Residência médica em medicina do trabalho: contradições e consensos
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2020-02-28
Autores
Bravo, Ecléa Spiridião
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Universidade Estadual Paulista (Unesp)
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Introdução: Diferentes concepções ainda vigoram nas relações saúde-trabalho no Brasil. A Medicina do Trabalho (MT)/Saúde Ocupacional (SO), tem como principal objetivo o controle e reprodução da força de trabalho de acordo com os interesses do capital. A Saúde do Trabalhador (ST), voltada aos determinantes sociais da relação saúde-doença, preconiza ações interinstitucionais e seu principal objetivo é extinguir a naturalização social da ocorrência evitável de acidentes de trabalho (AT) e doenças ocupacionais (DO). Essa dualidade não responde aos desafios postos para a intervenção nos determinantes dos agravos à saúde dos trabalhadores. Diferente das demais especializações, a ST exige dos profissionais lidar com situações paradoxais e conflituosas agravadas por mudanças rápidas e radicais do mundo do trabalho. Justificativa: A demanda deste estudo veio da implantação do Programa de Residência Médica no CEREST Piracicaba e sua crítica aos modelos de MT e SO. No âmbito da saúde pública, as relações trabalho-saúde são de grande relevância quando se considera as causas externas de morbimortalidade das populações. A alta prevalência de subnotificação dos agravos à saúde, decorrentes das condições de trabalho pode ser um dos fatores que indicam a deficiência do ensino médico em saúde do trabalhador. A evolução do conhecimento necessário ao controle dos perigos e riscos é mais lenta que as mudanças do mundo do trabalho. Objetivo: analisar a formação do médico em nível de pós-graduação para atuação no campo saúde-trabalho, à luz das mudanças do mundo do trabalho. Metodologia: através de uma abordagem qualitativa, buscou-se fazer um estudo exploratório e descritivo de quatro programas de Residência Médica em MT (PRM I, II, III e IV), através de entrevistas semiestruturadas, com auxílio de um roteiro previamente estabelecido. Foram selecionados programas com tradição na área e que nos últimos dez anos ofereceram residência médica em MT. Foram entrevistados, nas respectivas instituições, coordenadores de três programas localizados na região sudeste e um na região nordeste. As entrevistas foram gravadas, transcritas e analisadas, juntamente com o material documental fornecido, segundo descrição dos conteúdos organizados no roteiro, resultando em três eixos temáticos: 1) conteúdo programático; 2) aspectos gerais e representação social dos coordenadores; e 3) a formação e seus conflitos. Resultados: dos quatro coordenadores entrevistados duas eram do sexo feminino; ocupavam os cargos de professora associada, docente, supervisor e coordenador da Saúde do Trabalhador no curso graduação da instituição. A Comissão Nacional de Residências Médicas (CNRM) é instituição de regulamentação e controle dos programas, mas não estimula a prática de atividades didáticas e a integração dos hospitais universitários ao SUS. Todos os programas cumprem os conteúdos programáticos mínimos estabelecidos pela CNRM, mas observou-se que, em alguns programas, há dificuldades no oferecimento de conteúdos teóricos obrigatórios devido ao não envolvimento de professores dos cursos “stricto sensu”. Quanto ao conteúdo programático, destacou-se o PRM II que inseriu a matriz de competências como estratégia pedagógica. Todos os coordenadores relataram dificuldades na construção do campo de práticas originadas pela desestruração dos serviços públicos, resistência das empresas no acesso dos alunos aos setores produtivos, descenso da ST no movimento sindical, entre outras. Três programas destacaram a mudança do perfil dos alunos nos cursos de RM caracterizada, por um deles, como “ruptura geracional”. Todos relataram que a especialidade está desprestigiada entre os médicos. Em todos os programas observou-se conflitos de várias origens, mas aqueles relacionados às competências de juízo moral como, por ex., a falta de uma escuta empática do médico às queixas dos trabalhadores, são os que mais desafiam os coordenadores e suas propostas didático-pedagógicas. Discussão: O SUS é projeto contra hegemônico e isso dificulta a institucionalização da ST como espaço para a formação médica. Na lógica do capitalismo contemporâneo os profissionais que atuam na área da Medicina do Trabalho nas empresas não conseguiram dar respostas prevencionistas aos agravos à saúde dos trabalhadores, a despeito das exigências legais vigentes. Observa-se que as bases estruturais do mundo do trabalho que conceberam a ST hoje não são as mesmas. Nesse contexto, observou-se que houve programas pensados para atender ao SUS, voltados para a ST, e não conseguiram manter seus propósitos, assim como houve quem formasse só para a MT e precisou incorporar elementos da ST. Considerações finais: O despreparo dos programas em lidar com as questões didático-pedagógicas os distancia de outras alternativas/apoio de práticas criativas. As mudanças que ocorrem no campo das práticas são aproveitadas de modo pontual e parcial para estimular reflexões críticas como o desenvolvimento de competências de juízo moral. ST não se inseriu estrategicamente na Atenção Básica de forma a atender o “proletariado de serviços“, os PRMMT não parecem ter campos de práticas para atuação nesse segmento. A educação permanente como estratégia nos PRMMT poderá aproximar cursos lato sensu e stricto sensu, permitir a discussão das competências de juízo moral, enfim dar apoio aos docentes nos enfrentamentos dos conflitos.
Introduction: In Brazil, the medical specialization programs that approach the work-health relationship first emerged in the 1970’s, as a requirement of the former Ministry of Labor, in order to qualify physicians for corporate medical services. As an alternative to old solutions, in the 1980’s, service training with distinctive designs, of which some were more focused on the field of Occupational Health in the public sphere, while others were more influenced by the traditional Occupational Medicine and Occupational Health, not yet evaluated in the country. Such duality does not respond to the challenges posed by the intervention in the determining factors for the workers’ health issues. Differently from other specializations, OH requires medical professionals to deal with paradoxical and conflicting situations, aggravated by rapid and radical changes in the world of work. Purpose: The demand for this study followed the implementation of the Medical Residency Program in CEREST Piracicaba and its criticism to OM and OH models. Objective: to review the physician’s training during a Medical Residency Program (MRP), for subsequent performance in the work-health field, in the light of changes in the world of work. Methodology: from a qualitative approach, a descriptive exploratory study of four Medical Residency Programs in OM (MRP I, II, III and IV) was developed, based on semi-structured interviews and a previously established script. Programs with a tradition in the area, which in the last ten years have offered medical residency in OM, were selected. Coordinators of three programs located in the Southeast and the Northeast were interviewed in their respective institutions. Interviews were recorded, transcribed and analyzed jointly with the documental material provided. Findings: According to the description of contents organized in the script, the analysis resulted in three axes: 1) program content; 2) general aspects and social representation of the coordinators; and 3) education and its conflicts. Of the four coordinators interviewed, two were female; they held the positions of associate professor, professor, supervisor and coordinator of the Occupational Health program. According to the respondents’ report, the medical residency in Occupational Medicine is underappreciated by both the Ministry of Education and the Ministry of Health. The relationship between MR and graduate programs seem to associate competition and symbiosis. Some programs have difficulty to offer mandatory theoretical contents, partly because they are evaluated by criteria that do not value specialization; however, others have stricto sensu graduate courses being attended by MR students. In one of the programs, the skills matrix was inserted as a pedagogical strategy, facilitating the perception of the current challenges to specialist education. All the coordinators reported difficulties building a field of practice, which stem from a combination of absent public service structure, corporate resistance to providing students with access to the productive industry, OH decrease in the union movement, among others. Three programs have highlighted the change in the students’ profile in MR programs, named by one of them as a “generational rupture”. In all of them, this specialty is seen as discredited among medical doctors. There were reports on conflicts of various origins; however, those related to moral judgment skills such as, for example, a physician's lack of empathetic listening to workers’ complaints, are the most challenging for the coordinators and their pedagogical proposals. Discussion: The SUS is a counter-hegemonic project, which makes it difficult for the OH to be institutionalized as an area of medical education. According to the logic of contemporary capitalism, professionals working for corporations in the Occupational Medicine area have failed to provide preventive measures to avoid the aggravation of workers’ health, despite the legal requirements in effect. It is noteworthy that the structural foundations of the world of work present in the early days of OH are not the same today. Data show programs designed to fulfill the SUS demands that have failed to maintain their purposes and have adopted parts of traditional OM/OH education programs. On the other hand, programs originally designed for OM/OH began to adopt elements of the OH education program. Final considerations: The MRPs reviewed have failed to become a substitute for specialization programs, and are proposals in search of an object. Which proposal should be offered, given that all of them seem to associate the contents of traditional Occupational Medicine/Occupational Health inside the SUS while, at the same time, they seem to remain distant from the fields of practices that would allow qualified professionals to handle the health impacts of the new service proletariat, as well as exposure to emerging, little known risks. The educational challenges seem to go through both the absence of a planned insertion of OH in the Basic Care service demanding, for example, strategies that focus on the impacts of the upsurge of precarious work, and the access to fields of practice that handle the consequences of emerging risks according to molds that combine the rollout of pedagogical strategies encouraging the development of moral judgment skills from pre-selected situations, and an optimized management of daily service situations.
Introduction: In Brazil, the medical specialization programs that approach the work-health relationship first emerged in the 1970’s, as a requirement of the former Ministry of Labor, in order to qualify physicians for corporate medical services. As an alternative to old solutions, in the 1980’s, service training with distinctive designs, of which some were more focused on the field of Occupational Health in the public sphere, while others were more influenced by the traditional Occupational Medicine and Occupational Health, not yet evaluated in the country. Such duality does not respond to the challenges posed by the intervention in the determining factors for the workers’ health issues. Differently from other specializations, OH requires medical professionals to deal with paradoxical and conflicting situations, aggravated by rapid and radical changes in the world of work. Purpose: The demand for this study followed the implementation of the Medical Residency Program in CEREST Piracicaba and its criticism to OM and OH models. Objective: to review the physician’s training during a Medical Residency Program (MRP), for subsequent performance in the work-health field, in the light of changes in the world of work. Methodology: from a qualitative approach, a descriptive exploratory study of four Medical Residency Programs in OM (MRP I, II, III and IV) was developed, based on semi-structured interviews and a previously established script. Programs with a tradition in the area, which in the last ten years have offered medical residency in OM, were selected. Coordinators of three programs located in the Southeast and the Northeast were interviewed in their respective institutions. Interviews were recorded, transcribed and analyzed jointly with the documental material provided. Findings: According to the description of contents organized in the script, the analysis resulted in three axes: 1) program content; 2) general aspects and social representation of the coordinators; and 3) education and its conflicts. Of the four coordinators interviewed, two were female; they held the positions of associate professor, professor, supervisor and coordinator of the Occupational Health program. According to the respondents’ report, the medical residency in Occupational Medicine is underappreciated by both the Ministry of Education and the Ministry of Health. The relationship between MR and graduate programs seem to associate competition and symbiosis. Some programs have difficulty to offer mandatory theoretical contents, partly because they are evaluated by criteria that do not value specialization; however, others have stricto sensu graduate courses being attended by MR students. In one of the programs, the skills matrix was inserted as a pedagogical strategy, facilitating the perception of the current challenges to specialist education. All the coordinators reported difficulties building a field of practice, which stem from a combination of absent public service structure, corporate resistance to providing students with access to the productive industry, OH decrease in the union movement, among others. Three programs have highlighted the change in the students’ profile in MR programs, named by one of them as a “generational rupture”. In all of them, this specialty is seen as discredited among medical doctors. There were reports on conflicts of various origins; however, those related to moral judgment skills such as, for example, a physician's lack of empathetic listening to workers’ complaints, are the most challenging for the coordinators and their pedagogical proposals. Discussion: The SUS is a counter-hegemonic project, which makes it difficult for the OH to be institutionalized as an area of medical education. According to the logic of contemporary capitalism, professionals working for corporations in the Occupational Medicine area have failed to provide preventive measures to avoid the aggravation of workers’ health, despite the legal requirements in effect. It is noteworthy that the structural foundations of the world of work present in the early days of OH are not the same today. Data show programs designed to fulfill the SUS demands that have failed to maintain their purposes and have adopted parts of traditional OM/OH education programs. On the other hand, programs originally designed for OM/OH began to adopt elements of the OH education program. Final considerations: The MRPs reviewed have failed to become a substitute for specialization programs, and are proposals in search of an object. Which proposal should be offered, given that all of them seem to associate the contents of traditional Occupational Medicine/Occupational Health inside the SUS while, at the same time, they seem to remain distant from the fields of practices that would allow qualified professionals to handle the health impacts of the new service proletariat, as well as exposure to emerging, little known risks. The educational challenges seem to go through both the absence of a planned insertion of OH in the Basic Care service demanding, for example, strategies that focus on the impacts of the upsurge of precarious work, and the access to fields of practice that handle the consequences of emerging risks according to molds that combine the rollout of pedagogical strategies encouraging the development of moral judgment skills from pre-selected situations, and an optimized management of daily service situations.
Descrição
Palavras-chave
Formação médica, Saúde do trabalhador, Medicina do trabalho, Saúde ocupacional, Avaliação em saúde, Medical education, Worker health, Occupational medicine, Occupational health