INTRODUCTION

Inadequacies in the training of medical professionals considering humanized care and focused on the health needs of the population have long been discussed¹. The medical training model in Brazil was influenced by the recommendations proposed by Abraham Flexner in his report, published in the United States at the beginning of the 20^th century^2),(3, imprinting mechanistic, biologicist, individualizing and specialization characteristics in medicine⁴. However, it has been acknowledged that, in order to provide comprehensive care, the medical professional needs to better understand the determinants of the health-disease process, in addition to the biological aspects of people’s illness. It also requires that the social and psychological context of users and population be considered, that is, it requires the broadening of one’s view⁵, which demands changes in their training.

In an attempt to propose changes to the current medical training, different international entities have prepared recommendations, such as the Association of American Medical Colleges (1981) with the Panel for the General Professional Education of the Physician and College Preparation for Medicine; the World Federation for Medical Education (1988) with the Edinburgh Declaration; and the Robert-Wood Johnson Foundation. In common, all documents reinforce the importance of including aspects of health promotion and prevention, community integration and expanding the practice environment beyond the hospital, with the inclusion of students into local health systems^6)-(8.

In the perspective of reaching the objective “Health for All in the Year 2000”, the World Health Organization (WHO) identified Primary Health Care (PHC) as a central strategy for the organization of Health Systems and recommends that a good part of the undergraduate medical practice take place inside the Health System and, therefore, also have PHC as a practice scenario⁶.

In Brazil, since the 1980s, some projects and programs have been organized aiming to attain changes in medical training, such as the Assistance Teaching Integration Project (IDA, Integração Docente Assistencial), and the Promed, Pró-Saúde, and Pet Saúde Programs, among others. All these initiatives had as a common axis the restructuring of the curriculum of medical courses, in the schools where they were developed, aiming to overcome the biomedical model and to include students into new practice scenarios³.

These strategies also had the capacity to influence, in the national scenario, the publication of new National Curriculum Guidelines (DCNs, Diretrizes Curriculares Nacionais) for Medical Courses, with the first being published in 2001 and the second in 2014. The guidelines propose the reformulation of the curricula, including new practice scenarios and other strategies, such as active teaching-learning methodologies aiming to generate actual changes in the profile of graduate physicians³.

Gomes et al. (2012)⁹ defend the necessary changes in medical education and recognize the importance of curricular guidelines that point in this direction. They recognize that, although this scenario has been gradually changing in the 21^st century, they warn of the risk that the changes will only affect methodological issues, and there are still doubts about the best ways to enable successful inclusion in PHC.

Considering the above, as well as the publication of a new DCN in 2014, this literature review study was carried out with the objective of analyzing how the inclusion of medical students in Primary Health Care occurs during undergraduate school and the perception of the different actors involved on this process.

METHODS

For data collection, the “scoping review” or “scoping study” was used as a tool, an approach that has been increasingly used to analyze evidence in health research. This modality of literature review was proposed by researchers Hilary Arksey and Lisa O’Malley¹⁰ in 2005, and allows assessing the extent, scope and nature of research activity, summarizing and disseminating study results, as well as identifying research gaps in the existing literature¹⁰. This study followed the following steps: (1) identification of the research question; (2) identification of relevant studies; (3) study selection; (4) data mapping; (5) comparison, summary and reporting of results.

The problem that guided the development of this research was the need to know the content in the literature on medical training in relation to the inclusion of students in Primary Care, which motivated the implementation of the PHC practice scenario, the teachers’ and students’ perceptions and the challenges for the changes in the curricular structure. Therefore, the following research question was defined: “How does the inclusion of Primary Care as a field of practice occurs in the different undergraduate medical courses in Brazil?”

The following inclusion criteria were used for the study: original articles that had free access abstracts; published in Portuguese, English and/or Spanish; published in the period from 2001 to 2020, considering that the first Curricular Guideline for the Medical Course was published in 2001. Books or book chapters, monographs, theses, dissertations, official documents and review articles were excluded from the research, as well as articles that did not portray training in Brazilian universities.

The literature search was carried out in the following databases: Literatura Latino-Americana e do Caribe em Ciências da Saúde - Lilacs and Medical Literature Analysis and Retrieval System Online - Medline. The website of the Virtual Health Library (VHL) was used to search the LILACS database and PubMed for the Medline database.

The following Health Sciences Descriptors (DeCS) were used: Atenção Primária à Saúde; Educação de Graduação em Medicina; Educação Médica; Currículo; Primary Health Care; Education, Medical, Undergraduate; Education, Medicine; Curriculum.

For the search in the databases, the descriptors were aggregated using the Boolean operator AND as follows: “Atenção Primária à Saúde” and “Educação de Graduação em Medicina”; “Primary Health Care” and “Education, Medical, Undergraduate”, “Atenção Primária à Saúde” and Currículo and Médico and “Primary Health Care” and Medicine and Curriculum. The search was carried out during the month of November 2020.

Study selection was performed based on the analysis by two judges (the standard examiner is the main author of the study and examiner I, the second author of the study), according to the guiding question and the previously defined inclusion and exclusion criteria. All studies found during the search using the descriptors were initially evaluated by the standard examiner through the analysis of titles and abstracts.

Figure 1 depicts the methodological route, detailing the search results by descriptors and by databases, as well as the results of the selection of the articles included in the study, based on the analysis of the judges.

Source: Prepared by the authors, 2020.

Figure 1 Methodological route for the selection of the articles included in the scoping review 

RESULTS

Data mapping using data from the studies was performed and the extracted information comprised three analysis groups, with the first being: article references, with place and year of publication, article title, authors, place of publication, objectives and methodology. The second analysis group included medical training for PHC and the third included the perception of the different actors involved on the inclusion in PHC internships. Subsequently, the results and conclusions were compared and discussed for a more in-depth analysis of the selected studies.

Medical training for Primary Care

To evaluate training for Primary Care, the 17 articles that addressed this topic were analyzed.

During the presentation of the driving motive for the curricular change, the DCN appeared in 14 publications, in addition to the Promed in one, the Pet-saúde in one and both the DCN and Pet-Saúde in another one.

Among the analyzed articles, 12 of them reported that the students attend the PHC internships as early as in the first semester of the course. The distribution of the semesters during which the students attend the PHC internships is shown in table 1.

Table 1 Semesters during which students attend the PHC internships 

	Semester	%
First to Eighth semesters	8	47.1
First and Second semesters	2	11.7
Third and Fourth semesters	2	11.7
First or Third semester	1	5.9
First to Third semesters	1	5.9
First and Third semesters	1	5.9
Second to Eighth semesters	1	5.9
Not informed	1	5.9

Source: prepared by the authors, 2020.

In 15 medical courses, this inclusion takes place in the Basic Health Unit, and in another, in addition to the Basic Health Units, it also includes Secondary and Tertiary Care services, whereas another one does not clearly mention the place of inclusion. The duration of the internship is shown in Figure 2.

Source: prepared by the authors, 2020.

Figure 2 Duration time of inclusion of students in the PHC internship 

The articles reported that PHC inclusion during the internship occurred in only five courses, whereas there is no record of this information in the remaining twelve.

Regarding why students should attend practical internships in Primary Care, several justifications appear, among them: generalist training, critical and reflective training, humanized care, care based on people, families and community, and teamwork, among others, which are detailed in Chart 2.

Chart 2 Student learning objectives with PHC inclusion in selected articles 

What does the course expect in terms of student development with PHC inclusion?
• Getting in touch with the complexity of the person-centered practice, with the obligation to work in a team and network, doing longitudinal follow-up, allows the student to acquire essential skills for the exercise of the profession.
• At the end of the course, the student will be able to: perform community diagnosis, perform a medical consultation using the person-centered clinical method, perform the family approach, work as a team, recognize the difficulties faced by the health system users and propose actions to mitigate them, offer integral and humanistic care, understand people in their life, family, social and environmental context.
• To develop and qualify in generalist medical skills and attitudes
• To develop the preparation and skills necessary to solve real-life problems, work in multidisciplinary teams, valuing each FHS professional, develop critical and reflective capacity and promote comprehensive care to the population, focusing not only on the disease, but on the health of the entire human being.
• Training of a general practitioner, therefore, the experience of all students at all levels of SUS care, but with an emphasis on family health.
• Train a physician who understands the expanded concept of health and knows how to embrace and establish accountability bonds, in the coordination of the necessary actions to improve the quality of life of people, families and the community.
• To train physicians with a generalist, humanistic, critical and reflective performance, capable of acting in the health-disease process at its different levels of care, keeping coherence with the epidemiological profile of the population, based on ethical principles, aiming to promote the integral health of the human being.
• To train a general practitioner more suited to the challenges of modern society.
• To encourage undergraduate students to understand the determinants and relationships of diseases with people’s way of life and work. Care based on the health of individuals, families and community. To understand the difficulties and possibilities of combined health practices, experiencing the real context of the SUS.
• To identify and act on real-life problems, assuming increasing responsibilities as an agent providing care compatible with their degree of autonomy. Comprehensive and humanized actions to solve the population’s health problems.
• To interact and connect the university with the health services and the community and the medical student in the daily life of the FHUs, create the opportunity to know models of health care for a population, health planning, enable the observation of the work of a FHP team, at home and in the community, knowing people’s health needs, raising awareness for the development of educational and pedagogical practices that facilitate the sharing of knowledge and information
• To enable the understanding of the process of building collective health knowledge, correlating it with the performance of professionals in the practical field; conceptualize important aspects of the SUS and their applicability in the internship practice.
• To enable a humanistic and ethical critical training. To incorporate knowledge, skills and attitudes necessary for the construction of the person-centered medical practice and sensitive to the realities of the health system.

Source: Prepared by the authors, 2020.

DISCUSSION

After the review was carried out, it was observed there was a lack of studies at the national level with a more robust methodology, especially controlled studies comparing inclusion and non-inclusion in PHC with medical training outcomes. In other words, most of the selected studies comprise experience reports and this may lead to result fragility, as well as limit the understanding of how the inclusion of Primary Care is taking place as a field of practice in the different undergraduate medical courses in Brazil - the question chosen to be answered by this scoping review. It is also recognized, as a limitation of the present study, the review methodology used, due to the fact that selection bias can occur in this type of study.

Despite the widespread importance of strategies such as the Promed and Pet-Saúde, for the implementation of changes in medical training, it was found that most of the selected studies recognize the DCN as a driver of curricular changes. Another result that reinforces this finding is the fact that most articles were published between 2015 and 2020, after the publication of the second curricular guideline.

The DCNs point out that one should:

Art. 29. VI - include the student in the health service networks, considered as a learning space, since the initial years and throughout the Undergraduate Medical course. VII - use different teaching-learning scenarios, especially the health units of the three levels of care. VIII - provide the student with active interaction with users and health professionals, since the beginning of their training³⁸.

If we analyze the fact that the articles above deal with curricula whose influence on structuring consisted primarily of the DCN 2014, it can be observed that they meet what is described in these topics.

Demarzo et al.³⁹, describe the guidelines for the teaching of Primary Care in Undergraduate Medical Schools, recommending that the internship should occur longitudinally throughout the course, with increasing complexity and whose activities should be included since the first year, also corroborating the findings of this study

The development of these activities at the beginning of the undergraduate course allows students to have the opportunity to integrate themselves early into the daily life of a community, in its different contexts and to face theoretical-practical aspects with an activity based on the experience of teaching-service integration⁴⁰.

The inclusion of the medical student in primary health care must occur in an integrated manner with health systems. In a study carried out with 108 Brazilian medical schools, it was evident that they also followed the recommendations of the DCNs and established teaching-service integration with agreements with local management, aiming at promoting integration and interdisciplinarity in curricular development and seeking changes in their curricular matrix and methodologies⁴¹.

A study carried out in 259 medical schools in Europe found that 81% of them also had a PHC internship. In another study, a questionnaire applied in 40 medical schools in Europe identified that 80% of these schools implemented a timely clinical exposure as early as in the first year, as shown in this study; however, in Europe this inclusion occurred as of the end of the first semester and not right at the beginning of the course as observed. The inclusion period varied from two weeks to two years⁴², a shorter time than that described in the researched articles. In another study, carried out in twenty-eight schools in the United Kingdom, it was found that 50% of the schools had this inclusion throughout all five years of the course and 25% in two or three years¹⁶, which is more similar to what was identified in this article.

Bazak et al.⁴² reported that the inclusion in PHC would aim at several aspects related to medical practice, in addition to the introduction of medical skills such as anamnesis and physical examination. A study of 28 schools in the United Kingdom that evaluated documents related to internships in PHC, showed as training objectives consultation and communication skills, teamwork and individual development, diagnosis and treatment, promotion, and prevention⁴³. Another study, also carried out in the UK with undergraduate students, highlighted that the integration between theory and practice, the students’ motivation to study for career goals, the practice of skills and clinical assessment, communication development, consultation skills, working with patients, understanding the Health System are benefits of timely curricular inclusion⁴⁴. These objectives are very similar to those found in the articles depicted in Chart 2.

Harvard educators developed a curriculum content for PHC training with the following characteristics: longitudinality, generalist training, central coordination of care, communication skills for building therapeutic alliance, knowledge about acute and chronic conditions, care in the different phases of the life cycles, including health promotion and prevention actions, addressing the most prevalent mental disorders and changes in lifestyle habits, practice scenarios in outpatient clinics of the health system, teamwork and health determinants⁴⁵. All these characteristics were also reported in the selected studies, except for actions related to mental health care.

The DCNs of 2014³⁸ present all the objectives found in this review, such as learning objectives for medical students, and some of those described objectives are part of the characteristics of the graduate’s profile. Demarzo et al.³⁹ also mention individual, family and community skills and competences as a justification for training in PHC.

It is verified that the positive aspects that appear in the teachers’ evaluation are also perceived by the students, although there are many more aspects evaluated by the latter as positive. In relation to the negative aspects, the lack of teacher training and the lack of infrastructure of the units, perceived by both students and teachers, are highlighted.

The DCNs³⁸ of 2014 bring as important aspects of medical training all the items identified as positive points of medical training pointed out by students and teachers, demonstrating how much the PHC scenario has been used by the assessed institutions with the objective of adapting training to the profile expected by the DCNs.

An article that analyzes the experience of a Brazilian public institution shows that internship teachers do not know Primary Care and that students should be “specialists”, corroborating some of the negative results pointed out by students and teachers in the analyzed studies⁴⁶. This perception appears as a negative aspect, demonstrating that the training of teachers, whether they are service preceptors or teachers at educational institutions, is one of the problems that need to be analyzed in PHC training.

In a survey carried out in Spanish medical schools with students in the 1^st, 3^rd and 5^th years, it was found that 87% of the students believe that there are sufficient justifications for theoretical-practical learning in Medicine and Community, which plays an essential social role. However, less than 20% consider it to have similar status to other medical specialties⁴⁷. Another study carried out in Genova and Lausanne showed that learning in PHC has a positive influence on the students’ concept of medical work at this level⁴⁸. Students from Athens, who attended a clinical practice internship at PHC, evaluated that there was a significant improvement in their clinical skills, physical examination and interest in specializing in PHC⁴⁹. Similar results were found regarding the students’ perception in the articles included in this review.

The participation of students in PHC should aim at creating bonds with the community and actions to be developed on the community demands identified by the residents and health professionals, on how to deal with users. This inclusion should promote benefits to the team and the community, not harming or complicating the existing work process⁹. It can be observed that these aspects appear in the students’ analysis, but mainly in the evaluation of the service preceptors, demonstrating it remains a challenge to be overcome in the teaching-service integration in Brazil.

CONCLUSIONS

Considering the methodology used in this review, it is known that a selection bias can occur. Another limitation of the study is due to the fact that the degree of evidence of the selected studies was not analyzed and, considering that most of them comprise experience reports, this may lead to result fragility. More studies, with better levels of scientific evidence, are shown to be necessary.

As discussed by different groups of scholars, as well as described in several articles, both national and international ones, training in PHC plays an important role in the transformation of medical training, especially the changing of the biomedical model into a model in which the social determination of the health-disease process and the individual’s social, family and work contexts are included in the care process and, consequently, in the training process of medical students.

To think of a doctor with humanistic, critical and reflective training, with skills and competences that allow them to act from the health promotion, prevention, treatment and rehabilitation actions, capable of using tools of individual, family and community approach, demands their inclusion in practice scenarios in which the closest contact with the individual and their context occurs. This scenario is undoubtedly the PHC.

Analyzing the selected articles, it can be observed that much has already been done in terms of curricular adequacy to the 2014 DCNs and the training that contemplates the aforementioned changes, but much remains to be done, considering that the number of schools that appear in the study is much lower than the total number of Brazilian medical schools, a limiting factor for this analysis.

Also, when discussing the perception of the different actors, it can be observed that the importance of a timely inclusion in PHC is acknowledged in most cases, with PCH being an important training space for the physician and that the teaching-service integration, with the approximation of theory and practice undoubtedly play an important role in the quality of training. However, the lack of teacher training, lack of physical structure in the Health Units, lack of integration of the basic cycle with the clinical one, lack of appreciation of the SUS, in addition to the prioritization of the specialization areas by the students and many teachers, as well as the curricular structure that predisposes the training of specialists have also been recorded.

Therefore, the DCNs for the medical course represent a milestone for the change in the hospital-centered and biomedical model of medical education; significantly influenced a number of medical schools, but much remains to be improved, if we really want to train doctors with the profile that Brazil and that national and international leaders understand as necessary.

Thinking about strategies to improve the teaching-service integration, regarding better established agreements between teaching institutions and health departments, as well as tools to qualify teachers for teaching in PHC seem to be important steps to be established.