ABEM consensus for the brazilian medical schools’ communication curriculum

Grosseman, Suely; Hokama, Newton Key; Cruvinel, Agnes de Fátima Pereira; Franzoi, Ana Cristina; Moura, Eliane Perlatto; Muraguchi, Evelin Massae Ogatta; Novaes, Fernanda Patrícia Soares Souto; Raimondi, Gustavo Antonio; Moura, Josemar de Almeida; Torreão, Lara de Araújo; Pereira, Maria Amélia Dias; Philippi, Miriam May; Oliveira, Mônica da Cunha; Alves, Rosana

doi:10.1590/1981-5271v46.3-20210392.ING

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ORIGINAL ARTICLE • Rev. bras. educ. med. 46 (3) • 2022 • https://doi.org/10.1590/1981-5271v46.3-20210392.ING copy

ABEM consensus for the brazilian medical schools’ communication curriculum

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract:

Introduction:

Communication is an essential competence for the physician and other professional categories, and must be developed their professional training. The creation of a communication project including a Brazilian consensus aimed to subsidize medical schools in preparing medical students to communicate effectively with Brazilian citizens, with plural intra and inter-regional characteristics, based on the professionalism and the Brazilian Unified System (SUS) principles.

Objective:

The objective of this manuscript is to present the consensus for the teaching of communication in Brazilian medical schools.

Method:

The consensus was built collaboratively with 276 participants, experts in communication, faculty, health professionals and students from 126 medical schools and five health institutions in face-to-face conference meetings and biweekly or monthly virtual meetings. In the meetings, the participants’ experiences and bibliographic material were shared, including international consensuses, and the consensus under construction was presented, with group discussion to list new components for the Brazilian consensus, followed by debate with everyone, to agree on them. The final version was approved in a virtual meeting with invitation to all participants in July 2021. After the submission, several changes were required, which demanded new meetings to review the consensus final version.

Result:

The consensus is based on assumptions that communication should be relationship-centered, embedded on professionalism, grounded on the SUS principles and social participation, and based on the National Guidelines for the undergraduate medical course, theoretical references and scientific evidence. Specific objectives to develop communication competence in the students are described, covering: theoretical foundations; literature search and its critical evaluation; documents drafting and editing; intrapersonal and interpersonal communication in the academicscientific environment, in health care and in health management; and, communication in diverse clinical contexts. The inclusion of communication in the curriculum is recommended from the beginning to the end of the course, integrated with other contents and areas of knowledge.

Conclusion:

It is expected that this consensus contributes the review or implementation of communication in Brazilian medical schools’ curricula.

Keywords:
Communication; Medical Schools; Curriculum; Undergraduate Medical Education; Consensus

To develop competence in communication, throughout the medical course, the student must:
Become capable of communicating based on theoretical foundations, including
( theoretical frameworks and models of the Humanities, Social Sciences and Health on communication and human relationships, which include psychology and psychiatry;
( scientific evidence on communication in health;
( principles and guidelines of the Unified Health System (SUS)⁶⁴64. Brasil. Lei nº 8.080, de 19 de setembro de 1990. Dispõe sobre as condições para a promoção, proteção e recuperação da saúde, a organização e o funcionamento dos serviços correspondentes e dá outras providências. Diário Oficial da União ; 20 set 1990. and public health policies
( professionalism and its components⁵²52. Medical Professionalism Project. Medical professionalism in the new millennium: a physicians’ charter. Lancet . 2002;359(9305):520-2.^)-(⁵⁶56. Rabow MW, Remen RN, Parmelee DX, Inui TS. Professional formation: extending medicine’s lineage of service into the next century. Acad Med . 2010;85(2):310-7.;
( history, culture, knowledges and practices of care and healing of the different social groups that constitute the Brazilian population;
( understanding of Metadiscourse, especially concerning the process of production, circulation and legitimation of the structured language and normative conventional beliefs that value or devalue certain social groups⁸⁵85. Hyland K. Metadiscourse: what is it and where is it going? JoP. 2017;113:16-29.^),(⁸⁶86. Jaworski A, Coupland N, Galasinski D. Metalanguage: social and ideological perspectives. Berlin: Walter de Gruyter; 2004.;
( concepts and characteristics of constructs related to intra- and interpersonal communication, such as emotional intelligence⁸⁷87. Goleman D, Boyatzis R, McKee A. O poder da inteligência emocional. Rio de Janeiro: Campus; 2002. and social skills⁸⁸88. Del Prette ZAP, Del Prette AD. Psicologia das habilidades sociais: diversidade teórica e suas implicações. Petropólis: Vozes; 2009.;
( forms of expression of verbal and non-verbal communication and characteristics for their effectiveness⁶⁰60. Fortin VI AH, Dwamena FC, Frankel RM, Smith RC. Smith’s patient centered interviewing: an evidence-based method. 3rd ed. New York: McGraw Hill; 2012.^),(⁶¹61. Chou C, Cooley L, editors. Communication RX: transforming healthcare through relationship-centered communication. New York: McGraw Hill ; 2018.^),(⁸⁹89. Hojat M. Empathy in health professions education and patient care. New York: Springer; 2016.^),(⁹⁰90. Lunenburg, FC. Louder than words: the hidden power of nonverbal communication in the workplace. IJ SAID. 2010;12(1):1-5.;
( operational levels of verbal communication⁸⁶86. Jaworski A, Coupland N, Galasinski D. Metalanguage: social and ideological perspectives. Berlin: Walter de Gruyter; 2004.^),(⁹¹91. Craig RT. Metacommunication. In: Jensen KB, Rothenbuhler EW, Pooley JD, Craig RT, editors. The international encyclopedia of communication theory and philosophy. West Sussex: John Wiley & Sons. 2016. Doi:https://doi.org/10.1002/9781118766804.wbiect232. https://doi.org/10.1002/9781118766804.wb... ;
( pragmatic communication and its characteristics⁹²92. Watzlawick P, Beavin JH, Jackson DD. Pragmática da comunicação. São Paulo: Culturix; 2010.^),(⁹³93. Bosco FM, Tirassa M, Gabbatore I. Why pragmatics and theory of mind do not (completely) overlap. Front Psych. 2018;9:1453. Doi: https://doi.org/10.3389/fpsyg.2018.01453. https://doi.org/10.3389/fpsyg.2018.01453... .
Search, critically evaluate the literature and prepare and write documents adequately, becoming able to
( recognize documents used in health care, medical education and health management; The documents include consultation files / physical and electronic medical records, exam request document, prescription, transfer report, discharge summary, reference and / or counter-reference form, compulsory notification, informed consent, living will, death certificate, notification of adverse events / errors, territorialization matrix/map, projects and documents for health education, reports and minutes in health care, among others; additionally, protocols, innovation and research projects, planning and resource management spreadsheets and health management contracts, among others; and, additionally, texts, narratives, reviews, scientific articles, abstracts, portfolios, presentations, extension and research projects in medical education, among others. - write the documents, filling out the necessary fields, in a clear, structured and organized way, with coherence and cohesion, without redundancy or ambiguity, in legible handwriting (when written by hand), using correct Portuguese and appropriate medical technical terms, when relevant; - include the name of the person in charge and, in health care documents, also the signature and stamp or digital certification of the professional; - update information as soon as possible in registration documents.
( seek, organize and file information, with the help of information and communication; technologies (ICT), select relevant information through critical reading and prepare syntheses
( critically analyze the information posted on social media, identify false information and fake news and provide arguments about its untruth, based on evidence;
( develop research, extension and technological innovation projects with clear, structured, organized, coherent and cohesive writing, scientifically based and in correct Portuguese of the project, the Free and Informed Consent (FIC) form and/or Free and Informed Assent (FIA) form, of the partial and final report and of articles and abstracts;
( recognize that plagiarism is characterized as a crime of ideological falsehood.
Develop as a person (intrapersonal communication), with improvement of self-knowledge, adaptability, critical reflection and critical thinking, becoming capable of
( cultivate their own - presence/mindfulness; - empathy; - resilience; - creativity; - curiosity and the ability to ask questions -- in everyday life to reflect and broaden perspectives and understand relationships in complex situations; -- to critically seek and evaluate scientifically-based information for clinical reasoning and responses to clinical situations; - capacity to debate; - assertiveness¹⁹19. World Health Organization. WHO patient safety curriculum guide: multi-professional edition. Geneva: WHO. 2011. Disponível em: Disponível em: https://www.who.int/publications/i/item/9789241501958 . Acesso 10 jan. 2021. [Marra VN, Sette ML, coordenadores. Guia curricular de segurança do paciente da Organização Mundial da Saúde: edição multiprofissional. Rio de Janeiro: Pontifícia Universidade Católica do Rio de Janeiro; 2016 [acesso em 10 jan. 2021]. Disponível em: https://cdn.who.int/media/docs/default-source/patient-safety/9788555268502-por519565d3-e2ff-4289-b67f-4560fcd33b9d.pdf?sfvrsn=9e58a092_1.] https://www.who.int/publications/i/item/... ^),(²⁶26. Omura M, Maguire J, Levett-Jones T, Stone TE. The effectiveness of assertiveness communication training programs for healthcare professionals and students: a systematic review. Intern J Nurs Stud. 2017;76:120-8.^),(²⁷27. O’Connor P, Byrne D, O’Dea A, McVeigh TP, Kerin MJ. “Excuse me”: teaching interns to speak up. Jt Comm J Qual Patient Saf. 2013;39(9):426-31.;
( recognize one’s own emotions and emotional responses, and their influence on interpersonal relationships;
( identify situations that may trigger strong emotions and anticipate contexts that may arouse them;
( use strategies to manage their own emotions and seek support when needed;
( promote and preserve one’s physical and mental balance with self-care and self-compassion;
( recognize signs of overload and changes in one’s physical and mental health, including stress, anxiety, burnout and depression, seeking strategies to mitigate their causes and treat their diseases;
( commit to learning to learn, to do, to be and to live together and develop progressive autonomy for learning;
( recognize one’s own strengths, limitations, desires, expectations, concerns, fears, prejudices and communication style and their influence on interpersonal relationships, strengthening potentialities and seeking strategies to overcome limitations;
( demonstrate critical thinking;
( demonstrate the capacity to debate;
( identify one’s prejudices and biases in clinical reasoning, which can affect the consultation and lead to diagnostic errors;
( request feedback and receive it openly and flexibly to change one’s knowledge and practices
( reflect on the ethical / bioethical challenges experienced and witnessed, with ethical and legal principles as a reference;
( reflect on shared messages and attitudes witnessed throughout the training, understanding the socio-historical aspects that perpetuate the hidden curriculum and the power relations and prejudices, identifying the values consistent with professionalism that must be incorporated into the construction of one’s professional identity;
( be co-responsible for - promoting strategies to change messages and attitudes not consistent with professionalism; - building an academic and work environment in health that promotes respect, ethics and sensitivity;
( differentiate between simple and complex situations that lead to uncertainties;
( deal with high levels of complexity and uncertainty, asking for support when necessary;
( recognize one’s limits in academic performance and health work and seek support when necessary.
Improve interpersonal communication, becoming able to
( express oneself in meetings and individual or group presentations, in an ethical, sensitive, respectful, inclusive and non-prejudiced manner (non-racist, non-sexist, non-capacitist, non-LGBTQIA+phobic, non-xenophobic, among others), appropriate for the age, level of schooling and other characteristics of the target audience, through - clear, organized, logical, cohesive and coherent oral verbal communication, with an appropriate flow of information and balanced use of open and closed questions - legible written verbal communication (when written by hand), organized, with a logical sequence, coherent, cohesive, without ambiguity or redundancy; - nonverbal communication consistent with the verbal communication that shows respect and attention; -- using --- written and/or illustrated educational resources (such as images, drawings, diagrams, three-dimensional models), artistic-cultural creative material and audiovisual resources in a balanced manner to motivate, improve the sensitivity and facilitate the understanding of participants; --- interactive strategies to maximize the participation of those who are interested when communicating with families, social groups and the community; --- maximize people’s participation when their communication has limitations; -- demonstrating --- mastery of the Portuguese language spoken in Brazil; --- mastery of medical technical terms used in the academic-scientific environment; --- knowledge of the Brazilian Sign Language (LIBRAS, Linguagem Brasileira de Sinais) and other forms of inclusive communication, including alternative and extended communication (CAA, alternative and augmentative communication)⁹⁴94. Elsahar Y, Hu S, Bouazza-Marouf K, Kerr D, Mansor A. Augmentative and alternative communication (AAC) advances: a review of configurations for individuals with a speech disability. Sensors. 2019;19(8):1911. Doi: https://doi.org/10.3390/s19081911. https://doi.org/10.3390/s19081911... ^)-(⁹⁸98. Gomes CA, Rugno FC, Rezende G, Cardoso RC, De Carlo MM. Tecnologia de comunicação alternativa para pessoas laringectomizadas com câncer de cabeça e pescoço. Medicina (Ribeirão Preto). 2016;49(5):463-74. and support systems for people with alterations in expressive or receptive communication⁹⁷97. American Speech-Language-Hearing Association. Augmentative and Alternative Communication [acesso em 20 em 2022]. Disponível em: www.asha.org/Practice-Portal/Professional-Issues/Augmentative-and-Alternative-Communication/. www.asha.org/Practice-Portal/Professiona... ; --- knowledge of the language used in the different ethnicities and cultures of the Brazilian population and regions of Brazil (“communication geography”); --- knowledge of at least one foreign language, ideally the one that most often conveys medical scientific information;
( adapt interpersonal communication to the method and channel / means of communication used, covering - face-to-face communication; - distance / virtual communication through ICT management, also considering -- when communicating asynchronously, --- being careful when writing messages to avoid misinterpretation; --- a shorter presentation time; -- when communicating synchronously, also considering --- the need for cultural sensitivity, encouraging dialogue, qualified listening, encouraging questions and the expression of concerns and fears, and an empathic and supportive response; --- technical, ethical and legal aspects of telehealth (teleconsultation / telecare) and other remote medical activities (telemedicine); --- the needs of the target audience and the characteristics of information to be conveyed in the media;
( building and maintaining rapport;
( perform qualified listening;
( recognize and demonstrate respect and sensitivity to cultural diversity and to values and other unique characteristics of each person;
( recognize verbal and non-verbal signals of emotions and respond with empathy and solidarity;
( deal with strong emotions, anticipating them when there are signs of tension, understanding their origin, managing one’s own emotions, responding with sensitivity, empathy and solidarity and taking care of one’s own safety, seeking help when they feel they may be at risk;
( provide respectful, constructive and appreciation feedback and accept feedback respectfully and with an openness to the change in attitudes and practices;
( understand and recognize factors that influence interpersonal relationships, including the phenomenon of transference and countertransference;
( recognize barriers and limitations that interfere with communication, consider the possibilities for their management, including their elimination, explain their existence and say that you will try to minimize their interference, search for interpreters or use other resources, including the CAA;
( interact in a sensitive and respectful way and value the active participation of people who use CAA in the meeting;
( in research projects, explain the FIC and FIA forms to participants in an ethical, clear and honest way and interact respectfully and ethically with research participants when collecting information and validating their results;
( socialize knowledges in teaching, extension (including health care and health management activities) and in research;
( work in an interdisciplinary and interprofessional collaborative way as a member and a leader, with clear language and openness to “different opinions and respect for the diversity of values, roles and responsibilities”³²32. Brasil. Resolução CNE/CES nº 3, de 20 de junho de 2014. Institui Diretrizes Curriculares Nacionais do Curso de Graduação em Medicina e dá outras providências. Diário Oficial da União; 2014. and, in health care¹⁹19. World Health Organization. WHO patient safety curriculum guide: multi-professional edition. Geneva: WHO. 2011. Disponível em: Disponível em: https://www.who.int/publications/i/item/9789241501958 . Acesso 10 jan. 2021. [Marra VN, Sette ML, coordenadores. Guia curricular de segurança do paciente da Organização Mundial da Saúde: edição multiprofissional. Rio de Janeiro: Pontifícia Universidade Católica do Rio de Janeiro; 2016 [acesso em 10 jan. 2021]. Disponível em: https://cdn.who.int/media/docs/default-source/patient-safety/9788555268502-por519565d3-e2ff-4289-b67f-4560fcd33b9d.pdf?sfvrsn=9e58a092_1.] https://www.who.int/publications/i/item/... ; - include the person under care, their family members and caregivers as part of the team¹⁹19. World Health Organization. WHO patient safety curriculum guide: multi-professional edition. Geneva: WHO. 2011. Disponível em: Disponível em: https://www.who.int/publications/i/item/9789241501958 . Acesso 10 jan. 2021. [Marra VN, Sette ML, coordenadores. Guia curricular de segurança do paciente da Organização Mundial da Saúde: edição multiprofissional. Rio de Janeiro: Pontifícia Universidade Católica do Rio de Janeiro; 2016 [acesso em 10 jan. 2021]. Disponível em: https://cdn.who.int/media/docs/default-source/patient-safety/9788555268502-por519565d3-e2ff-4289-b67f-4560fcd33b9d.pdf?sfvrsn=9e58a092_1.] https://www.who.int/publications/i/item/... ; - take responsibility for the person under care and the continuity of their care; - subordinate one’s own interests to those of the person under care and the team for shared decision-making; - be responsible for the safety of the person under care, with special attention to processes with greater safety risk such as emergencies, procedures, changes in work shifts, transfers between sectors and institutions, relying on scripts and checklists to ensure effective communication¹⁹19. World Health Organization. WHO patient safety curriculum guide: multi-professional edition. Geneva: WHO. 2011. Disponível em: Disponível em: https://www.who.int/publications/i/item/9789241501958 . Acesso 10 jan. 2021. [Marra VN, Sette ML, coordenadores. Guia curricular de segurança do paciente da Organização Mundial da Saúde: edição multiprofissional. Rio de Janeiro: Pontifícia Universidade Católica do Rio de Janeiro; 2016 [acesso em 10 jan. 2021]. Disponível em: https://cdn.who.int/media/docs/default-source/patient-safety/9788555268502-por519565d3-e2ff-4289-b67f-4560fcd33b9d.pdf?sfvrsn=9e58a092_1.] https://www.who.int/publications/i/item/... ^),(⁹⁹99. Agency for Healthcare Research and Quality. TeamStepps 2.0, Team Strategies & Tools to Enhance Performance and Patient Safety: Pocket guide. AHRQ Pub. No. 14-0001-2. Revised December 2013 [acesso em 10 set 2021]. Disponível em: Disponível em: https://www.ahrq.gov/sites/default/files/publications/files/pocketguide.pdf . https://www.ahrq.gov/sites/default/files... ; - manage/mediate conflicts¹⁹19. World Health Organization. WHO patient safety curriculum guide: multi-professional edition. Geneva: WHO. 2011. Disponível em: Disponível em: https://www.who.int/publications/i/item/9789241501958 . Acesso 10 jan. 2021. [Marra VN, Sette ML, coordenadores. Guia curricular de segurança do paciente da Organização Mundial da Saúde: edição multiprofissional. Rio de Janeiro: Pontifícia Universidade Católica do Rio de Janeiro; 2016 [acesso em 10 jan. 2021]. Disponível em: https://cdn.who.int/media/docs/default-source/patient-safety/9788555268502-por519565d3-e2ff-4289-b67f-4560fcd33b9d.pdf?sfvrsn=9e58a092_1.] https://www.who.int/publications/i/item/... ^),(⁹⁹99. Agency for Healthcare Research and Quality. TeamStepps 2.0, Team Strategies & Tools to Enhance Performance and Patient Safety: Pocket guide. AHRQ Pub. No. 14-0001-2. Revised December 2013 [acesso em 10 set 2021]. Disponível em: Disponível em: https://www.ahrq.gov/sites/default/files/publications/files/pocketguide.pdf . https://www.ahrq.gov/sites/default/files... with assertiveness and non-violent communication⁷⁵75. Rosenberg MB. Comunicação não violenta: técnicas para aprimorar relacionamentos pessoais e profissionais. 3ª ed. São Paulo: Ágora; 2006., aiming to -- reach a consensus when there are differing opinions in teamwork; -- address errors and behaviors that jeopardize the safety of the person under care; - when acting in leadership, additionally¹⁹19. World Health Organization. WHO patient safety curriculum guide: multi-professional edition. Geneva: WHO. 2011. Disponível em: Disponível em: https://www.who.int/publications/i/item/9789241501958 . Acesso 10 jan. 2021. [Marra VN, Sette ML, coordenadores. Guia curricular de segurança do paciente da Organização Mundial da Saúde: edição multiprofissional. Rio de Janeiro: Pontifícia Universidade Católica do Rio de Janeiro; 2016 [acesso em 10 jan. 2021]. Disponível em: https://cdn.who.int/media/docs/default-source/patient-safety/9788555268502-por519565d3-e2ff-4289-b67f-4560fcd33b9d.pdf?sfvrsn=9e58a092_1.] https://www.who.int/publications/i/item/... , -- contribute to the construction and strengthening of the bond and cohesion of the team and of a collaborative environment that promotes a “team spirit”; -- agree with and clarify one’s own role and function and that of other team members; -- coordinate and facilitate the rapid and regular flow of information relevant to teamwork -- encourage the sharing of ideas, perspectives and concerns, listening carefully to everyone and agreeing on decisions; -- provide appreciation feedback and request it on a regular basis; -- organize and coordinate meetings and keep up-to-date records; -- monitor the work situation, including psychological and social aspects that influence it and balance each member’s workload; -- mobilize resources to enhance team performance; -- plan and organize team improvement/training activities.
Additionally, in health care, the student must become able to
( communicate in the different stages and processes of the clinical encounter at all levels, scenarios and processes of health care and dimensions of care, focusing on relationships and empowering people under care and their families / caregivers, as described in Figure 1; The scenarios include the home, outpatient clinic/office, urgent/emergency care sectors, wards, intensive care unit and palliative care, surgery and recovery room, institutional therapeutic spaces, community spaces, institutions where people with certain characteristics and needs live, such as nursing homes and orphanages, among others. The processes include consultation, embracement (both users receiving care on demand, and listening to them when referring to health services and actions), home visits, territorialization, exceptional therapeutic team project in contexts of vulnerability, matrix support (specialized technical support offered to the interprofessional team, to qualify their actions in health), coordination of health promotion groups, surgical and non-surgical procedures, health education, change of work shift, transfer of care between sectors and units, planning of advanced care, family talk and conference / medical report, risk communication and team meetings, among others. - adapt the encounter and communication to -- age group [neonatal, infants, preschool and schoolchildren, adolescents, adults and the elderly]; -- stage of the life cycle (from pregnancy and birth to aging and the dying process); -- specialty; -- cultural aspects, literacy, perspectives, needs, expectations and preferences of the person under care, their family members and/or caregivers; - approach in a respectful, ethical and sensitive manner -- meetings with people under care and with families on home visits; -- the sexuality of the person under care, conducting the meeting according to their choices and needs; -- the experiences of the person under care regarding social, ethnic, racial and cultural aspects, knowing and recognizing their perspectives and values; -- spirituality, if the person under care so desires; -- people under care who have symptoms with no organic explanation, understanding their biopsychosocial context and their possible causes; -- people in situations of violence, including bullying, neglect and physical violence, dealing with their own emotions, responding with empathy and solidarity, empowering and promoting the autonomy of the person under care, and seeking psychological and social support and taking the necessary measures; - build shared singular therapeutic projects, encouraging self-care and the “autonomy of individuals, families, groups and communities and recognizing users as active protagonists of their own health”³²32. Brasil. Resolução CNE/CES nº 3, de 20 de junho de 2014. Institui Diretrizes Curriculares Nacionais do Curso de Graduação em Medicina e dá outras providências. Diário Oficial da União; 2014.; - carry out matrix support activities, considering the knowledge of each team member;
( communicate in specific contexts (Figure 2), which encompass several processes, among them, but not exclusively, - health risk situations to the person under care; - motivational interview, to identify the stage of behavioral change of the person under care, their degree of confidence and conviction to change, as well as the potentials and challenges perceived by them; - change of habits according to the person’s willingness to change; - health risk behaviors, with their identification, approach when present and agreement on a therapeutic plan; - management of uncertainties about the diagnosis, best therapeutic option, prognosis and other aspects of care, sharing them with sincerity and sensitivity to the person under care and to family members / caregivers and team members, demonstrating willingness to seek support for decision making, recognizing one’s own emotions and responding with empathy to the emotions of the people present at that moment¹⁹19. World Health Organization. WHO patient safety curriculum guide: multi-professional edition. Geneva: WHO. 2011. Disponível em: Disponível em: https://www.who.int/publications/i/item/9789241501958 . Acesso 10 jan. 2021. [Marra VN, Sette ML, coordenadores. Guia curricular de segurança do paciente da Organização Mundial da Saúde: edição multiprofissional. Rio de Janeiro: Pontifícia Universidade Católica do Rio de Janeiro; 2016 [acesso em 10 jan. 2021]. Disponível em: https://cdn.who.int/media/docs/default-source/patient-safety/9788555268502-por519565d3-e2ff-4289-b67f-4560fcd33b9d.pdf?sfvrsn=9e58a092_1.] https://www.who.int/publications/i/item/... ; - difficult news¹⁰⁰100. Baile WF, Buckman R, Lenzi R, Glober G, Beale EA, Kudelka AP. SPIKES-A six-step protocol for delivering bad news: application to the patient with cancer. Oncologist. 2000;5:302-11.^)-(¹⁰³103. Narayanan V, Bista B, Koshy C. BREAKS protocol for breaking bad news. IJPC. 2010;16(2):61-5.; - error / adverse event management, including¹⁹19. World Health Organization. WHO patient safety curriculum guide: multi-professional edition. Geneva: WHO. 2011. Disponível em: Disponível em: https://www.who.int/publications/i/item/9789241501958 . Acesso 10 jan. 2021. [Marra VN, Sette ML, coordenadores. Guia curricular de segurança do paciente da Organização Mundial da Saúde: edição multiprofissional. Rio de Janeiro: Pontifícia Universidade Católica do Rio de Janeiro; 2016 [acesso em 10 jan. 2021]. Disponível em: https://cdn.who.int/media/docs/default-source/patient-safety/9788555268502-por519565d3-e2ff-4289-b67f-4560fcd33b9d.pdf?sfvrsn=9e58a092_1.] https://www.who.int/publications/i/item/... -- identifying areas prone to their occurrence; -- recognizing the ethical and legal issues related to its disclosure; -- meeting with the team and authorities involved to reflect and discuss what happened and why the adverse event happened, focusing on the task and not on the people; -- recording the adverse event in a specific form, with justification; -- planning measures to ensure that the mistakes that were made are not made again -- providing support to the team; -- disclosing the incident to the people under care, family members / caregivers and other people who respond for them in an ethical, respectful, sincere, objective way, without a defensive posture, demonstrating that one regrets what happened, recognizing the suffering it generated, sharing information and in clear language, without technical terms, following the process of communicating difficult news and explaining what happened and its causes, what is expected, the resources mobilized to support the affected people, how its investigation was and is being carried out and the measures being taken so that it does not occur in the future; - crises, emergencies and disasters¹⁰⁴104. Organização Mundial da Saúde. Comunicação eficaz com a mídia durante emergências de saúde pública: um manual da OMS. Brasília: Ministério da Saúde ; 2009. [Tradução de: WHO. Effective Media Communication during Public Health Emergencies: a WHO Handbook; 2007.] [acesso em 20 jan 2022]. Disponível em: https://bvsms.saude.gov.br/bvs/ razilian o/ razilian o_eficaz_midia_durante_emergencias.pdf. https://bvsms.saude.gov.br/bvs/ razilian... ^)-(¹¹¹111. Secretaría Interinstitucional de la Estrategia Internacional para la Reducción de Desastres, Naciones Unidas. Vivir con el riesgo: informe mundial sobre iniciativas para la reducción de desastres. Genebra: ONU; 2004. -- act fast, effectively communicating with the health team, with responsibility for the safety of the person under care; -- plan and carry out risk communication for different audiences, recognizing and valuing the media as one of the main opportunities to communicate with the public, whose processes are well detailed in manuals and guides from international and national institutions¹⁰⁴104. Organização Mundial da Saúde. Comunicação eficaz com a mídia durante emergências de saúde pública: um manual da OMS. Brasília: Ministério da Saúde ; 2009. [Tradução de: WHO. Effective Media Communication during Public Health Emergencies: a WHO Handbook; 2007.] [acesso em 20 jan 2022]. Disponível em: https://bvsms.saude.gov.br/bvs/ razilian o/ razilian o_eficaz_midia_durante_emergencias.pdf. https://bvsms.saude.gov.br/bvs/ razilian... ^)-(¹¹¹111. Secretaría Interinstitucional de la Estrategia Internacional para la Reducción de Desastres, Naciones Unidas. Vivir con el riesgo: informe mundial sobre iniciativas para la reducción de desastres. Genebra: ONU; 2004.; -- recognize signs of overload, stress and moral distress and seek support to deal with their consequences; - intensive/critical care, with frequent sharing of information, in a respectful, empathetic and sincere manner -- with the person under care, to update them on their health conditions, keep them in contact with the external reality and encourage their participation in decision-making within their reach¹¹²112. Corrêa M, Del Castanhel F, Grosseman S. Percepção de pacientes sobre a comunicação médica e suas necessidades durante internação na unidade de cuidados intensivos. Rev Bras Ter Intensiva. 2021;33:401-11.^)-(¹¹⁴114. Scheunemann LP, McDevitt M, Carson SS, Hanson LC. Randomized, controlled trials of interventions to improve communication in intensive care: a systematic review. Chest. 2011;139(3):543-54., using CAA¹¹⁵115. Ju XX, Yang J, Liu XX. A systematic review on voiceless patients’ willingness to adopt high-technology augmentative and alternative communication in intensive care units. Intens Crit Care Nurs. 2021;63:102948.^),(¹¹⁶116. Ten Hoorn S, Elbers PW, Girbes AR, Tuinman PR. Communicating with conscious and mechanically ventilated critically ill patients: a systematic review. Crit Care. 2016;20(1):1-14., when they are intubated, tracheostomized or with other barriers and limited speech; -- with family members, caregivers and loved ones at a family conference / “medical report”, preferably in a private place, encouraging their active participation in the meeting¹¹⁷117. Seaman JB, Arnold RM, Scheunemann LP, White DB. An integrated framework for effective and efficient communication with families in the adult intensive care unit. Ann Am Thorac Soc. 2017;14(6):1015-20.^)-(¹¹⁹119. Brooks LA, Bloomer MJ, Manias E. Culturally sensitive communication at the end-of-life in the intensive care unit: a systematic review. Austr Crit Care . 2019;32(6):516-23.; - palliative and end-of-life care, additionally¹²⁰120. Carvalho RT, Parsons HÁ, organizadores. Manual de cuidados paliativos ANCP. 2ª ed. São Paulo: Academia Nacional de Cuidados Paliativos; 2012 [acesso em 20 jan 2022]. Disponível em: file:///G:/Documents/Habilidades_comunicacao/2022/manual_de_cuidados_paliativos_ancp.pdf.^)-(¹²⁴124. Schrijvers D, Cherny NI. ESMO Clinical Practice Guidelines on palliative care: advanced care planning. Ann Oncol. 2014;25:iii138-iii42., -- share information about health conditions and the lack of perspective of therapeutic cure in a sincere manner, using the steps for the communication of difficult news -- when there is a transfer to a palliative care unit, explain clearly and sincerely about its reason; -- talk about what the person under care wants to talk about or address, including their desires, their spirituality, information about the dying process, and other issues brought up by their families and/or loved ones; -- coordinate the planning of advanced care, together with the person under care, their families and/or loved ones and the members of the health team, agreeing on the place where they want to be cared for, the type of care they want to receive, if the situation gets worse, and record it; - when asking about the intention to donate organs, demonstrate sensitivity and solidarity with the grieving process of family members/caregivers, responding to emotions with empathy, and showing respect and understanding when consent is denied¹²⁵125. Knox K, Parkinson J, Pang B, Fujihira H, David P, Rundle-Thiele S. A systematic literature review and research agenda for organ donation decision communication. PIT. 2017;27(3):309-20.^),(¹²⁶126. Jacoby L, Crosier V, Pohl H. Providing support to families considering the option of organ donation: an innovative training method. PIT . 2006;16(3):247-52.;
( effectively communicate in processes and actions aimed at collective health³²32. Brasil. Resolução CNE/CES nº 3, de 20 de junho de 2014. Institui Diretrizes Curriculares Nacionais do Curso de Graduação em Medicina e dá outras providências. Diário Oficial da União; 2014., including - health promotion groups; - “health diagnosis and problem prioritization [...] by investigating the health needs of groups of people and the living and health conditions of communities, identifying their risk and vulnerability based on “the political, cultural, institutional discrimination, socioeconomic, and environmental context and of the relationships, movements and values of populations in their territory” and on “biological, psychological, socioeconomic and cultural aspects related to illness and vulnerability” and the coping strategies³²32. Brasil. Resolução CNE/CES nº 3, de 20 de junho de 2014. Institui Diretrizes Curriculares Nacionais do Curso de Graduação em Medicina e dá outras providências. Diário Oficial da União; 2014.; - “discussion and construction of intervention projects in social groups [...] always considering their autonomy and cultural aspects”, encouraging the “inclusion of health promotion and education actions [...] and encouraging the “inclusion of perspective of other professionals and representatives of social segments involved in the creation of health projects” ⁽³²32. Brasil. Resolução CNE/CES nº 3, de 20 de junho de 2014. Institui Diretrizes Curriculares Nacionais do Curso de Graduação em Medicina e dá outras providências. Diário Oficial da União; 2014.; - “development of plans directed at prioritized problems” and implementation of actions³²32. Brasil. Resolução CNE/CES nº 3, de 20 de junho de 2014. Institui Diretrizes Curriculares Nacionais do Curso de Graduação em Medicina e dá outras providências. Diário Oficial da União; 2014.; - “planning and evaluation of projects and actions within the scope of the Unified Health System” [...] aimed at improving collective health³²32. Brasil. Resolução CNE/CES nº 3, de 20 de junho de 2014. Institui Diretrizes Curriculares Nacionais do Curso de Graduação em Medicina e dá outras providências. Diário Oficial da União; 2014..
Additionally, in health management, the student must become able to
( focus on relationships when organizing, monitoring and evaluating people and actions in health work and teaching-service integration;
( embrace users, families, social groups and the community, listening to their perspectives
( make decisions including listening to users, families, social groups, community and health team members;
( coordinate, create and implement intervention plans “together with users, social movements, health professionals, health sector managers and also from other sectors” ⁽³²32. Brasil. Resolução CNE/CES nº 3, de 20 de junho de 2014. Institui Diretrizes Curriculares Nacionais do Curso de Graduação em Medicina e dá outras providências. Diário Oficial da União; 2014.;
( develop “scientific, technological and innovation development” projects, encouraging the participation and creativity of members of the interprofessional team(s) and the community³²32. Brasil. Resolução CNE/CES nº 3, de 20 de junho de 2014. Institui Diretrizes Curriculares Nacionais do Curso de Graduação em Medicina e dá outras providências. Diário Oficial da União; 2014.;
( participate “in formal spaces for collective reflection on the work process [...] and intervention plans” ⁽³²32. Brasil. Resolução CNE/CES nº 3, de 20 de junho de 2014. Institui Diretrizes Curriculares Nacionais do Curso de Graduação em Medicina e dá outras providências. Diário Oficial da União; 2014.^);
( develop the diagnosis of the territory in a participatory way, together with the team professionals, local leaders and members of the community³²32. Brasil. Resolução CNE/CES nº 3, de 20 de junho de 2014. Institui Diretrizes Curriculares Nacionais do Curso de Graduação em Medicina e dá outras providências. Diário Oficial da União; 2014.;
( disseminate the diagnosis of the territory among users, families, social groups, community and team members and agree with them on strategies to improve the reality³²32. Brasil. Resolução CNE/CES nº 3, de 20 de junho de 2014. Institui Diretrizes Curriculares Nacionais do Curso de Graduação em Medicina e dá outras providências. Diário Oficial da União; 2014.;
( develop and/or participate in existing movements and projects to improve health and social conditions, at the local, regional, national and international levels³²32. Brasil. Resolução CNE/CES nº 3, de 20 de junho de 2014. Institui Diretrizes Curriculares Nacionais do Curso de Graduação em Medicina e dá outras providências. Diário Oficial da União; 2014..

Term	Detailing
Assertiveness	Ability to share thoughts, perspectives, feelings and emotions in a respectful, calm, direct and sincere manner, defending personal and other people’s rights, even asking for a change in behavior when perceiving the risks for them, with arguments based on facts and not on personal characteristics and without making value judgments, embarrassing, offending, humiliating or violating the rights of other people, remaining open and flexible to listen to everyone and sensitive to their feelings, dealing with one’s own emotions and maintaining self-control¹⁹19. World Health Organization. WHO patient safety curriculum guide: multi-professional edition. Geneva: WHO. 2011. Disponível em: Disponível em: https://www.who.int/publications/i/item/9789241501958 . Acesso 10 jan. 2021. [Marra VN, Sette ML, coordenadores. Guia curricular de segurança do paciente da Organização Mundial da Saúde: edição multiprofissional. Rio de Janeiro: Pontifícia Universidade Católica do Rio de Janeiro; 2016 [acesso em 10 jan. 2021]. Disponível em: https://cdn.who.int/media/docs/default-source/patient-safety/9788555268502-por519565d3-e2ff-4289-b67f-4560fcd33b9d.pdf?sfvrsn=9e58a092_1.] https://www.who.int/publications/i/item/... ^),(²⁶26. Omura M, Maguire J, Levett-Jones T, Stone TE. The effectiveness of assertiveness communication training programs for healthcare professionals and students: a systematic review. Intern J Nurs Stud. 2017;76:120-8.^),(²⁷27. O’Connor P, Byrne D, O’Dea A, McVeigh TP, Kerin MJ. “Excuse me”: teaching interns to speak up. Jt Comm J Qual Patient Saf. 2013;39(9):426-31.
External barriers to communication and intrapersonal limitations to communicating	Barriers that can be located in the physical environment, which include computer and sounds of appliances and equipment, among others; they can occur due to the use of protective equipment, which prevent the total or partial visualization of the meeting participants. They may result from the use of the virtual environment, with difficulty in access, internet instability, loss of visualization of the participants and impossibility of in-person approach. The limitations include: lack of mastery of the language spoken by the physician or by the person under care and caregivers, without the mediation of interpreters; early stage of neuropsychomotor development, with consequent lack of native language repertoire and social skills, as in the case of children; alterations in the neurological development, resulting in cognitive impairment and global developmental disorders, which also impair social interactions (such as autism spectrum disorders); auditory sensory alteration not mediated by an interpreter; visual sensory alteration that prevents the reading of documents such as the prescription; diseases of neurological, neuromuscular or oncological origin that cause dysphasia, aphasia, cognitive impairment or limitation of motor movement responsible for speech, including stroke, brain injuries, dementia, locked-in syndrome, head and neck cancer, Parkinson’s disease and Amyotrophic Lateral Sclerosis, among others; and, situations that generate the transient impossibility of speaking, such as ventilatory support and tracheostomy, among others; psychiatric disorders and alterations in mental status due to intoxication by psychoactive substances
Alternative and augmentative Communication (CAA)	Diversity of linguistic resources (communication systems) with the aim of mediating, supplementing and/or facilitating interactions between people with impaired oral, gestural and/or written communication, of physical, mental, intellectual or sensory origin. It allows the person’s social participation and the sharing of their emotions, perspectives and desires. It tends to improve motor, cognitive and affective development with improved self-esteem, self-confidence and empathy. Extended communication complements the existing speech, and its users have difficulties in speaking and understanding language. In the alternative communication, speech is non-existent or non-functional and its users have a cognitive understanding of language, but have difficulty speaking, and it can be permanent or temporary due to interventions such as intubation and tracheostomy. CAA can be non-assistive (unsupported), when only the human body is used to communicate, or assistive, when it depends on resources that are external to the body. Resources with no or low technology include communication by written and sign language, by gestures, facial expressions, alphabet boards or pictographic symbols, among others. High-tech resources include mobile devices, voice communicators, computers, tablets and software with programmable functions, which convert text into natural sounds and symbols, according to the user’s needs. They use a variety of methods to detect human signals generated by body movements, such as image sensors activated by eye tracking and head signals, mechanical and electromechanical sensors activated by mechanical boards and switch access to use the computer screen, touch-activated sensors such as touchscreens, breath-activated sensors by microphones and low-pressure sensors, and sensors with invasive or non-invasive brain-computer interface⁹⁴94. Elsahar Y, Hu S, Bouazza-Marouf K, Kerr D, Mansor A. Augmentative and alternative communication (AAC) advances: a review of configurations for individuals with a speech disability. Sensors. 2019;19(8):1911. Doi: https://doi.org/10.3390/s19081911. https://doi.org/10.3390/s19081911... ^)-(⁹⁸98. Gomes CA, Rugno FC, Rezende G, Cardoso RC, De Carlo MM. Tecnologia de comunicação alternativa para pessoas laringectomizadas com câncer de cabeça e pescoço. Medicina (Ribeirão Preto). 2016;49(5):463-74..
Support systems for people with expressive or receptive communication disorders	Support systems for people with expressive or receptive communication disorders include expanded additional support, and assistive hearing technology systems. They include Braille, hearing amplification through hearing aids, cochlear implants and assistive hearing technology systems (such as personal amplification devices via text telephones and telecommunication devices for the deaf); and, artificial phonation devices and voice amplifiers, such as intraoral devices and valves for speech (as used in people with tracheostomy, for instance)⁹⁷97. American Speech-Language-Hearing Association. Augmentative and Alternative Communication [acesso em 20 em 2022]. Disponível em: www.asha.org/Practice-Portal/Professional-Issues/Augmentative-and-Alternative-Communication/. www.asha.org/Practice-Portal/Professiona... .
Non-violent communication	It aims at maintaining peaceful everyday interactions, cultivating self-awareness and self-compassion, and honoring one’s own needs and values and the needs and values of others. Its process includes observing and listening attentively to others without judgment, reflection to identify one’s feelings in relation to what is observed and the recognition of the personal needs, values and desires that generate these feelings, confirmation of the understanding about what the other person speaks, paraphrasing to check for accuracy, using specific words to express feelings and emotions rather than unclear words, making requests clearly and specifically without demanding their fulfillment, being empathetic, understanding, and compassionate when they are refused, respecting the person’s choice to do something or comply with our request of their own free will⁷⁵75. Rosenberg MB. Comunicação não violenta: técnicas para aprimorar relacionamentos pessoais e profissionais. 3ª ed. São Paulo: Ágora; 2006..
Pragmatic communication	Ability to use language in context and to understand and express the basic meanings of words (semantics) with correct grammatical forms (syntax). Its characteristics include providing information that is appropriate to the needs of those who receive it, expressing perspectives and ideas in a logical and coherent sequence, sharing problems and monitoring the adequacy of the production of one’s own speech in a specific context, among others⁹²92. Watzlawick P, Beavin JH, Jackson DD. Pragmática da comunicação. São Paulo: Culturix; 2010.^),(⁹³93. Bosco FM, Tirassa M, Gabbatore I. Why pragmatics and theory of mind do not (completely) overlap. Front Psych. 2018;9:1453. Doi: https://doi.org/10.3389/fpsyg.2018.01453. https://doi.org/10.3389/fpsyg.2018.01453... .
Verbal and non-verbal communication	Verbal communication expresses the word, either orally or in written/typed form. Non-verbal communication encompasses all other forms of communication that do not represent the word, but influence its interpretation, such as paralanguage (tone, intensity, rhythm, volume and sounds that are not words like “Uh huh”), kinesics (body movements, including gestures, posture, head movements, facial expressions, way of looking, among others) and proxemics (how people perceive and use interpersonal space), among others⁶⁰60. Fortin VI AH, Dwamena FC, Frankel RM, Smith RC. Smith’s patient centered interviewing: an evidence-based method. 3rd ed. New York: McGraw Hill; 2012.^),(⁶¹61. Chou C, Cooley L, editors. Communication RX: transforming healthcare through relationship-centered communication. New York: McGraw Hill ; 2018.^),(⁸⁹89. Hojat M. Empathy in health professions education and patient care. New York: Springer; 2016.^),(⁹⁰90. Lunenburg, FC. Louder than words: the hidden power of nonverbal communication in the workplace. IJ SAID. 2010;12(1):1-5..
Disaster	Serious disturbance in the function of a community or society, due to the interaction between hazardous events and conditions of exposure, vulnerability and capacity, which results in human, material, economic and/or environmental losses and impacts. It can have a natural origin (meteorological and hydrological, extraterrestrial and/or geological), biological (such as epidemics and pandemics) and/or anthropogenic (technological, chemical, social and environmental). It is currently considered that all disasters are mixed, due to the interdependence between these phenomena¹¹⁰110. The international Federation of Red Cross and Red Crescent Societies (IFRC). What is a disaster? [acesso em 10 fev 2021]. Disponível em: Disponível em: https://www.ifrc.org/what-disaster . https://www.ifrc.org/what-disaster... ^),(¹¹¹111. Secretaría Interinstitucional de la Estrategia Internacional para la Reducción de Desastres, Naciones Unidas. Vivir con el riesgo: informe mundial sobre iniciativas para la reducción de desastres. Genebra: ONU; 2004..
Social skills	Specific behaviors in specific contexts in a given social environment, to interrelate and complete social tasks. The main classes of social skills include: communication, civility, making and maintaining friendships, empathy, assertive skills, expressing solidarity, managing conflicts and resolving interpersonal problems, expressing affection and intimacy, coordinating groups, and public speaking⁸⁸88. Del Prette ZAP, Del Prette AD. Psicologia das habilidades sociais: diversidade teórica e suas implicações. Petropólis: Vozes; 2009..
Emotional Intelligence	Ability to understand oneself, including one’s own emotions, fears, feelings and motivations, and to understand other people’s emotions, motivations and expectations, which can be categorized into five domains: emotional self-knowledge, emotional control, self-motivation, recognition of emotions in other people and social skills for interpersonal relationships. The last two are crucial for group organization and leadership, conflict management and solution agreement, empathy and social sensitivity⁸⁷87. Goleman D, Boyatzis R, McKee A. O poder da inteligência emocional. Rio de Janeiro: Campus; 2002..
Idiom	System of codes with rules that allow the communication between certain social groups¹1. Houaiss A, Villar MS, Franco FMM. Dicionário Houaiss da língua portuguesa. Rio de Janeiro: Objetiva; 2001..
Language	According to the Houaiss¹ dictionary, on page 1763: “1. Any systematic means of communicating ideas or feelings through conventional signs, sound, graphics, gestures, etc. [...]”.
Metadiscourse	Discourse function through the analysis of how signs are designed to influence meanings and attitudes⁸⁵85. Hyland K. Metadiscourse: what is it and where is it going? JoP. 2017;113:16-29.^),(⁸⁶86. Jaworski A, Coupland N, Galasinski D. Metalanguage: social and ideological perspectives. Berlin: Walter de Gruyter; 2004..
Operational levels of verbal communication	They include three levels. One of them is concrete, which is the denotative level, related to the content. Two of them are more subjective; the metalinguistic one, related to the type of language used, and metacommunication one, related to the interpretation of the received messages, mainly through implicit messages of non-verbal signals, but also, more rarely, by explicit verbal ones⁸⁶86. Jaworski A, Coupland N, Galasinski D. Metalanguage: social and ideological perspectives. Berlin: Walter de Gruyter; 2004.^),(⁹¹91. Craig RT. Metacommunication. In: Jensen KB, Rothenbuhler EW, Pooley JD, Craig RT, editors. The international encyclopedia of communication theory and philosophy. West Sussex: John Wiley & Sons. 2016. Doi:https://doi.org/10.1002/9781118766804.wbiect232. https://doi.org/10.1002/9781118766804.wb... .
Information and communication technologies (ICT)	Set of integrated technological resources to process information and assist in communication. They cover all forms of transmission of information and technologies that interfere and intervene in information and communication processes between human beings. It can be performed through computers, tablets, cell phones, software and telecommunications. The exchange of information can occur in a virtual synchronous way, with tools such as, for example, telephones, virtual platforms, WhatsApp and other applications; and, asynchronously, with tools such as e-mail messages, text messaging applications such as SMS, virtual platforms, websites, television, radio, among others. Their use in health care includes several activities, including, but not limited to, videoconferences, consultations, virtual procedures, filling out medical records and electronic forms, sharing of messages, exams, data and other documents.

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[1] Chief Editor: Rosiane Viana Zuza Diniz. Associate editor: Daniela Chiesa.