Intensive Care in Medical Gruduation: A Study in Maranhao, Brazil - Nursing Research Paper

Intensive Care in Medical Gruduation: A Study in Maranhao, Brazil - Nursing Research Paper

Abstract - There is data to suggest that Intensive Care remains in search of academic independence. In Brazil, Intensive Care is part of the curriculum of the graduation course of some medical schools, including this one. Aim To analyze the contribution of the study of Intensive Care to the medical course in medical graduation. The National Curricular Directories and revision of global literature are used as a reference for the Medical Course.

Setting Federal University of Maranhão, situated in Northeastern Brazil

Methods Quality research in a case study. A semi-structured interview takes place for the sixth-year graduates of the medical course after their on-the-job training in the ICU and for the teachers of this university. The itinerary of the interview was relative to the interest and usefulness of Intensive Care in medical graduation and the grasp of real life experiences with the critically ill patient.

Results The interest through the approach of Intensive Care in medical graduation exists and initially has the need to recognize, establish conducts and procedures for the critically ill patient, something that those interviewed deem necessary for all doctors. The conviviality in the Intensive Care Unit arouses reflex actions in graduate students concerning technical and humane aspects in medicine. The student that participates in the on-the-job training in the ICU reports diverse experiences of being a doctor, that deal with physio-pathology, therapeutics, ethics, a multi-faceted team, communication, self-limit and contact with death.

Conclusions The on-the-job training in the ICU aids in the formation of the medical graduate student as described by the global literature, and in the same direction that is proposed by the National Curricular Directories.

Key Words: Intensive Care Medicine, undergraduate, medical education, curriculum, intensive care unit

The study of Intensive Care in the world

Intensive Care is a specialty that developed due to the need for technological improvement in various areas of medicine. This happened especially after the poliomyelitis epidemic in the middle of the last century, to care for the victims that needed assistance from a mechanical ventilator.
This specialty is an area of multi-professional convergence directed towards the patients care with effective or potential commitment of the vital functions, originating from the flaws of one or more of the organic systems. That's why the ICU is a place where you find critically ill patients. The function of Intensive Care and the ICU in the hospital environment is already well established.
Intensive Care is winning its space as a course of study in medicine, on a worldwide level, principally in the last decades, although the function of the Intensive Care Unit as a learning environment did not develop in the same proportion, as it's clinical function. As a result, Intensive Care still seeks its academic independence in various countries.1
Approaching Intensive Care within medical study has been done preferentially for the post-graduate level, although the introduction in the medical graduate curriculum already exists in diverse parts of the world, like Australia,2 China,3 Europe,1 England 4 and the United States,5,6,7,8 the last mentioned with specific educational requirements into a new and multidisciplinary critical care medical curriculum for medical students since the seventies´ decade.9
The inclusion of Intensive Care in the medical graduate’s curriculum on a worldwide level is related to the subject of the abilities to recognize a critically ill patient, to prematurely begin urgent intervention, to execute procedures, of communication, of leadership, of integration of basic knowledge with the doctors, and to discuss ethical aspects.7 All these aspects are frequently found on a day-to-day basis of this specialty.
In Brazil, although Intensive Care is a specialty recognized by the Federal Council of Medicine, its inclusion in the graduate curriculum takes place in few Brazilian schools.
Two years ago, the Federal University of Maranhão (UFMA), located in the state of Maranhão, in Northeastern Brazil, incorporated Intensive Care as part of the rotational on-the-job training for the academicians of medicine in their last year, constituting in such a manner, a research field for study.

What directs the curriculum in the Brazilian medical schools?

The medical course in Brazil is accomplished in six years. After the conclusion of the course, the professional is capacitated to practice in all national territory as a doctor. In the case of the professional opting for a specialty, after the conclusion of the graduate course, he/she should begin medical residence or post-graduation.
For the level of graduation in Brazil, the document that defines the principles, foundations, conditions and procedures of the doctor’s formation are the National Curricular Directories of the Graduate Course in Medicine.10 This document was established by the Chamber of Higher Education of the National Council of Education and confirmed in October of 2001. The Directories are references for the elaboration of the curriculums and should be observed in the curricular organization in all of the Institutions of the Higher Educational System of the Country. All of the medical schools have the liberty to make innovations in the pedagogical project and in the definition of their entire curriculums, following these general guidelines.
In their initial articles, the Directories define the profile of the graduate/professional Brazilian doctor. This professional must have a general, humane, critical and reflective formation. The graduate must be capable to practice, regulated in ethics, at different levels of attention, with promotional action, prevention, recuperation and rehabilitation in health in its integral of care and possess a sense of social responsibility and commitment with citizenry.
The doctor’s formation, according to these Directories, have as their objective, that the graduating professional possess the required knowledge to practice his competence and general abilities: give attention to health on all levels of assistance, to make decisions to evaluate and decide the most adequate conduct based on scientific evidences aiming for efficiency and cost effectiveness; of communication in dealing with the general public and other health professionals; of leadership; of administration and management of physical and material resources and of permanent education.
In this manner, the need to study Intensive Care came up in the present context of Brazilian medical education. What would be the contribution of this specialty in the professional medical formation in Brazil?
This task has as its objective to analyze Intensive Care as a formation period for the medical graduate of the Federal University of Maranhão.

This is a quality research in a case study. It is used as an instrument for the collection of data, the semi-structured interview for the sixth year students for the UFMA medical course that already finished their on-the-job training in the ICU and for teachers related to medical on-the-job training.
The quality research pays special attention to a level of reality that cannot be measured. While the quantity approach works with the visible, morphological and concrete; the quality study works with the universe of meanings, motives, aspirations, beliefs, valor and attitudes, which occurs within a deeper area of relations and cannot be reduced to the operation of variables.11
The semi-structured interview is role model of a “conversation with results”, with questions where the one interviewed has the possibility to discuss the proposed theme without answers or conditions determined beforehand by the researcher.
In 2002, the last year medical students began their 60-hour curricular on-the-job training in the general ICU supervised by the local staff that does not have teachers.
One of the groups to participate in this on-the-job training (group nº66 from the UFMA medical course) was used as a study population in the “student” group. Eleven students were interviewed, six males and five females. The interviews took place after the on-the-job training finished at the ICU and followed an itinerary that observes two-theme nucleus: Interest/usefulness of Intensive Care in medical graduation and the grasp of real life experience with the critically ill patient in the ICU. All interviews were recorded on cassette tape and afterwards integrally transcribed. The students were numerically identified.
Fourteen teachers involved in the on-the-job medical training in the four basic areas (medical clinic, surgical clinic, pediatrics, gynecological-obstetrics) were used as the study population in the “teacher” group. Eight male teachers and six female teachers were interviewed, also numerically identified. The itinerary for the teachers’ interviews included only questions related to interest/usefulness of Intensive Care in medical graduation. The questions about ICU experience were restricted to the group of teachers because they did not participate in the ICU on-the-job training together with the students.
The commentaries about the criterion of selection of the quality methodology are indispensable. The quality research is less concerned with generalization, it aims to deepen the comprehension of the complexity of phenomenon of a determined social group, without basing itself on a numeric criterion to guarantee its representation as in the creative quantity research. A good example is that it makes it possible to approach several dimensions of a researched problem.
After the detailed reading of each interview, the similar speeches of students and teachers were grouped together, to enable empirical categories of analysis to emerge. The word “category” is connected to the idea of class and refers to a concept that includes elements with common characteristics that are related among them.
Two categories emerged from the speeches of those interviewed: “Discovering interests: diverse reasons under multiple aspects” and “After the ICU: reporting experiences”.
The best-represented speeches in each category were chosen to be discussed.

Category 1: Discovering interests: multiple reasons, diverse aspects
1a “The students don’t see critically ill patients.”
Student-3 “Oh, it's great, first to have contact, since we don’t have contact, the majority, with a critically ill patient at great risk.”
Teacher-2 “Because the student gets to experience a practice that before then was unknown: the critically ill patient.”
1b “Procedures of the ICU”
Student-3 “I saw intubations for the first time, it's something new for us. We see the patient intubated under anesthetic, it's a lot easier.”
Teacher-4 “The procedures like a deep vein puncture, orotraqueal intubations. This is done in the infirmary, but not as frequently as you see it in the ICU.”
Teacher-3 “Any graduate doctor, and even the general public should know how to treat a heart attack.”
1c “Recognize the critically ill patient and the referral to the ICU”
Student-9 “The ICU is an extreme need. The doctor becomes much more secure, because you can diagnose a critically ill patient a lot earlier.”
Teacher-2 “The importance of knowing the exact moment for that patient to go to the ICU.”
1d “All doctors see critically ill patients.”
Student-10 “Because I know that I’m going to run into this situation in the future (referring to a heart attack) and seeing that once in the ICU was very important.”
Teacher-9 “I think it has to be part of the curriculum as a whole, because in any specialty that the students choose, they’re going to run into a critically ill patient at some time or another, isn’t that so?”
1e “There are general things in the ICU.”
Student-2 “The question about hydro electrolyte balance, volemic replacement, blood vessel active drugs, is something that everyone needs to know.”
Teacher-2 “Because in Intensive Care there are the most diverse pathologies and this enriches knowledge. The general practitioner has to have global knowledge.”

Category 2: After on-the-job training in the ICU: relating experiences
2a “It's scary in the beginning.”
Student-4 “Well, I think that the initial contact that we have with the ICU patients is shocking.”
Student-2 “To begin with, I’m not afraid of the ICU anymore. I thought it was something out of this world, and suddenly I saw that it wasn’t something so unapproachable. I had never gone into an ICU; I didn’t know what it was like. (..) I thought of the ICU as a cold place and not very humanized and I realized that it's not like that, I think it's just the seriously ill patients´ situation in itself.”
2b “An adequate education is necessary.”
Student-9 “The doctor knew what to do at that moment- certainly the patient would have died if the doctor hadn’t acted on time. Beside the doctor saving his life, he knew how to proceed.”
2c “The ICU is a team.”
Student-8 “I saw everyone working. They all worked together at the same time- the doctor, nurses, assistants, all concentrated on stabilizing the patient.”
2d “contact with death”
Student-7 “I had never lost a patient. I arrived the next day. Where’s my patient? His bed and table were empty. Wow! Did he die? He died. I was expecting that, but I never thought it would be the next day…”
2e “self-limit”
Student-7 “ I felt very impotent. That wasn’t stimulating for me, because I already knew the end of the story. So I convinced myself that we try to do the maximum, see the best way to solve a situation, but many times we can’t.”
2g “ethic discussions”
Student-7 “He stopped…did resuscitation, and he came back, but we thought like this: how much is it worth fighting for, because he would be a vegetating patient for the rest of his life. I was in conflict, we discussed it…”
2h “news for the family”
Student-5 “Usually when you have a critically ill patient, their family is distressed. You need to have discernment, to know how to talk to the family. It's not easy for a doctor to give negative information concerning the patient. But at times it's necessary. It's great when the patient continues to improve, isn’t it?

In relation to the first practical experience category of analysis, several subjects came up from the speeches, from the students as well as the teachers that showed interest in Intensive Care in medical studies in UFMA.
Initially, the speeches referred to a lack of contact with the critically ill patient during the medical course.
A lack of opportunities in managing the critically ill patients can result in undesirable consequences related to caring for the population. If medical graduates are not exposed to the management of critically ill patients during their training, when they are confronted with real life emergency situations, their inadequacies will be blamed on deficiencies attributable to undergraduate curriculum.12
Within the topics of the Curricular Directories related to the structure of the graduation course for medicine: there exists the utilization of different scenes of study and learning, allowing the student to get familiar with various life situations, of practical organization and of professional work.10 There is literature to support the idea that medical students should be exposed to a large number of clinical cases to practice their diagnostic and clinical management skills.13 The critically ill patient’s evaluation cannot be alienated from this context and the ICU, as an educational scenario, offering experience in real life situations and problems, favoring active participation from the student in the construction of knowledge, a fundamental step for a critical and reflective posture expected from the graduate.
The related topics to basic procedures of urgency and emergency are part of the Curricular Directories.10 Undoubtedly, the ICU is a place where these procedures occur at a superior frequency than in other sectors of the hospital, due to the seriousness of the patients there. The students sometimes feel more secure in their decision and attitude to perform, once they have seen and experienced the practice in a sequenced and systematized manner. These procedures are something that they consider new and necessary to dominate for their resultant professional life, since they are in the last year of the course.
A Critical Care working party, of the New South Wales University in Australia, adopted the following Mission Statement “No medical student should graduate without the ability to prevent the loss of a life of a patient with acute reversible life threatening illness”.2
McAuley and Perkins´ work in England4 analyzes that the care for the acutely ill patient is frequently less than desirable, including the recognition of this acutely ill patient and the initial conduct for his care, like airway, oxygen therapy, homodynamic resuscitation and monitoring. For Garcia Barbero and Such, teaching CPR is a particular problem in medical schools. While the response to emergencies and concepts of CPR are taught to many paramedical professionals, and schoolteachers are being introduced in the community; many medical professionals and medical students lack this knowledge. This lack of education puts them in an awkward position in a critical situation.1 In the comparative analysis among the topics approached in Intensive Care programs in English-speaking medical schools, there are clear consensuses that resuscitation skills needed to be taught.14 The same is mentioned in the UFMA teachers’ statement, concerning the need for this initial approach.
Other studies2,15 revealed that the interns had had few opportunities to practice some procedures during their medical courses,15 and the students lack confidence in their ability to manage acute emergencies if they were the only clinicians available.2 This present study, accomplished in the Federal University of Maranhão, that uses a methodology of a qualifying nature, presents compatible data whereas the description: “It's a very new thing.” For many interviewed students in this study after the ICU on-the-job training, this unit was a place where they witnessed the basic procedures of revival in one of the first opportunities, if not the first opportunity.
Besides the initial approach of emergency care, the doctor needs to recognize and adequately direct the patients whose problems are beyond the reach of his general knowledge. This means, in case the critically ill patient needs to be referred to the ICU, that the first step is to recognize when the patient is evolving in an unfavorable and serious way to be able to refer him to the most appropriate sector. The capacity to adequately refer the critically ill patient to the ICU and begin urgent emergency procedures so that the patient can be transferred into better clinical conditions was one of the motives that impelled the retaking of the discussion about the time spent in medical study for emergency and for Intensive Care in the 90´s decade, to discuss that there is a gap between what student physicians are required to learn and what they need to know to effectively initiate critical care interventions and appropriately refer patients to ICUs.5
The presentation of systematic conducts and the need to establish and quickly decide the priorities in the care make the ICU a real environment for this type of skill to become reality.7 The building of this competence was expressed in the student’s speech “the doctor becomes…we feel more secure.”
From another angle, there is the belief that contact with the critically ill patient is something that unavoidably happens in a doctor’s life, in any specialty. The interest to be familiar with this patient, as well as the importance of competence of his care was reported in the teachers´ and students´ statements.
In this way, the general practitioners´ formation is foreseen in the Curricular Directories.10 The graduate doctor needs to possess them before specializing or sub specializing, which is part of the student’s report. It is worth noting that one of the motives of interest to be familiar with the ICU is in the fact that the subjects thought that there could be found, besides highly specific knowledge, the possibility of contact with general aspects that can be useful for their professional career.
The students also reported aspects related to experience in the ICU during the interview as a whole, especially after a question leading to this theme.
Initially they reported anxiety and insecurity caused during their first contact in the ICU. Some tasks with graduates6,8 begin with a group discussion to lessen the existing anxiety for an apprentice in an ICU, since the students could feel frustrated because of their lack of familiarity with the material-technological part that surrounds this environment, like monitors and mechanical ventilators, besides the anxiety and insecurity to deal with critically ill patients. To make them understand that they will only undertake responsibilities at a gradual pace, as they acquire experience, is part of the approach.6 If these subjects aren’t correctly worked on, it can reduce the efficiency of the educational experience.8
The graduate’s lack of access to the ICU, to a hospital sector different than the student’s habitual routine, causes insecurity, fear, and fantasy. After experiencing this new routine, the students clearly understand the ICU, and the impressions become more real, based on tangible situations. This change permits the students to have an analytical viewpoint and attitude in the presence of this new experience.
In this way, reflecting on the doctor’s formation makes it indispensable to the extent that it permits criticism concerning the doctor’s role in society. This critical viewpoint should be present during the graduate’s entire life and it's on this long road ahead that the curriculum is based.
Another acquired perception in the ICU is the multi-subjected theme of Intensive Care that has its origin in it's own history. The multi-subjected approach enriches the assistance in the way that it permits multiple viewpoints of the different areas of health for the same purpose, proportioning an indispensable sense of teamwork for the student. In this way, being in such an explicit multi-subjected environment favors this reflection. The doctor’s performance on a multi-professional team also takes part in the specific competence and abilities foreseen by the Curricular Directories.10
Equally important, the doctor’s experience with death is something inevitable during his professional career. Evidently, depending on the professional course and specialty adopted by each professional, the loss of a patient will come about more or less frequently, but rarely will it not occur. The loss of a patient, reported in diminutive expressions transmitted the affection established in the doctor-patient relationship by the student that participated in the ICU on-the-job training. The “surprise” of death came in an attempt of denial at the first moment of loss, albeit expected. Brazilian studies16,17 concluded that there exists a consensus about the students and teachers not being emotionally prepared to face death, resultant of a web of factors that begins with the health service organization in itself, the process of professional formation and the lack of valorizing life in the present society, besides the factors related to the professional doctor’s life story that frequently associates it to failure.16 The theme “death” is of interest to the vast majority of these professionals, but many face a certain degree of difficulty to approach it, especially the student.17 Studies in New Zealand revealed that students can learn how to care at the end of life in a positive way, and this can influence the patterns of care provided by doctors in the future.18
Death occurs more than frequently in the ICU, in various ways: expected, unexpected, suddenly, gradually, in youth, in the elderly, due to the most diverse pathologies. The student’s contact with death and the diverse forms of discussion of how to face it makes it indispensable for the doctor’s formation.
In the same way, to work with the notion of limits that is present in critical situations and with a predictable unfavorable outcome is a relative question. To recognize self-limit is a challenge for the doctor and to present and discuss these questions in actuality with the graduate starts a process of permanent reflection concerning this. Keeping a graduate near an unfavorably evolving case is important so that he perceives his commitment to the sick, and not to the disease; an aspect that takes part in the fundamental doctor-patient relationship.
In the same way, questions concerning ethics are present in a quite intense way in the ICU. The graduate’s exposure to situations, where there is reflection on this subject, brings growth. The student’s report about his conflict is a fundamental part for his personal and professional maturation.
Another experience that the on-the-job training group took part in was concerning the relatives visiting hours to the ICU. This is a delicate moment for both sides, the doctor as well as the family. The professional himself sees the moment where he has to join compassion, technique, truth, and posture. All this joined together in a comprehensible vocabulary for relatives coming from the most diverse social-cultural levels, stemming from the most diverse experiences of education, and to top it all off, emotionally insecure, when not disconsolate. The abilities to communicate are in constant debate in Brazilian medical education and take part in the Curricular Directories.10 The graduate’s exposure to variable situations of communication with the family becomes necessary, since rarely the graduate will not run into an adverse situation in his/her professional career in that that ability has to be expressed.
Maybe the big difference between those that sporadically and punctually participate with the critically ill patient and the daily conviviality with the same, in a specific unit like the ICU, has the possibility of witnessing all these kinds of aspects together: technical, humane, ethical, relatives, difficulties, relationship, limits and many others. In the ICU, they are all present at the same time and all the time. The certainty that the actual day-to-day situations have plural and interrelated aspects is very evident for those that participate with a closer contact to the ICU.
This “making” of a doctor that necessarily involves all these aspects together is expressed and will be expressed in any workplace, in any specialty, when in perception of his/her commitment to the patient in particular and with society at large. Intensive Care, after the first contact, “scare” and fear for the graduates, favors this type of reflection for the building of competency and technical and humane abilities together, to be carried outside of the university walls.

The interest for the approach to Intensive Care in medical graduation exists and stems from a number of factors that begins with a curiosity to get familiar with and establish conducts with the critically ill patient, something that students as well as teachers deem necessary for all doctors.
Intensive Care is a specialty that awakens in the medical graduate, reflections concerning technical and humane aspects of the “making” of a doctor. The student that participates in the ICU on-the-job training witnesses diverse experiences from the doctor himself that deal with physiopathology, therapeutics, ethics, a multi-faceted team, communication with the patient himself and his relatives, self-limit, and contact with death.
In this way, the on-the-job training in this sector aids in the general, humane, critical and reflexive formation of the doctor, as proposed by the National Curricular Directories.


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