Health System Integrated Residency in Pediatrics and Obstetrics/GynecologyABSTRACT
Introduction: Medical residency is an effective model for both training professionals and reshaping healthcare practices. With the necessary expansion and improvement of the healthcare network, there has been a growing need to train more professionals. Most institutions involved in the teaching and learning process are already operating at full capacity within their practice settings. As a result, increasing the number of residency positions requires identifying new learning environments across the healthcare network, including primary, secondary, and tertiary care. The aim is to share the experience of implementing an Integrated Medical Residency Program in Pediatrics and Obstetrics/Gynecology.
Experience Report: The initial phase involved mapping out the various services within the healthcare system to identify those with the infrastructure, equipment, supplies, and staff needed to support a residency program. This was followed by engaging healthcare professionals and training preceptors. The practice settings included a range of services, with a special focus on primary and secondary care, areas where residency programs had not previously existed. The programs were launched in 2012 and currently offer 14 positions in Pediatrics and 16 positions in Obstetrics/Gynecology, having already graduated 105 Pediatricians and 98 Obstetrician/Gynecologist.
Discussion: We challenged existing norms by placing residents in newly created practice settings where medical residency programs had never been offered before. One of the main challenges was ensuring the integration of residents rotating through these diverse services. To address this, we implemented educational strategies to coordinate the training process and ensure compliance with CNRM regulations.
Conclusion: This experience is considered successful, having overcome initial obstacles related to engaging both managers and preceptors. It resulted in the restructuring of services and greater involvement of clinical staff in the programs, ultimately providing integrated training and offering future specialists a broader perspective on the healthcare system.
Keywords:
Medical Residency; Pediatrics; Obstetrics/Gynecology; Continuing Health Care Network; Medical Education
RESUMO
Introdução: A residência médica (RM) é um modelo eficaz de formação e reestruturação da prática nos serviços de saúde. Diante da ampliação e qualificação - aspectos imprescindíveis - da rede de atenção, surgiu a necessidade da ampliação na formação de profissionais. Nas instituições implicadas no processo de ensino-aprendizagem, há, em sua grande maioria, cenários de prática em utilização máxima de sua capacidade. Assim, ampliar a oferta de vagas de residência passa pela identificação de novos ambientes de aprendizagem na rede assistencial, incluindo as atenções primária, secundária e terciária. O objetivo do estudo foi relatar a experiência da RM em rede em pediatria e ginecologia/obstetrícia no Ceará.
Relato de experiência: A primeira etapa do processo foi conhecer os diversos serviços da rede de atenção e identificar aqueles que potencialmente ofertavam infraestrutura de equipamentos, insumos e pessoal. Em seguida, verificaram-se a sensibilização dos profissionais e a posterior capacitação dos preceptores. Os cenários de prática incluíram diferentes serviços, com ênfase nas atenções primária e secundária, onde não existia programa de residência médica (PRM). Os programas iniciaram em 2012 e atualmente ofertam 14 vagas em pediatria e 16 vagas em ginecologia, tendo formado105 pediatras e 98 ginecologistas/obstetras.
Discussão: Quebraram-se paradigmas quando os residentes passaram a rodar nos novos cenários construídos onde antes não havia RM. Um desafio consistiu em integrar os residentes que realizaram rodízios nesses diversos serviços, e uma solução foi a presença de dispositivos educacionais que assegurassem a coordenação do processo formativo e atendimento das normativas da Comissão Nacional de Residência Médica (CNRM).
Conclusão: Considerou-se a experiência exitosa, que foi implantada após superar adversidades iniciais relativas à sensibilização de gestores e preceptores e culminou com reestruturação e maior envolvimento do corpo clínico nos serviços que acolheram esses PRM. Por meio da oferta de uma formação integrada, oportunizou-se aos futuros especialistas uma visão mais ampla do sistema de saúde e do mercado de trabalho.
Palavras-chave:
Residência Médica; Pediatria; Ginecologia/Obstetrícia; Rede de Cuidados Continuados de Saúde; Educação Médica
INTRODUCTION
Medical Residency (MR) is developed through supervised in-service training for graduates and is recognised as the gold standard for training medical specialists1),(2. It is a fundamental pillar for the quality of health systems, through the acquisition of professional competencies and the development of progressive professional autonomy. In Brazil, one of the principles of MR is to train specialists in line with the principles and needs of the Unified Health System (SUS), especially in strengthening Primary Health Care (PHC) and integrating the different levels of health care3. Traditionally, Medical Residency Programmes (MRPs) are offered by isolated services, usually general or specialised hospitals, in practice settings mostly centred on a single institution or with few external rotations2),(3. The excellence and standardisation of this training is outlined by the guidelines of the National Medical Residency Commission (CNRM), which defines the competency matrix and minimum requirements for each speciality3),(4),(5. The Health System Integrated Medical Residency, a modality that still has limited coverage in Brazil, has emerged as a strategy to transpose the traditional training model, aiming for a qualified insertion of resident doctors in different health system settings. Based on initiatives such as the Ministry of Health’s Ordinance No. 1,248/2013, which established the Strategy for Qualifying Healthcare Networks (RAS), with a focus on encouraging the training of specialists via medical residency in strategic areas of the SUS6. The Health System Integrated MR was designed to take into account the demands of the lines of care and services that make up the priority thematic networks of the SUS, promoting a broader understanding of the system7. The Health System Integrated Residency transcends the mere decentralisation of practice settings, constituting a learning network in the SUS, and contemplates a new pedagogical model, based on teaching-service integration and synergy between the actions of the training institution and the care needs of municipal or state management7. A model of this format is the Integrated Family and Community Medicine Residency Programme in Fortaleza, demonstrating that this approach makes it possible to train specialists on a large scale, in partnership with the implementation and strengthening of services in the Family Health Strategy (ESF)8. The Federal University of Paraíba offers a MRP in Family and Community Medicine in partnership with the João Pessoa Health Department, with a networked configuration8. The effectiveness of this training model is directly linked to the acquisition of a general profile that encompasses other competencies in addition to the specific and clinical specific skills defined in the competency matrix for the speciality, such as managing traffic between different services, teamwork, adaptability and the functioning of the SUS7. To this end, preceptorship plays a central role, becoming the main teaching-learning strategy in service and requiring co-management mechanisms between the institution promoting the MRP, the services where the training takes place and health managers7.
Although it represents an advance in professional training and in the organisation of teaching and service in the SUS, the Health System Integrated MR faces significant challenges. The need for regulation and standardisation of curricular matrices, the continuous development of preceptors, overcoming the barriers of the peculiarities of the services and the coordination of different practice settings are fundamental elements for consolidating and guaranteeing the quality of this training modality7. Few MRP initiatives structured in this way have been described in the literature, and the two experiences found were MRPs in Family and Community Medicine8. Other specialities continue to offer MRPs in the traditional format, centred on a single hospital or health service3),(4),(5. Most paediatric and Obstetrics and Gynecology MR programmes follow a traditional hospital-based training model4),(5. The competency matrices of these two specialities cover the maternal-child cycle and child, adolescent and women’s health and share essential structural and pedagogical foundations, dictated by the CNRM’s normative resolutions3),(4),(5. Both specialities have three years of training and are classified as direct access4),(5. Both MRPs are clearly aligned with the precepts of the SUS, emphasising health promotion, disease prevention and an understanding of the different levels of care4),(5. Both matrices highlight the need to develop non-clinical skills, such as valuing multidisciplinary teamwork, and include a common curricular basis that prioritises comprehensive health and primary care, reinforcing the role of these specialities in consolidating the lines of care in the SUS4),(5. To exemplify an innovative initiative in an integrated MR, this report looks at the 13-year experience of Health System Integrated Medical Residency in Pediatrics and Gynecology and Obstetrics in Ceará, exploring the challenges of implementation and the consolidation of an innovative model in the training of specialists.
EXPERIENCE REPORT
The Obstetrics and Gynecology (GO) and Pediatrics MRs are effective training models, but as they have traditionally been developed in high complexity units, they have not responded to the need to restructure practice in the health services and train specialists to work in the various healthcare settings for women, children and teenagers3),(4),(5. Therefore, the justification for planning and building networked MRPs arises from the possibility of broadening the understanding of specialist doctors in the face of the lack of response to the challenges of dealing with emerging issues in the SUS, such as guaranteeing equitable and timely access, rational use of diagnostic and therapeutic resources and patient-centred practice. Steering the MR curriculum towards the health system enables a better understanding of the local-regional context, making professional practice more assertive and efficient. It is difficult to recruit specialists in primary and secondary care, especially outside the state capital city. Given the strategy of expanding the healthcare network in Ceará, with the construction of polyclinics and regional hospitals in all the state’s macro-regions, the need to train new professionals emerged, qualifying them to work in primary care, polyclinics and regional hospitals in view of the contemporary healthcare scenario. Most of the institutions involved in the teaching-learning process had practice scenarios at full capacity. Therefore, expanding the supply of medical residency places involves building new clinical environments that facilitate the process of acquiring competencies. Thus, it was proposed that the training take place at various points in the care network, including primary, secondary and tertiary care.
The implementation of the Municipal School Health System in the Municipality of Fortaleza (SMSE) provided a favourable scenario for offering this training model. The SMSE’s main idea is to transform the entire health services network into a space for contextualised education and professional training10. Added to this is the creation, in 2009, of the National Programme to Support the Training of Specialist Doctors in Strategic Areas (Pró-Residência), through an Interministerial Ordinance between the Ministry of Health and the Ministry of Education, thus creating a favourable scenario for the expansion of MR vacancies in the state10. Subsequently, Ordinance 1248 of 2013 established the Strategy for Qualifying Healthcare Networks by encouraging the training of MR specialists in strategic areas of the SUS, which also contributed to the implementation of network residencies6.
In 2012, Fortaleza had 3 MRPs in Pediatrics and the same number of MRPs in Obstetrics and Gynecology, all offered in state and federal public hospitals. When the integrated residency pedagogical project was being built, municipal hospitals and primary care units were invited to join the training network. The pedagogical construction took place through a partnership between the Public Health School of Ceará (ESP-CE) and the Municipal Health Department of Fortaleza (SMS-Fortaleza). The first stage of the process was to get to know the various services in Fortaleza’s healthcare network and identify those that potentially offered an infrastructure of equipment, supplies and personnel compatible with offering an MRP. This was followed by actions to raise awareness among professionals and the subsequent offer of three training courses for preceptors, given that the team of paediatricians and gynaecologists/obstetricians identified as potential preceptors, for the most part, had no training in teaching. As the project was presented in the units, we tried to involve their multi-professional teams, since health work is collective. The design of the programmes’ curricular matrices followed CNRM Resolution 02/20063. Applications for accreditation of the Health System Integrated Residency in Pediatrics and Obstetrics and Gynecology were submitted to the CNRM and authorised in 2012, resulting in a responsible expansion of the number of residency places, involving careful planning in relation to the settings, identifying places that did not previously offer any MR space. Twelve Pediatrics vacancies and seven Obstetrics and Gynecology vacancies were accredited. The scholarships have been funded by Pró-Residência10 since they were set up. For the implementation, the settings were visited beforehand and agreements were made with staff and managers. Not all staff were initially receptive to guiding residents in the field of practice, which gradually changed after the processes of change that the residency triggered in the services that are the field of practice. The provision of teacher training for preceptors was also essential.
Three secondary hospitals, one tertiary hospital, a specialised outpatient clinic (secondary care) linked to the University of Fortaleza (UNIFOR) and two Primary Health Care (PHC) units were selected as fields for the Pediatrics Residency, offering eight places in the year of implementation, 2012. It should be noted that the tertiary unit already hosted paediatric residents on a sporadic basis. In the Obstetrics and Gynecology MR, two vacancies were offered in the year of implementation, 2012, because provisional accreditation was granted in April, after the conclusion of the selection process for the other MRPs, and the R1s joined in May 2012. In its first year of operation, the MRP spent most of the months in a secondary municipal maternity hospital and in a contracted secondary outpatient clinic, and was developed in other settings from R2 onwards, with an emphasis on practice spaces at primary and secondary levels of care, where there was no residency. The rotation in high complexity units was instituted in services that already had their own programmes. The practice spaces are reviewed in meetings with the MRP supervisors and by analysing the logbooks. Residents are monitored through weekly joint activities with all the residents (R1, R2 and R3) specific to each MRP in the network, tutoring activities (Pediatrics) and mentoring (Obstetrics and Gynecology). The assessment system consists of a quarterly theoretical test and a structured monthly assessment applied by the MRP preceptors. Using specific instruments developed by the MRP supervisors and preceptors, an overall score is considered including assessment of clinical skills, procedural skills and attitudes.
The Pediatrics MRP lasted 2 years and the Obstetrics and Gynecology MRP 3 years. The first class of Pediatrics residents finished their training in 2014 (March 2012 to February 2014) and Obstetrics and Gynecology in 2015 (May 2012 to April 2015). In 2019, the Pediatrics MRP changed to a 3-year duration, in accordance with CNRM Resolution 1/20164, and there were no graduates in 2021, due to the change in the duration of the MRP. By 2025, 11 classes from each MRP had completed their residency, totalling 105 paediatricians (out of 106 places on offer) and 98 gynaecologists/obstetricians (out of 100 places on offer). Currently, in Fortaleza, the Pediatrics MRP offers 10 R1 vacancies and has 30 residents in progress (R1, R2 and R3) and the GO MRP offers 12 R1 vacancies and has 36 residents in progress (R1, R2 and R3). The data is presented in Table 1.
The two MRPs provide specialities with experience in practice spaces of different levels of complexity, where the diverse profile, the volume of patients seen, the number of procedures carried out and the supervision of qualified preceptors supports learning in highly effective, quality care settings. A major differentiator of both programmes is the strong longitudinal insertion in PHC, where the resident can collaborate with Family and Community Medicine and understand the importance of longitudinality and PHC as the gateway to the SUS. Another special feature is the rotation at the Ceará State Health Department’s Regulation Centre, which gives residents an understanding of the management and structuring of the state health care network and prioritising access to services. The rotations last between 1 and 3 months in the same practice setting and in some cases the resident repeats stages of training (R1, R2 and R3), ensuring the maximum possible learning and use of each rotation. Both MRPs fully comply with the competency matrices of the specialities defined by the CNRM4),(5.
The rotations of the Pediatrics programme are currently distributed in three municipal hospitals, two state hospitals, the hospital complex of the Federal University of Ceará, a private hospital, the specialist outpatient clinic (secondary care) linked to the Unichristus University Centre and in Primary Health Care (PHC) units. The curricular matrix of this programme has a 10-month longitudinal outpatient rotation, in R3, in early childhood development and behaviour, in a philanthropic institute, IPREDE - Early Childhood Institute, accompanying the multiprofessional team. It is the only residency that includes this rotation, an outstanding feature of the MRP.
The Obstetrics and Gynecology network MRP rotations take place in three municipal hospitals, two state hospitals, the maternity hospital of the Federal University of Ceará hospital complex, a philanthropic hospital, the specialist outpatient clinic (secondary care) linked to the University of Fortaleza, the Cancer Prevention Institute (outpatient clinics and surgical centre) and PHC units. The distinguishing features of this programme include the rotations in the delivery room, emergency room and obstetric centre in maternity hospitals with a high volume of normal childbirth deliveries and references in Appropriate Delivery Care with multidisciplinary teams and respecting the mother’s autonomy; the rotation in a reference service for multidisciplinary care for women in situations of violence; the multiplicity of preceptors and the offer of elective rotations in different areas of expertise such as Infertility, Sexuality and Gynaecological Endoscopy.
A product of both the MRPs are speciality manuals and books produced by residents and guided by preceptors from multiple health services/practice settings, with the development and implementation of clinical guidelines and local protocols. There is integration of the state’s Obstetrics and Gynecology MRPs in joint theoretical activities promoted by the state speciality society. The second- and third-year resident assesments, including by preceptors from other MRPs, identified the acquisition of competencies required for good training at an earlier stage and with an emphasis on attitude.
DISCUSSION
The vacancies offered in the first year (eight in Pediatrics and two in Obstetrics and Gynecology) were all filled, against a backdrop of certainty shown by the proposing institutions in their offering of training programmes with the potential to support teaching-service integration and qualify specialists who understood the needs of the area, resulting in a responsible expansion of the number of residency vacancies. However, the project raised several doubts among academics and the managers of the state’s other MRPs as to the viability of the model and its ability to offer quality training. Building this credibility was one of the initial challenges.
A distinguishing feature of the project was the development of devices and arrangements to ensure the longitudinal follow-up of residents, even in different settings. Thus, integrated weekly practical and theoretical activities were implemented for all residents in each programme, integrated assessment tools were built for application in the services by the preceptors, a management collegiate was set up made up of preceptors from the practice services and tutoring and mentoring activities. Encouraging the pedagogical development of preceptors by offering preceptorship courses and technological development grants also facilitated this process. Several preceptors were nominated to take part in specialised courses in programme management and preceptorship, promoted in partnership with the ESP/CE. Professionals in the municipal network are provided with qualification and refresher teacher training courses run by the ESP.
The partnership with UNIFOR and later with UniChristus was also innovative, enabling the sharing of practice settings with interns and preceptors and the use of the skills laboratory to train residents in realistic simulation environments, favouring the learning and training of skills specific to the speciality. We broke paradigms when “traditional” residency programmes started to run in the newly constructed settings and with the inclusion of settings where there was no previous medical residency. Currently, graduates of the MRPs take up positions as preceptors and managers of the services where they completed their rotations, demonstrating the qualification of the settings and the professionals and demonstrating the training of specialists with knowledge of the care network. There has been restructuring and greater involvement of the clinical staff in the services that host these MRPs, as well as an excellent level of learning and utilisation of the practice spaces by the residents.
Another important feature that sets them apart is the participation of residents in the evaluation of practice settings, through periodic feedback, allowing supervisors to analyse the practice fields and the preceptorship from the trainee’s point of view and supporting the acquisition of the expected competencies. Residents feel valued in their learning process and are active subjects in their training, prioritising their metacognition.
Today, in the evaluation of preceptors, supervisors of other MRPs that interface with network MR and health service managers, the effectiveness of this MR model is recognised, with earlier identification of the acquired competencies required for the good training of paediatricians and gynaecologists/obstetricians, with an emphasis on attitude. An intangible result is the bridges built between previously isolated institutions, with the resident being the connecting link, bringing these scenarios closer together, with an excellent level of learning and utilisation of practice spaces. We stress that what characterises the network programme based on the experience of the ESP/CE and SMS Fortaleza is not only the multiple practice settings, but its development at various points in the care network, thus breaking with the model of qualifying a specialist preferably within a hospital. Integrating these points has represented a challenge, and one solution has been the use of educational devices that ensure coordinated training process and compliance with CNRM regulations.
The implementation of this model is complex and the challenges range from drawing up solid and well-structured pedagogical projects, the need to standardise minimum training requirements in the various services, the implementation of an assessment system that takes into account the peculiarities of this type of training and the continuous pedagogical development of preceptors. Other issues that have an impact on training are effective integration between services, the possibility of modelling different professions and guaranteeing quality in teaching-learning processes in settings with less teaching practices.
CONCLUSION
Health system integrated medical residency is an idea that is gradually gaining ground in an innovative way. It offers integrated training, giving future specialists a broader vision of the health system and the labour market that awaits them on completion of their training. The implementation of this model is complex, bringing challenges in terms of coordination between services, preceptorship and standardisation of the training process. We consider this to be a successful experience, which emerged after overcoming the initial challenges of sensitising preceptors and structuring new practice scenarios. We can say that the integrated MRPs have developed a conception of the network, where units with diverse patient demands and the potential to integrate humanisation projects have been recognised as teaching-learning scenarios for training specialists, strengthening the comprehensiveness of care. Graduates from the Health System Integrated MRPs are recognised for their in-depth knowledge of the care network and preceptors from other MRPs validate the effectiveness of this model.
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Research data is available in the body of the document.
