Perceptions of the Early Medical Student Insertion in Primary Care : Analysis by Environment Study

Results: the students highlighted the importance of the premature experience to the community health care, making critical to the learning process the experiences proposed in the Environment Study. they also related the importance of a well-equipped physical structure and an appropriated ambience, which gave them conditions to learn and to reflect about the reality in which they are inserted. the proposed activity provided stimulus to seek new sources of knowledge to understand the reality in which they were inserting themselves.


Introduction
In Brazil, the great augment of the workstations number, with the acute expansion of the Primary Care assistance cover, produced by the progressive implantation of the Health Unique System (HUS), highlights the necessity to invest in the process of medical formation and permanent HUS workers education, according to the assistance model centered in the care [1].Knowing the complexity of the necessities and problems of Brazil's health, the Superior Education Institutes (SEI) have been building a pedagogic model that consider the social, economic and cultural dimensions of the population [2].
In the medical formation field, the propose of a pedagogic model that comprises more than the simple trade of knowledge valorizing the experiences of the students intends to transform the traditional conception (biologic, mechanistic, centered on the professor and on the knowledge transmission) into a constructive conception, wherein the student is the main actor of his knowledge formation.thus, he would be capable to understand the questioning of the practices and the lore, encouraging the knowledge production in services [3].
the actual guidelines curriculum of the medical courses in Brazil underline the graduate student profile as: "doctor with generalist formation, humanistic, critic and reflexive, qualified to actuate, ruled by ethical principles, in the health-disease process in its different attention levels" [4,5].Although some Brazilian medical schools already present curriculum changes, in way to promote the formation of professionals capable to integrally actuate in health vigilance and more conversant with the main health population programs, the national scenery is still based in a traditional learning [6].
Preado et al., [7] highlighted the importance of studies that points to what is necessary, in a physician education perspective, to reach transformations in health professionals' profile that is being build.In national and international scopes, the studies point as alternative the usage of active methodologies, centered in the student and based in the health necessities of population, with the early insertion of students in Primary Attention to health teams and for a longer period.[6] As one of the insertion methods in community, the Environment Study is highlighted, which must guide the student to the observation, to the analysis and to the interpretation of many ambience aspects.these take him to a better understanding of them, allowing to intervene critically, in way to participate actively in the improvement and valorization of the sorroundings [8,9].
Our study aimed to analyze the perception of the students of the first semester (2014.1) of the Medicine course of a public university in Ceará interior about the early insertion in sceneries of Primary Attention to Health, trying to verify how the sceneries diversification of teaching and learning process approach the students to the everyday reality of his future work, and the role of this activity as promoter of a criticize look development, to capacitate them when dealing with real health problems of the community in which they are inserted.

Method
It was performed a transversal and qualitative study that use the Environment Study as guiding tool.the Environment Study can be comprehended as an interdisciplinary teaching method, which aims to provide, to students and teachers, a direct contact with a determined reality, any ambience, rural or urban, which was chosen to study [10].It is all the didactical modalities in which the classroom is changed to another ambience, like a factory, a museum, a free fair, a quadroon, the square in front of the school, etc.It still refers to a natural or unnatural ambience habited by several live being, in which there must be conditions to study or comprehension of the relation among the seve-ral live being that dwell there, the relation among them and the other components of the ambience and the interaction of the human being with all of them [11,12].
the Environment Study provides to students the opportunity to develop knowledge and skills that allow them to take decisions and act in a sensible way when facing the ambience issues and own ways of being of an active citizenship, which involves the knowledge about their rights and social responsibilities, at local and global levels [8].
the study subjects were medical students of the Federal University of Cariri (UFCA) located in Barbalha city, interior of the Ceará State, in Northeast Region of the country, during the period from January to June of 2014.
Researches about the medical student insertion in Primary Attention, dialogued expositions in classrooms and seminars were promoted before the data collect.these provided to the students theoretical and methodological support to the task that would be proposed to them.
Four groups of ten students were formed, using the rotation system.the activities occurred under orientation of an instructor researcher, a monitor of the discipline and a nurse of the Basic Health Unit (BHU) in which occurred the work.
the students responded an investigation guide composed by three subjective questions, namely: (a) What is the meaning of Primary Attention to Health in HUS structure?(b) How do you realize the contribution of Primary Attention to Health to your formation?(c) How do you evaluate the field activity in your teaching and learning process?After the completion, these documents were given to the coordination of Medicine course, remaining in its guardianship.the guide consisted in a source of information of the present research.
thirty-five students' reports matched the inclusion criteria: students' report that coursed the module of Basic Assistance to Health I at the semester 2014.1, in faculty of Medicine; and fill satisfactorily the data collect instrument.
the data were organized in thematic areas that expressed the same meaning, content and emotional charge, being primarily analyzed by two researchers and, after that, by two more senior professionals in the field of Medical Education and Public Health, respectively.
the following steps were performed in the analysis of collected material: (a) material rereading, organizing it in a determined sequence; (b) data ordination, being performed an exhaustive and repeated reading, with the constitution of one or several corpus, and being detected the sense nucleus; (c) final analysis, by means of triangulation with the theoretical referential and the collected material.Due to ethical reasons, a number correspondent to a numerical order represented each student.the reports were codified as E for student, followed by the number order of the delivered reports.
the study obtained terms of Custodian from the coordinator of the Medical course of UFCA (Attachment 1).

Results
the data analysis allowed the building of two empirical categories: "the practical-theoretical experience at Basic Health Unit as a facilitating tool of the teaching and learning process" and "the Environment Study as complementary instrument in the educational process in Medicine".

Category 1
The practical-theoretical experience at Basic Health Unit as a facilitating tool of the teaching and learning process At the first category, the students assigned meaning to the experience of their early insertion in the community and how this activity facilitated their the teaching and learning process.

Category 2
The Environment Study as complementary instrument in the educational process in Medicine the entrance could evaluate how the early insertion by the technical of Environment Study for their medical formation.

Discussion
the 35 students that participated in the intervention highlighted the importance of the early experience in the health care of the community, making these experiences fundamental to the learning process, since this is allied with the discussed theory in classroom to the practice performed in the context of a determined community in a BHU.
Reinforcing the aspects related with the importance of the work, the exposition of the student to a situation in community with possibilities of mediations between student and supervisor, student and mother-child and student and professional, it is better realized the potential that specifically represents this scenario, once it offers different learning situations, distinctive of those proper of the academy, or the hospital ambience or, still, the specialties ambulatory [7].
the insertion in the community since the first periods allow to the student to create critical conscien-ce about the health conditions of the country, to develop a humanization process in his social relations and, mainly, feel responsible to give his contribution to reverse this situation [13].
It was observed in Table 1 that 22 students realized the existence of an attempt, by the management and the health team, to promote changes in technical and biological assistance paradigm of the medical education, once the Primary Attention is centered in family, understood and perceived from a physical and social ambience.For that, a permanent dialogue with the professional involved in the formation is necessary, with the clarity of the responsibility, possibilities and limits of the practice sceneries in the formation process [2].
the greater emphasis in health community aspects in the medical formation is a world tendency [14][15][16].In the medical schools of European universities, the Family Medicine is taught in almost all countries, holding established departments and, sometimes, in the medical schools, without general clinic department [17].
In Brazil, the changes and curriculum adjustments proposed to the courses of health area, seek, mainly, the attention to the health necessities of the population and the consolidation of HUS, expanding the access to the population and to its coverage area, as well as the work posts [18].Table 1.Attributed meanings by the medical students to their early insertion in community.Barbalha, Ceará, 2014.

Meanings Subcategories Extracted texts of the reports
Integrate practice and theory "[...] the most important at this first contact was to realize how we are capable to integrate the theory with the practice, in addition to find that our knowledge can be transmitted to the community, being fundamental the role of Primary Attention to Health to our formation process."(E5) Experience the reality of the service "Experience the reality of the BHU allowed us to have a more concrete vision, the Medicine apart the academy context, apart the technology."(E35) to know the structure and the work process of the team "[...] the BHU structure is great, well equipped and has complete health team.this allowed us to execute our activities without deficiencies.Besides, we can realize how the UBS health team treats the patients integrally and humanly, and not just as a sick organ."(E2) BHU: Basic Health Unit.

InternatIonal archIves of MedIcIne
Section: Global HealtH & HealtH Policy Issn: 1755-7682 J the perspective is to reorganize and incentive the Primary Attention in HUS, that requires the professionals' formation, especially doctors, provided with a coverage social vision and technically able to perform continuous and resolute cares to the community health [19].
From the students that participated of the early insertion, in Board 1, 29 highlighted the importance of a well-equipped BHU and a proper ambience, which could give them conditions to learn and think about the reality in which they are inserted.Study performed in Rio de Janeiro (RJ) city that evaluated the main difficulties of the Primary Attention managers concluded that the biggest obstacles encountered were related to the structure, like the excess of bureaucracy, the activities overcharge and the small physic area, which, somehow, difficult the work process of the team, causing stress and conflicts, as far among colleagues as these and the community [20].
the teaching and learning process cannot be seen as an adynamic and linear process, neither as a sum of contents, which can be added to the previously accumulated ones.It is a complex and demands directed actions, so that the student can deepen and expand the acquirements elaborated by means his participation [21].
In our study, it is observed, based in Table 2, that 32 students emphasized the going to the Primary Attention unit as camp experience that allow them to change their vision of the service and to build new concepts about this. the formation with the usage of the active methodologies differentiate from the traditional teaching [2], once it represents a paradigm change: an education merely centered in the professor and in the acquirements transmission, for an inspiring constructive methodology, centered in the student and in the development of abilities and attitudes to resolve problem, knowing previous experiences of knowledge, culture and life [22].
the adoption of active teaching methodologies has grown significantly to attend the new social demands.In Brazil, the Londrina State University (LSU), in Paraná State, and the Faculty of Medicine of Marília (FAMEMA), in São Paulo, are pioneers in this model.In Bahia State, in Brazilian Northeast, we have as examples the State Universities of Feira de Santana (SUFS), of Santa Cruz (SUSC) and of the Southwest of Bahia (SUSB) actuating in curriculums based in significant, problem-solving and centered in student and in community learning [23].
Experiences with active methodologies have already recognition from Medical Schools outside Brazil.the Problem Based Learning (PBL), for example, was adopted in the Maastricht University, New Zeland, in Harvard, United States, in Sherbrook, Canada, reaching a total of 60 other faculties and universities around the world [24].Champin and Dominguéz [12] highlighted that the curriculum reform in medical schools in Peru is necessarily correlated to the learning based in experience (the courses are 60% practical and use active methodologies), and the focus of the Primary Attention to Health occurs in progressive way (including the analysis of the social determinants of health, the promotion and prevention of health and the integral and integrated attention).Rodríguez et al. [26] refers that, among the education principles in health sciences in Cube, there are the combination of study-work: teaching, assistance and investigation integration; and active methodologies of teaching and learning.
However, the integration process of the Primary Attention in its plenitude in medical curriculums is not simple, and a reflex of this is the several publications that points how this challenge of future doctor adequate formation is not solved with simple curriculum changes [16,22,26].Similar works in England and in Canada reaffirm such preoccupation.
In our study, 18 students referred in their reports that the proposed activity provided them stimulus to seek new sources of knowledge to understand the reality in which they were being inserted.the mold in which the medical education contributes to ensure the population health is to be considered a continuous learning process that is started with the entrance in medical faculty and ends with the clinical practice final [25].Andrade et al., [29], evaluating 120 students between the first and the sixth years of the graduation in a medical faculty in Rio de Janeiro, found positive attitudes reports of the students, related to the medical contribution to the scientific advance of Medicine, and ratified the importance of scientific texts reading since the beginning of the course and the knowing of the scientific methodology to the medical research.thence the early insertion in the community systematized in scientific bases contributes to a medical formation.
the 34 participating students of the study highlighted, as can be verified in Table 2, the importance of the theory-practice integration.the active methodologies provided the reflection about the thinking and the practical experiences, offering opportunity to change what we think and do, by mean of a critical analysis, leading to the full understanding of health [30].Silva et al., [31] affirmed that the work in health can be understood as a diary interference of actions related to human life.thus, to develop a job focused to life quality demands a conscious formation about the role that each worker exerts when providing services to the community.

Conclusion
It is noted the importance to integrate the theoretical teaching to the practical, as to develop in the students a critic perception to the health and to fortify the relevance of public politics.this will reflect in the formation of medical professionals with profile to actuate in Health Unic System, as the National Curriculum Guidelines of medical formation, reedited in 2014, recommends.
the usage of the Study of Social Environment allowed to the students to realize themselves as direct agents in their learning process, providing ways to build possibilities to do an active, participative, productive and reconstructive work.this approach has options linked with the multidisciplinary and the interdisciplinary, providing the integration of basic and clinic-epidemiological sciences, as well as enriches the teaching and learning process, since this provided to students a new way to experience the knowledge.this allowed them to explore new ambiences not known before and appropriate them in order to produce new ones, rescue old ones and rebuild the acquirements obtained during their personal and academic life. .
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Table 2 .
Attributed meanings by the medical students to the usage of Environment Study as early insertion technique in community, Barbalha, Ceará, 2014.