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A (unit organization)
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| A1 |
Physical space |
Medical offices |
MRP1 and MRP6: construction of school units that accommodate residents and students (grade 4). |
MRP2: Insufficient number of rooms to accommodate all attending physicians plus the resident (grade 1). |
MRP2: resident: there is a lack of one room - six office rooms to be distributed among seven people, with one always without access (not experienced in the residency due to the absence of a professional with schedule - COVID room schedule). Municipal management: there is an office rotation, and it is not possible to guarantee the office for 100% of the required time. |
| Procedures |
MRP3: activities developed at secondary level (with a greater number of materials and procedures) and matrix support of specialist professionals in Primary Health Care (PHC) to expand actions in the unit (grade 4). |
MRP2: cytology - nursing only, collection. MRP5: It is not agreed that primary care performs procedures, except IUDs and ear washes. Lack of material to perform small procedures in PHC, purchased with funds from the preceptor (when the preceptor wishes to do so) (grade 1). |
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A (unit organization)
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| A2 |
Unit schedule |
Resident’s schedule |
MRP1 and MRP6: preceptors present 40 hours, and always available (even if the undergraduate students are present at the same time - preceptor’s schedule) (grade 4). |
MRP2: CLT (Consolidation of Brazilian Labor Laws) contract for 15 hours, sharing the team with the preceptor (mandatory target of 20 hours of consultations, home visits, etc.). To achieve this goal, the optional internship outside the unit was suspended. Discussion of cases via WhatsApp, as the preceptor has a simultaneous schedule, with a common schedule of 20 hours/week. Meeting schedule is protected (grade 1). MRP4: second-year residents stay alone in rural units. The two preceptors are hired for 20 hours/week for two units and all the residents. Case discussion 1 hour per week. The schedule of visits and meetings depends on the care demand and “directions from the health secretariat” (grade 1). |
MRP2: management’s perception that the resident has 35 hours to reach the goal of 20 hours, making it feasible to see and discuss cases, regardless of the organization and the preceptor’s simultaneous schedule. Consultations scheduled every 15 minutes, and rarely meets the preceptor during the week (resident). There have already been discussions with management regarding the residency to “do the job” versus learning (residency preceptor/supervisor). MRP4: management’s perception that there is a guideline to maintain home visits and time for case discussion, which is sufficient. Resident and program supervisor report guidance from the municipal secretariat to suspend home visits, team meetings and case discussions to the detriment of direct assistance. |
| Population size |
MRP1: maximum 3,000 (grade 4). MRP2 and MRP 5: 3,000-3,500 (grade 4). |
MRP3: 5,000-7,500 (grade 1). MRP 4: 3,500 (takes over team) to 5,000 (grade 1). |
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| A3 |
Management-residency ratio |
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MRP6: management does not interfere with the unit’s schedule or volume of care, even if the resident receives a scholarship. Perception of support and joint construction. Difficulty in structuring human resources in the units (temporary) and exchanging information between the health secretariat and the university (grade 3). |
MRP2: see resident’s schedule. Guidelines and organizations by the municipal management (grade 1). MRP5: problems between the residency and the health unit management, mainly due to political appointments by non-technical people. Sudden changes to schedules without agreement. The increase in resident numbers in the last year has disorganized the structure of the MRP-FCM in the municipality (perception of the resident, preceptor and supervisor). The manager believes that the increase in resident numbers has made the environment less harmonious, making it more difficult to control all units with more residents (grade 1). |
MRP2: The program supervisor’s perception was that the management listened to demands but did not change due to the difficulties caused by the pandemic. The resident’s response was emphatic: no help was given in two years. |
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B (human resources)
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| B1 |
Preceptor is resident or has a degree in FCM |
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MRP5: mandatory hiring of preceptors with title/residency in FCM plus mandatory training in a preceptorship course (grade 4). |
MRP3: residency training in traditional basic units with a clinician, obstetrician-gynecologist and pediatrician, maintaining configuration to date, but with the presence of FCM specialists present in the unit (mainly with adult clinical work) (grade 2). |
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| B2 |
Complementary training |
Permanent education taking place at the Family Health Unit (FHU) |
MRP6: After the meeting with the team , there is a discussion of topics relevant to the unit (generally chosen by the team, but also chosen by the resident/preceptor), but with a decrease during the COVID-19 pandemic (grade 3). |
MRP3: pressure from the municipal secretariat for assistance to the detriment of team training (grade 0). MRP4: presence of continuing education verticalized by the health secretariat, via remote learning, but with low access and difficulty in organizing the network (grade 0). MRP6: the management offers spaces on the schedule for continuing education, but not all teams use them, they just close the agenda (grade 3). |
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| Continuing education / Release for activities |
MRP1 and MRP6: release of the preceptor upon agreement and prior notice to the Municipal Health Secretariat, considered as the right of the worker/professional (grade 4). |
MRP4: presence of continuing education verticalized by the health secretariat, via remote learning, but with low access and difficulty in organizing the network. Ordinance during the pandemic preventing the release of professionals for courses (grade 0). |
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| B3 |
Theory about FCM |
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General: classes in the first year on the FCM specialty and work in family health units with FCM specialists (grade 4). MRP6: assessment of the curriculum in the residency exam to verify whether the residency candidate knows the specialty (grade 4). |
MRP3: presented in the first week of activity, but all activity takes place in basic health units with a standardized model (clinician, obstetrician-gynecologist and pediatrician in family health units) (grade 2). MRP4: matrix support of gynecologists and pediatricians for the MRP-FCM, with no counterpart in the volume of care for these professionals (grade 3). |
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B (human resources)
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| B4 |
Financial support (grant) |
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General: payment of a grant in addition to the salary to work as a preceptor, by carrying out the activities: theoretical classes, practical classes, number of residents under their supervision, among others (grade 4). |
MRP2: no financial support to be a preceptor at the unit, but receives payment for classes held at MRP-FCM (grade 1). MRP4: preceptorship grant type of contract, without receiving a salary to be a preceptor and/or doctor at the unit (grade 1). MRP5: variable subsidy according to the number of residents (1-5) and number of classes offered at MRP (grade 4). |
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C (preceptor-resident ratio)
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| C1 |
Three residents per preceptor (first and second year) |
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MRP3 and MRP5: variation of two to four residents per preceptor, most preceptors with a maximum of three residents (grade 3). |
MRP4: two preceptors for 14 residents (grade 0). |
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| C2 |
Five students per preceptor (resident and undergraduate students) |
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MRP1: maximum of three students for the two preceptors, plus the four residents, with students attending the preceptor’s schedule (grade 4). MRP2: the residency preceptor does not work with the undergraduate students, by contractual definition with the university (grade 4). |
MRP4: Even without undergraduate students together with the residency, the average is seven students (residents + undergraduate students) per preceptor (grade 0). MRP5: there is an excessive number of medical courses that use the network as an internship field every year, increasing the number of students under the preceptor’s supervision, who shares the preceptorship of students with second-year residents (grade 0). |
MRP6: It is common for the university to include undergraduate students in PHC without consulting the municipal secretariat about the possibility of using the unit, precisely because the residency preceptor is a medical undergraduate teacher in the same unit (grade 4). |
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Source: Created by the autors.