^52)-(56, which includes:

In the medical course curriculum, communication must be included from the beginning of the course and continue until its end. The contents must have increasing complexity and be appropriately integrated with other contents, having the “Human and Social Sciences as a transversal axis” and the inclusion of “transversal topics [...] that involve [...] “human rights” and [...] public policies, programs, strategic actions and current national and international guidelines for education and health”³².

The interaction “of the student with health users and professionals” must occur throughout the course and interprofessional learning and interdisciplinarity must be provided, integrating the “biological, psychological, ethnic-racial, socioeconomic, cultural, environmental and educational dimensions” in the different scenarios of teaching, extension and research, which are inseparable³².

The pedagogical approach must contain varied and interactive strategies that encourage student participation in the construction of their knowledge, associate theory with practice, stimulate curiosity, creativity, reflective practice, critical thinking and sensitivity, including, whenever possible, the humanities^32),(59)-(62.

Practices should aim to incorporate knowledge, skills and attitudes (KSAs) with increasing complexity and have appreciation feedback for their improvement. The practical learning environment should be more controlled initially, such as, for instance, with role-playing or simulation in a communication laboratory, and progress to a less controlled environment, such as real-life scenarios, under supervision^59)-(62.

The assessment should be predominantly formative, without disregarding summative assessments^59)-(62.

The educational environment must be a safe one and cultivate ethics, sensitivity, empathy, solidarity, affection⁷⁴ and non-violent⁷⁵, inclusive and non-prejudiced communication, which makes medical training a model “from” and “for” the care that enhance the medical student’s ability to establish respectful and constructive relationships in their process of learning and caring for themselves and others.

For this purpose, the institution must include the daily embracement of the student and the educator, listening to them and valuing their emotions, and it must contain structures for their psychological and pedagogical support. The problematization and critical reflection⁷⁶ of the socialization process must be carried out in a systematic and planned manner, for the development of the medical professional identity construction and the best use of the teaching-learning process, aiming at attaining the objectives of the undergraduate medical course, which is to train competent, ethical, critical, solidary physicians, with social responsibility and committed to the defense of human dignity and social justice³².

The hidden curriculum, characterized by witnessed attitudes and shared messages that are negative, ambiguous and not consistent with the objectives pursued by the course⁷⁷, must be the object of regular problematization and reflection in the formal curriculum. Based on praxis (reflection on practice), strategies must be developed to build a non-oppressive environment that encourages healthy relationships⁷⁸.

According to Bakhtin, we build ourselves in the interaction with other people⁷⁹, being the word the most pure and sensible form of the social relation and the communication the dynamic process for building social meanings. Language carries an ideology and a practice, and each “speech, statement or text expresses a multiplicity of voices, most of them without the speaker being aware of it”^2),(79),(80, which represent different interests and positions in the social structure. As what people “are or will become depends on a continuum of ruptures and transformations that occur as we interact with others”^2),(79, disrespectful messages run the risk of being legitimized and incorporated by the student of medicine, especially when they are shared in a subtle manner⁸¹, with derogatory gestures, jokes, images or comments. These strategies allow their disrespectful and unethical content to go unnoticed.

It is crucial that students and educators understand the ideologies that underlie the discourses about “the other”, and that the hegemonic discourse in a given society is historically constructed through struggles, being socially shared in its different institutions (e.g., family and religious and educational institutions, which includes the medical school). It contains arbitrary criteria of classification, stratification and normativity regarding superiority/inferiority and inclusion/exclusion, which serve specific interests of power, privileges and/or prestige^82),(83. The non-perception of this arbitrariness is what makes them legitimate and perpetuated as common sense, generating multiple prejudiced interpretations such as classism, racism, sexism, machismo, capacitism, LGBTQIA+phobia and xenophobia^82)-(84, and other authoritarian and oppressive attitudes, of discrimination and intolerance. Based on the reflection, it is expected that people involved in the academic environment will increase their awareness of the values of professionalism to be cultivated.

To ensure the implementation and quality of communication teaching in medical schools, it is essential to encourage and support faculty development for the teaching of communication in institutional programs or in existing programs outside the institutions.

According to the DCNs, in its single paragraph of chapter II:

[…] competence is understood as the ability to mobilize knowledges, skills and attitudes, using the available resources, and expressing itself as initiatives and actions that will translate into performances capable of solving, with relevance, opportunity and success, the challenges that arise in professional practice, in different contexts of health work, translated into the excellence of medical practice, primarily in the scenarios of the Unified Health System (SUS).

Therefore, we describe the KSAs to be developed throughout the course, described as specific objectives in Table 1. In it, the excerpts written between quotation marks are citations from the DCNs³². For certain specific purposes, relevant references are cited, which can help educators in the teaching of communication and physicians in their practice. For example, the “World Health Organization Patient Safety Curriculum Guide”¹⁹, quoted several times, addresses: characteristics of effective communication; cultural competence; teamwork communication; safety of the person under care; conflict management; error management and disclosure; management of uncertainties; and, communicating difficult news, among other topics; and contains roadmaps for the safety of the person under care in procedures, emergencies, changes in work shifts, transfer between sectors and between institutions and for other communication topics, as well as documents, including informed consent and the form for the reporting of adverse events and errors.

We emphasize again, however, that the cited references are just a few among the vastness of the existing literature on communication.

Table 2 provides some concepts and explanations of terms covered in this manuscript, to facilitate the readers' understanding.

Figure 1 illustrates the different stages and processes of the relationship-centered encounter.

Figure 1 Communication centered on relationships in the different stages and processes of the clinical encountera 

Figure 2 illustrates specific contexts in which the medical student must acquire the ability to communicate in health care, represented by a tree. Its trunk represents communication centered on relationships, its base represents its support by professionalism^52)-(56, the SUS⁶⁴, the DCNs³² and theoretical references and scientific evidence, by which it must be guided or on which it must be grounded, and its canopy cover contains the contexts for the teaching of communication in health care.

Source: the authors.

Figure 2 Health care contexts in which the medical student must acquire the ability to communicate 

FINAL CONSIDERATIONS

This is the first consensus for the teaching of communication in Brazilian medical schools. We emphasize, however, that it represents an initial step and that, due to its collective and collaborative construction with representatives from more than half of the medical schools and other areas of health and representatives of health institutions, the consensus must be seen as a process of ongoing construction, which may require additions in the future.

It is assumed that communication should be centered on relationships, based on professionalism, universality, integrality and equity in health care for the population and encourage social participation, and based on the DCNs, theoretical references and scientific evidence. Specific objectives are described to develop competence in communication in the medical graduate, covering the theoretical foundations, the search, critical evaluation of the literature, preparation and writing of documents, and intrapersonal and interpersonal communication to make the medical graduate competent in communicating with people involved in the academic-scientific environment and in health care and health management. It is recommended the inclusion of communication in the curriculum from the beginning to the end of the course, integrated with other contents and areas of knowledge.

The moments in which each objective must be developed in the course were not established, considering the peculiarities of the curriculum of each school and their autonomy in its planning.

We hope the consensus will contribute to the review of curricula of undergraduate courses in medicine that already contain communication or to its implementation, and, perhaps, in the curricula of medical residencies in Brazil, to promote communication in medical education, in the attention to individual and collective health and in health management, to strengthen the SUS and achieve social transformations that improve the population’s health conditions and the defense of social justice.

The next objective of this ABEM project is to offer teaching materials and workshops to support teacher development in the teaching of communication.

Finally, we clarify that, just like any collective construction process, this consensus can be updated when necessary.