Medical education applied to practical settings in the first college years: meanings given by photovoice

Abstracts

Nowadays, medical education aims at introducing students to their study field since the first college years in order to prepare professionals for a comprehensive health care. The aim of the present study is to assess educational potential through immersion in mental health studies based on focus-group discussions and photovoice images. Six undergraduate students were encouraged to work with local medical equipment from 2017 to 2018. Two themes in accordance to relevant literature and to meanings given to the pictures were chosen, namely: Introduction to Health Care Practice and Medical Education in Action. The picture-taking experience, which was shared and discussed by the group, gave life to education; it took students closer to their humanity and to the humanity of others. Therefore, it ensured comprehensive healthcare.

Medical education; Mental health; Comprehensive health care

Como estratégia para formação de profissionais aptos a promoverem assistência integral à saúde, na contemporaneidade, o ensino médico prevê inserção do acadêmico no campo de atenção, desde os anos iniciais da graduação. Objetivou-se analisar a dimensão formativa desta imersão em cenários da saúde mental a partir de imagens captadas pelo photovoice e reflexões em grupo focal. Participaram seis estudantes de uma disciplina de graduação que promove a integração desses nos equipamentos de saúde do município, no período de 2017 a 2018. Pela interpretação dos sentidos do material produzido, duas categorias temáticas se sobressaíram: a inserção nos cenários de práticas e a educação médica em ação. Esses núcleos de sentido foram descritos, estabelecendo-se um diálogo com a literatura pertinente. A experiência fotografada, relatada e discutida no grupo trouxe vitalidade à formação, aproximando-os do humano que há neles e nos outros, favorecendo a integralidade do cuidado.

Educação médica; Saúde mental; Assistência integral à saúde

Como estrategia para la formación de profesionales aptos para promover asistencia integral a la salud, en la contemporaneidad, la enseñanza médica prevé la inserción del académico en el campo de atención desde los años iniciales de la graduación. El objetivo fue analizar la dimensión formativa de esta inmersión en escenarios de la salud mental a partir de imágenes captadas por el photovoice y reflexiones en grupo focal. Participaron seis alumnos de una disciplina de graduación que promueve la integración de ellos en los equipos de salud del municipio, en el período de 2017 a 2018. Por la interpretación de los sentidos del material producido, se destacaron dos categorías temáticas: La inserción en los Escenarios de Prácticas y la Educación Médica en Acción. Se describieron estableciéndose un diálogo con la literatura pertinente. La experiencia fotografiada, relatada y discutida en el grupo brindó vitalidad a la formación, aproximándolos del humano que hay en ellos y en los otros, favoreciendo la integralidad del cuidado.

Educación médica; Salud mental; Asistencia integral de la salud

Introduction

Medical care essentially implies human relations, bonds and intimacy; therefore, it cannot be detached from the affective dimension of existence. However, the technological boom in recent decades and the subsequent enhancement of medical procedures were followed by gradual disassociation from human interaction in medical “doing”. Scientific knowledge and technical skills overshadowed the passion and compassion inherent to humane caregiving practices.

The traditional medical education model was created in 1910 by Abraham Flexner, an American educator who suggested associating medical schools with hospitals in order to qualify and standardize education. As a consequence, health theory and practice were divided into several specializations, and education was centered on the “anatomo-clinical” scientific method ¹ .

Medical education became gradually guided by “a set of structural principles: mechanisms, ‘biologism’, individualism, specialization, exclusion of alternative therapies, emphasis on curative care, concentration of resources and by the ‘technification’ of medicine” ² (p.325).

This scientific medical model fell into crisis in the second half of the 20th (twentieth) century. Its inefficiency was exposed by the growing need of investments, high costs and poor solutions for the health needs of the general population. Therefore, the doctor-patient relationship model isbased on the hospitalization process principles, such as listening to patient’s problems, humanism and the inseparable body/mind unity. ¹ , ³

Pedagogical strategies derived from this historical path due to Flexner’s model inadequacies for medical education. Back to the 1950s, George Miller, from the State University of New York, stood out among the American pioneers in pedagogical endeavors. After systematic research, Miller proposed the beneficial association with pedagogy and developed strategies to qualify teaching and learning processes in medical schools, the so-called “teaching medical teachers to teach” ⁴ (p.788).

In the early 20 ^th century, political and academic circles reinforced the consensus that the traditional medical training approach needed changes and adjustments, so that medical education could properly meet the needs of social settings where qualified doctors performed their jobs ⁵ , ⁶ .

Brazilian curricular changes - underway since 2001 - indicate the need of training doctors to assimilate the biological, psychological, social and environmental dimensions of the health-disease process; and to have a critical reflective approach to multi-professional health teams. Hence, teaching methodologies must encourage students to participate in knowledge production by associating medical-academic training with social health needs based on the Brazilian National Health System (SUS) principles ⁷ .

The modern era reflects the concern with challenges yet faced by medical education. The pioneering Alma Ata International Conference held in Kazakhstan in 1978 ⁸ suggested that the world should define primary care as a priority and aim at providing “Health for All in Year 2000”. One of the aforementioned challenges lied on retrieving the old “family doctor” spirit. In order to reach this goal, medical teachers should encourage the development of overall skills and the ability to understand diseases based on their biopsychosocial context ⁹ .

The National Curriculum Guidelines (NCGs) for the 2014 Medical Graduation Course, by the Ministry of Education and Culture established overall humanitarian medical education based on the following terms: “professionals qualified to work at different healthcare levels, with responsibility, and committed to defend citizenship, human dignity and universal access to health” ⁷ .

NCGs aim at ensuring the flexibility, creativity and responsibility of discipline matrix proposals from higher education institutions. The comprehensiveness principle is a way to achieve proper healthcare, since it takes into account the source of suffering. Students should be able to follow a non-reductionist approach in order overcome explicit complaints and to not suppress patients’ suffering ³ , ⁵ , ⁷ .

Working based on the Comprehensiveness and Expanded Clinic principles means fostering new “doings”. The term “psychosocial” defines practices aimed at replacing the dominant psychiatric care model, so far ¹⁰ .

Work aspirations are supposed to be guided by values such as professional autonomy and protagonism, co-responsibility, solidarity bonds, and collective participation in management processes ¹¹ . However, this approach is challenged by medical schools’ disregard to mental health issues ⁶ .

Universities have suggested the holistic approach, which prioritizes student-oriented training and vertically-aligned mental health content throughout discipline matrix, as the alternative to mental health disregard. Healthcare should go beyond the mind and body dichotomy, as well as take into consideration disease etiologies such as: emotional struggles, doctor-patient relationship, and environmental and social factors, since mental health struggles are prevalent across society. Such etiologies substantiate the importance of exposing students to a wide range of mental health conditions ¹² , ¹³ .

Students must be in touch with psychologically ill patients in healthcare settings since the first years of college in order to achieve comprehensive care. Therefore, the aim of the present study was to assess students’ educational dimension in mental health settings through photographs and focus group discussions.

Methodological path

The present study was based on social psychology theories focused on social phenomena; likewise, this type of approach enlightens the meanings and intentions separating social from natural phenomena. The aforementioned theories favor the comprehensive approach, rather than the cause-and-effect one, in interpretations about psychosocial phenomena ¹⁴ .

Photography is closely linked to qualitative research strategies because it helps describing events and understanding their subjective aspects. Moreover, photographs can be inductively understood ¹⁵ ; images captured in photos enable the study about life aspects not expressible by words, alone.

The Photovoice method, which was chosen and adapted for the present research, was developed by Wang et al. ¹⁶ in the mid 1990s. It allowed people to portray and share community experiences through a specific photography technique. The method gives voice to people since it lies on providing cameras to citizens so they can become reporters and the potential catalysts of political and social changes within their own communities ¹⁶ , ¹⁷ .

The critical pedagogy of Paulo Freire (1970 apud Wang ¹⁶ ) was one of the essential ideas underlying the theoretical body of this methodology. He advocated that “every human being, no matter how “ignorant” or “immersed in the culture of silence”, is able to hold a critical and dialectic outlook of the world around it and of the relationships it maintains” (emphasis added).

Furthermore, Photovoice is defined as a participatory action research approach that encourages people to take photographs of their experiences and discuss them as members of a particular community or group. Hence, the general population has the chance to hold accountable authorities and researchers through photographs and accompanying reports ¹⁷ - ¹⁹ .

Photovoice has been applied not only to community research, but also to several knowledge fields for more than two decades. The literature has only few examples of projects that have used photographs as the tool to set broader dialogues and boost social change in the health and education fields. The growing expansion of Photovoice supported the original remark by Wang and Burris ¹⁷: the reflective discussion about photographs encourages critical dialogues about specific issues of interest to researchers ²⁰ .

A study was carried out in Canada from 2010 to 2011 with four family and community medicine residents, two medical supervisors and two researchers (an anthropologist and a medical professor). The residents had to photograph their primary health care routine, choose five photographs portraying the topic and attend an interview and debriefing sessions with the researchers ²¹ .

A 2016 European essay focused on investigating the contributions of Photovoice to education; based on its conclusion, this method has benefits such as access to settings and subjective experiences that are harder to be understood through retrospective or observational research; student engagement to research process; real academic experiences; and reflection on teaching and learning processes ²² .

The herein adopted focus group method aimed at giving meaning to photos taken by the participants and at broadening the dialogue between facilitator and participants.

Focus groups are particularly useful for reflecting upon social and cultural realities because it helps accessing experiences, meanings, interpretations, behaviors, opinions, knowledge and beliefs given its qualitative profile ²³ . The greatest advantage of data collection through focus groups lies on the chance to form opinions and behaviors through discussions with others ²⁴ .

The present study was carried out between 2017 and 2018, data were collected in a rural city in São Paulo State, which presented estimated population of 344,704 people in 2016. A private medical school was launched in the city in 2012. The pedagogical school project embraced active teaching methodologies and followed the NCG guidelines ⁷ . The aim of the project was to prepare professionals to act according to scientific and humane values. The theoretical-practical discipline known as “Introduction Program for Family Health Education (IPFHE)” is taught from first to eighth semester in order to introduce students to public health networks and municipal hospitals through progressive complexity tasks.

Participants featured in Table 1 were chosen by convenience. A group of six IPFHE students enrolled in the 6th semester of medical school was invited to participate. After signing the Informed Consent Form (ICF), they attended two meetings for technical training. They were asked to focus and to take photos with their smartphone cameras to portray their daily lives as mental health care students.

Table 1
Participant profiles based on sex, age, marital status and education.

Participant	Sex	Age	Marital status	Education
JE	M	28	Married	Secondary
LO	F	28	Married	Secondary
RO	M	23	Common-law marriage	Elementary
TH	F	23	Single	Elementary
PRI	F	23	Single	Elementary
WE	M	22	Single	Elementary

Source: Elaborated by author.

Results and discussion

The project was submitted to the Human Research Ethics Committee, according to Decision N. 466/12. It was registered under CAAE N. 68579917.0.0000.5495 and received approval N. 2,261. 870.

The group took 32 photos, in total. Participants were asked to choose the two most significant photos and to assign a title and to give meanings to them at the initial interview. The representative photos were discussed in two focus group meetings led by the main researcher. The reports and collective voices accompanying the exhibitions were digitally recorded and fully transcribed.

The coverage of the Photovoice method brought challenges to researchers who used creative handicraft work as research resource applied to the images that had symbolic potential and ability to capture emotions impossible to be expressed in words.

The Sensory Interpretation Method ²⁵ was used to interpret the produced material. The interpretation process was defined as follows: thoroughly analyzing the collected dataand identifying themes, problematizing and interpreting meanings underlying the narratives and, finally, providing conclusion.

The research material was divided into two themes: Introduction to Health Care Practice and Medical Education in Action, which were intertwined and applied to mental health care settings in Franca City. Comprehensive dialogue was considered the basis of Medical Education in Action; therefore, the themes were developed based on the relevant literature of their scientific field.

Photographs: images and reflections

“Camera is a tool that teaches people to see without a camera.” (Dorothea Lange)

Introduction to health care practice and medical education in action

“The appalling reality of things is my everyday discovery.” (Alberto Caeiro)

The expansion of learning spaces beyond specialty hospitals is one of the ideas to reshape the educational model; this expansion implies new work experiences with humanitarian approaches and the development of interdisciplinary curriculums. Knowledge production, professional training and service provision must be deemed inseparable; accordingly, the relationship between universities and different social groups must be redefined in order to build a new and relevant social setting committed to overcoming inequalities and to consistently fulfill social demands ⁶ , ²⁶ .

NCGs provide a broader definition of health. The combination of courses into integrated discipline matrices is a desirable option to overcome disciplinary models since they add relevant and inspiring themes to these matrices frameworks. Therefore, the association of learning environments with health services and social settings of professional training can overcome the gap between theory and practice ²⁶ , ²⁷ .

Context 1: psychiatric hospital

Figure 1
Zero privacy

This image opened the theme Psychiatric Hospitalization, which was portrayed by the first photographs chosen during focus group discussions at the Psychiatric Hospital. According to the reports, this and other images seemed to convey an evident claustrophobic tension. The raw display may have been a way to bring up topics often left out of psychiatry manuals: patient’s multiple layers of suffering and health professionals’ sense of helplessness.

Group: Oh, this one is distressing! [...] It’s deep! We were at the Psychiatric Hospital learning mechanical restraint; there were nail scratches on the walls, the beds are attached to the floor, bars on the windows, an iron door, monitored twenty-four hours [...]. Escorted entrance, I felt like I was in prison [...]. Authorized arrest! Zero Privacy.

Group: Ah, the Hospital as a whole is depressing, the patients don’t have any control over their life anymore, no freedom for anything, trapped in a ‘prison’ authorized by justice. [...] It’s definitely a need, but it’s so sad, the disease takes over, to the point the patient is not seen as a citizen anymore, because he doesn’t contribute to society anymore, it’s a desolate place, I was shocked to see it. [...] We read the Psychiatric Reform theory about the need to build a care network, but we couldn’t imagine it was like that, I think about people being in that situation and not being able to leave, because it’s not always an option, right?? Mental illnesses can be really disabling.

All voices agreed that the Psychiatric Hospital is no longer a place in time and space. The introduction of students to private hospital spaces is the strategy to sensitize them for academic knowledge production; however, experiences must be given a voice, listened to and transformed so that their potential can be fulfilled. All participants called for the need of going beyond the first impact and of thinking about assistance on a broader perspective, since the “health vs disease” model is unsuitable for grasping the overall dimension of mental illness. Students who come across this unknown reality are invited to understand disease beyond their nosological features; they assess the suffering, inabilities and boundaries of a health care model that calls for “Reformation” ²⁵ .

Practices based on the comprehensiveness and expanded clinic principles are tools to build new ethics in mental health care. The “medicalized psychiatric hospital-centered” model has been gradually replaced by the psychosocial model ² , ⁵ , ¹⁰ . This replacement implies levelling the old hierarchy of knowledge, cooperation among care givers and favoring human-to-human knowledge (‘unknown’ and unconscious) over “encyclopedic knowledge” ¹⁰ .

Figure 2
Peace

The second photo representing this scenario did not even look like it was taken in the same claustrophobic and hostile place as the previous one. The sequence of themes proposed by the focus group pointed towards the double potential of the initial shock. The same experience can either overwhelm and render its essence unfeasible, or expand comprehension possibilities and foster students’ cognitive and emotional growth when they discuss and give meaning to their experience.

Facilitator: Do you think the visit raised awareness and helped you better understand the boundaries of mental illnesses and the difficulties of treatment?

Group: Definitely, because the patients there are very different from the person you’re going to see in the office [...]. Such hospitalization, with an indefinite prognosis, it’s so extreme. [...] So it definitely makes you aware, and to think you can get to this point, it’s sad, like ‘can any of us develop a mental illness tomorrow and deal with it?’, so shocking [...]! This photo shows people walking across the garden, a beautiful place, with good energy; even inside, there wasn’t a lot of noise, it was ‘awesome’ walking around and we made small talk all the time (laughs). [...] We were really at peace after the commotion at the start of the visit; I think patient care is supposed to help patients find peace again.

Ayres ²⁸ sheds light on the caregiving issues; the author addresses it as a health practice and describes it as the attitude of launching yourself into the world, but constantly redefining yourself and the world. The author states that caregiving can be therapeutic if its existential meaning is actively sought after. Participants recovered the balance of mental health care, and differences became familiar, when they put themselves in the shoes of others (“can any of us develop a mental illness tomorrow and deal with it?”). The close contact with patients rose interest in the existential sense of physical and mental illnesses; hence, students were able to find out possible health recovery practices that could help life rescueing.

Facilitator: And do you think that you talk a lot in stressful situations to try and ease the stress a little?

Group: A kind of relief, you mean? We feel a certain uneasiness, so we need to vent [...]. On the way to the hospital, we talked to the social worker that was accompanying us, she said she’d been working there for 20 years. She said she likes what she does, and she thinks it’s very important; I noticed that you gotta be skilled and dedicated to work there, it’s no use being ordinary... You can’t say ‘I’m going to take this job ‘cause I’ve got nothing to do’, you gotta trust yourself and give it your best, she made ‘it’ very clear.

Medical career as a choice implies responsibility and, consequently, it demands systematic reviews of concepts and values. The medical career is based on the sense of humanization, which is defined as the reason of each individual to be involved in the health provision process ⁹ . Accordingly, the literature adresses psychosocial care as an ethical, theoretical and political reference of the Psychiatric Reform movement in Brazil, as well as a realistic approach to mental health care ²⁹ .

The connection between rationality and sensitivity seems a possible measure to redefine health and illness; however, this connection is challenged by theoretical and political tensions. Therefore, effective public health management should be achieved through speeches and practices leading to new and broader approaches in scientific knowledge ⁸ , ³⁰ .

Context 2: therapeutic community

Figure 3
Needed Peace

Group: Now, this photo is from the Community, it’s humble but very beautiful and quiet, away from the city, no traffic, no noise [...] So I think the environment will help people to recover, they really need it, peace [...]. All patients enter the hospital by themselves, willingly, and they need to think about their own choices to become recovered, clean addicts.

Chemical addiction can be treated within “nonviolent” contexts, in healthy environments suitable for rehabilitation. This concept has broadened students’ outlook on dignified care to vulnerable patients subjected to psychoactive substances. On the other hand, some of these students’ speeches could be considered thoughtless and disregarded from others; saying “needs to think about their choices”, sounds like blaming the victim and disregarding several other layers of addiction. Confined addicts cause less discomfort than homeless addicts; thus, society does not understand “clean” as a threat.

Basaglia ³¹ mentions institutional violence in closed institutions, the author explains how they steal the freedom and recovery chances of hospitalized patients. Violence and exclusion are “justified” by an alleged educational and hierarchical separation of those who have power from the ones who do not. Human, egalitarian and welfare rights are disregarded by such separation.

According to Basaglia ³¹ , the Psychiatric Reform in Brazil brought about changes in the mental health context, especially in Psychiatric Hospitals, by developing alternatives to inpatient care. However, confinement remains the preferred option for alcohol and drug addicts; although this context is not as hostile as the ones addressed above, social exclusion remains blatant.

Group: We get there and get really impressed by the place, by the therapeutic pillars: faith, work and discipline; but then we check the statistics and the post-discharge abstinence rate is very low. Then we wonder, ‘Is there no other way’?

Group: We had read the references about the types of addiction treatment, but we couldn’t picture what a Community was really like. It’s interesting, the rotation: cooking, washing dishes, planting, taking care of the house [...]. ‘Labor therapy’, this type of activity, drug addicts under treatment should learn to follow a routine and have responsibilities. [...] But it’s still bad to be isolated from family and society

The mediated group formed opinions: When students looked more deeply into the “perfect” landscape, cleanliness and organization, they saw the negative side of hospitalization and expressed new thoughts (“Is there no other way?”; “It’s bad to be isolated”). A dialogue process is established by looking at photos, and by talking and listening about them. The meeting of voices in a lively and practical interaction gives meaning to experiences and theories. These are important steps towards “being a doctor”, complex human issues require the ability to see beyond physical laws and biological reductionism. After all, students allowed themselves to embrace the overall dimension of mental health care.

Group: Life stories are very diverse and sad. There were people like us there, with family, an education, who got into drugs at college [...]. There were other really tragic life stories, like the old man that said his mother was a streetwalker, he had never met his father, he was abandoned when he was 8, lived on the street and started to sniff glue as a child, he lived in Cracolândia. [...] That’s why treatment looks so hard, they are people with troubled backgrounds and I’m not sure if praying and working would be enough to help them recover.

Facilitator: [What about] alternative options?

Group: Lots of therapy, medical assistance... And a place where they could live, as in the case of that man.

Facilitator: Bonds?

Group: I think so. If nobody loves you, what is the point of living?

Edgar Morin ³² (XX century) claims that knowledge is built through dialogue, which makes comprehension go beyond surface and towards the essence. He proposes the redefinition of thought and invites readers to abandon the ruins of the building constructed under the pillars of fragmentation, hyperspecialization and reduced knowledge. Morin suggests that educational “folders” must be opened so that knowledge can be thoroughly explored.

Introduction to real, dynamic and complex contexts in the first years of medical school is key to achieve mindsets able to overcome narrow simplifications. Ethical-humanitarian medicine requires the applicability of complex thinking: the expression of unified and multiple ideas as a whole, and the elimination of simplistic, reductionist and disjunctive ideas.

[...] First stage of complexity: We have basic knowledge that does not help learning the properties of a whole. Banal findings have non-banal consequences: tapestry is more than the sum of threads that make it. A whole is more than the sum of its constituent parts ³² . (p.103)

Context 3: psychiatric emergency

Figure 4
: Emergencies

The photo shows the façade of the building whose Psychiatric Emergency was visited by the participants. The focus group went silent and hesitated to speak up at the moment the photo was taken.

Facilitator: [silence] It was there, at psychiatric emergency, that they met Guilherme (real name withheld). What did you think of his story?

Group: The young man from Fundação Casa? It was kind of shocking! He’s had three psychiatric admissions and none worked. [...] He said he did drugs and had lots of relapses, his mother helped him and said she used to be very worried about him, but now she gave up because it’s really hard; Last time, he left home for 3 days. [...] And his father died.

Facilitator: Did you hear that, when his father died of cancer, he promised on his deathbed not to use drugs anymore?

Group: Yes, and that he had already relapsed, he felt guilty, that was a huge frustration for the family [...]. It looks like that’s why he gave up living and taking care of himself, out of guilt; he had stopped eating, he was drawn. [...] So I keep thinking that there’s no point in admitting, giving medicine, he may take them while he’s at the institution, but what hope does this young man have? Emotional wellbeing, relationships, good character: Looks like he’s lost everything! [...] He has even participated in murder.

Facilitator: Do you see an alternative to these ‘Guilhermes’?

Group: We realized that family needs to be together for the sake of recovery. [...] And not only family, but a ‘multiteam’. You have to take care of the family too, to think of this mother’s situation, without a father and having a child like that? And work is important, he said he was a joiner, he learned it from his father, looks like he had talent!”

Life stories like Guilherme’s seem to be hidden in the untouchable corners of memory, where everything hard and painful to be processed is isolated. Only the facilitator could help rescuing the story, so that details and underlying suffering in the patient’s report could emerge.

Such life stories make students see a broader health care concept that includes not only the role of patients, but also the role of family members, teams and health services. Thus, the core of medical practice, historically supported by biological and curative knowledge, changes into a universe of health promotion and prevention actions. Such actions encompass the comprehension of social determinants and the interaction of health services with different societal levels and settings ²⁸ .

Disease-oriented medicine proves to be insufficient to provide the care demanded by many “Guilhermes”. Standards need to be challenged, and society must stop blaming victims as the only individuals accountable for their own choices. Brazilian discipline matrices must include teachers, managers and SUS network professionals sharing different traits and qualifications, for such inclusion could foster the interdisciplinarity and comprehensiveness targeted by medical professionals ³³ .

Medical education is supposed to comprise patient-oriented care including the following traits: recognition of patients’ ideas and emotions towards their illness; common goals between doctors and patients. Sharing decisions and responsibilities mean a new path and the great potential of modern medical measures ⁵ , ³³ .

Conclusion

I am no superman,

I have no answers for you.

I am no hero,

And that’s for sure.

But I know one thing,

That’s where you are, is where I belong.

I do know

Where you go

Is where I want to be [...]

(“Where Are You Going”, Dave Matthews Band, Busted Stuff, 2002)

Medical professionals belong to where the ‘other’ is; the main goal of medical education is to reach this ‘other’. Therefore, it is necessary to be present, to feel, to associate knowledge with action, to give life to experiences, to feel excitement, only then this medicine could make sense.

Medical education is supposed to be done by transit; Transitu , in Latin, refers to passage, movement. The permanent movement among knowing, doing and thinking is what motivates professionals to care about their job and to provide ethical-humanitarian care based on meaningful experiences. The transit between medical theory and practice raises awareness about the meaning-making process and the importance of connecting affective and cognitive dimensions for a good medical practice.

Medical competence is a complex term that encompasses cognitive, psychomotor and socio-affective learning, altogether. According to NCGs, the aim of skill acquisition is to provide humane, critical and thoughtful medical education, committed to social needs and aimed at providing comprehensive health care for human beings. Curricular activities must be enhanced in order to foster dialogue and to embrace the subjectivity of students throughout their educational journey.

Participants engaged in mental health care work in the city where there school is based in were able to think about their education and to express their thoughts. The process of leaving school to get in touch with reality proved to be a breeding ground for understanding theoretical concepts seemingly empty and unsupportive for “doctors-to-be” ^c . The photographed, reported and discussed experience brought life to education by taking students closer to the ‘human’ in them and in others.

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• c
  Donald Woods Winnicott (1896-1971).
• Translator: Good Deal Consultoria Lingüística

Publication Dates

• Publication in this collection
  22 Apr 2020
• Date of issue
  2020

History

• Received
  04 June 2019
• Accepted
  21 Dec 2019