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OBJECTIVE: To assess the MEWS association with the clinical outcomes (CO) of patients admitted to an internal medicine ward (IMW) at a Brazilian university hospital (UH). INTRODUCTION: It is important to quickly identify patients with clinical deterioration, especially in wards. The health team must recognize and act before the situation becomes an adverse event. In Brazil, nurses' work to overcome performance myths and the application of standardized predictive scales for patients in wards is still limited. DESIGN: An observational cohort study designed and developed by a registered nurse that followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist. METHODS: Data were collected from the IMW of a UH located in the city of São Paulo, Brazil (2017). An ROC curve was calculated to strengthen the use of a MEWS of < or ≥ 4 as a cutoff. CO of the two subgroups were compared. RESULTS: Three hundred patients completed the study; their vital signs were recorded consecutively throughout hospitalization in the IMW. The highest MEWS value each day was considered for analysis. Scores < 4 were significantly associated with a higher probability of hospital discharge, a lower chance of transfer to the ICU, a lower total number of days of hospitalization, and a lower risk of death. Score ≥ 4 had worse CO (orotracheal intubation and cardiac monitoring), transfer to the ICU, and increased risk of death. CONCLUSION: Scores < 4 were associated with positive outcomes, while scores ≥ 4 were associated with negative outcomes. MEWS can help prioritize interventions, increase certainty in decision-making, and improve patient safety, especially in a teaching IMW with medical teams undergoing professional development, thereby ensuring the central role of the nursing team in Brazil. RELEVANCE FOR CLINICAL PRACTICE: MEWS aid nurses in identifying and managing patients, prioritizing interventions through assertive decision-making.

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ABSTRACT BACKGROUND: Residents play the role of teachers in almost one-quarter of their activities in residency programs. OBJECTIVE: To evaluate whether a 45-minute class using summarize, narrow, analyze, probe, plan, and select (SNAPPS) could improve psychiatry residents' case discussion skills in diverse practical learning settings. DESIGN AND SETTING: This case-control, randomized, blinded study was conducted in a psychiatry hospital at Fortaleza-Ceará. METHODS: Using "resident as teacher" (RaT), objective structured teaching encounters (OSTEs), and SNAPPS, we conducted a study with 26 psychiatry residents. We analyzed video footage of psychiatric cases in three settings: outpatient, nursing, and emergency. An intervention was held two months later with the residents, who were then assigned to two groups: group A (lecture on SNAPPS) and group B (lecture on a topics in psychiatry). Shortly after the lectures, they were video recorded while discussing the same cases. Three blinded examiners analyzed the videos using an instrument based on the Stanford Faculty Development Program (SFDP-26). RESULTS: We found high internal consistency among external examiners and an interaction effect, group effect, and moment effect (P < 0.05). The residents who received the SNAPPS lecture scored significantly higher than their counterparts who received a traditional case presentation. CONCLUSION: This study indicates the efficacy of SNAPPS over traditional case presentation in all three settings as assessed by OSTEs and supports its implementation to improve the teaching of clinical reasoning.

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BACKGROUND: Residents play the role of teachers in almost one-quarter of their activities in residency programs. OBJECTIVE: To evaluate whether a 45-minute class using summarize, narrow, analyze, probe, plan, and select (SNAPPS) could improve psychiatry residents' case discussion skills in diverse practical learning settings. DESIGN AND SETTING: This case-control, randomized, blinded study was conducted in a psychiatry hospital at Fortaleza-Ceará. METHODS: Using "resident as teacher" (RaT), objective structured teaching encounters (OSTEs), and SNAPPS, we conducted a study with 26 psychiatry residents. We analyzed video footage of psychiatric cases in three settings: outpatient, nursing, and emergency. An intervention was held two months later with the residents, who were then assigned to two groups: group A (lecture on SNAPPS) and group B (lecture on a topics in psychiatry). Shortly after the lectures, they were video recorded while discussing the same cases. Three blinded examiners analyzed the videos using an instrument based on the Stanford Faculty Development Program (SFDP-26). RESULTS: We found high internal consistency among external examiners and an interaction effect, group effect, and moment effect (P < 0.05). The residents who received the SNAPPS lecture scored significantly higher than their counterparts who received a traditional case presentation. CONCLUSION: This study indicates the efficacy of SNAPPS over traditional case presentation in all three settings as assessed by OSTEs and supports its implementation to improve the teaching of clinical reasoning.

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Com a maior possibilidade de conhecimento e acesso a informações, o paciente deixa de ser uma parte passiva no relacionamento médico-paciente, sendo a cada dia mais contestador e argumentativo a respeito de seus diagnósticos e terapêuticas instituídas. Parte destes questionamentos, principalmente no que diz respeito a intercorrências médicas, acaba por desgastar esta relação, fenômeno que tem sido descrito como um potencializador na judicialização dos conflitos médicos no mundo. Com esta trajetória, assistiu-se de perto a um afastamento nessa relação médico-paciente, não apenas com um público geral mais desconfiado das prestações de serviços, mas também um médico mais desgastado, com posturas defensivas, hiperespecializado e, consequentemente, mais técnico e formalista do que humano e empático. O reforço na informação médica e na comunicação entre as partes é um sinalizador forte no que se pensa de uma profilaxia jurídica nas prestações de serviços médicos. Ainda assim, intercorrências ocorrem, e posturas diversas existem frente ao ocorrido. Quando isso ocorre, temos hoje a possibilidade de contar com um grande sistema jurídico dito "multiportas", capacitado a abrigar a contingência necessária, a depender do diagnóstico nas relações entre as partes, para uma terapia jurídica adequada a cada situação em particular. Tal "terapêutica jurídica" pode dar-se por autocomposição, como os consagrados métodos de mediação ou conciliação, já não estranhos à área da saúde, ou por métodos heterocompositivos, e, entres estes, a já conhecida tutela Estatal e a Arbitragem, por autonomia da vontade das partes desde que o direito a ser discutido seja disponível.

Highly empowered by knowledge and available information, patients are no longer a passive part of the patient-physician relationship but become more challenging and argumentative about their diagnoses and prescribed therapies. Part of the issues, especially regarding medical complications, may weaken this relationship, a phenomenon that has been described to enhance judiciary litigation against physicians worldwide. With this trajectory, there was a distance in this medical relationship. In this perspective, a wedge has been placed within the patient-physician relationship, delineating on one side a general public more suspicious of the services provided, and on the other side, a more worn-out doctor, with a defensive stance, hyper-specialized and consequently more technical and formalistic than humane and empathic. The reinforcement of medical information and communication between the parts strongly signal what is considered legal prophylaxis in medical services. Even so, complications do occur, and different attitudes do exist in the face of what may have happened. When this happens, one can count on a large legal system called "multi-doors," able to accommodate the necessary contingency, depending on the diagnosis in the relations between the parts, for a legal therapy appropriate to each particular situation. Such "legal therapy" can occur by self-composition, as are the established methods of Mediation and Conciliation, no longer foreign to the health area, or by heterocompositive methods, among which are the already well-known methods of judicial adjudication and Arbitration.

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Abstract: Introduction: Mini-CEX is an evaluation method that covers the domains: anamnesis, physical examination, counseling, clinical judgment, organization, and professionalism. It has been tested and validated for use in any practice scenario. With its characteristic of providing feedback after a clinical assessment, the Mini-CEX can also be used as a training method to guide the professional development of students and teachers, promoting greater knowledge retention in undergraduate students and continuously providing information for students to realize how far they are from the desired objectives. The aim of this study was to assess the perception of interns, residents, and preceptors of Internal Medicine (IM) regarding the Mini-CEX instrument. Methods: Qualitative study, using the focus group technique, carried out from February to July 2017. Twenty interns, thirteen residents, and five IM preceptors participated. It consisted of six focus groups, two with interns, two with residents, and two with preceptors, using semi-structured questions that identified perceptions, through the methodology used, on the quality of the evaluation and possible repercussions for the teaching-learning process. Results: In the focus group of interns, the feedback moment of the assessment was considered essential for the learning process, although the bedside assessment was tense due to the preceptor's presence. The residents reported that the evaluation was a valid one, as it led them to review some points in the medical literature, in addition to stimulating clinical reasoning in the face of a real situation. The preceptors validated the importance of the feedback for those who were evaluated and identified the bedside assessment as a moment for the best analysis of the individualities. Conclusion: Through the perceptions of the groups in focus, the mini-CEX was identified as a fundamental instrument for the teaching and learning process of all those involved and the need to structure the moment of feedback aiming to attain a more effective result. During the bedside assessment, the stimulus to clinical reasoning was identified as a positive point and the strangeness, anxiety, and tension as negative points.

Resumo: Introdução: O Mini-CEX é um método de avaliação que abrange os seguintes domínios: anamnese, exame físico, aconselhamento, julgamento clínico, organização e profissionalismo. Foi testado e validado para utilização em qualquer cenário de prática. Com sua característica de fornecer feedback após uma avaliação clínica, o Mini-CEX também serve como um método de formação para guiar o desenvolvimento profissional de formandos e formadores, promovendo maior retenção de conhecimento no corpo discente e fornecendo, continuamente, informações para que o estudante perceba o quão distante está dos objetivos almejados. O objetivo deste estudo foi verificar a percepção de internos, residentes e preceptores da clínica médica (CM) sobre instrumento Mini-CEX. Método: Trata-se de um estudo qualitativo realizado pela técnica de grupo focal no período de fevereiro a julho de 2017. Participaram 20 internos, 13 residentes e cinco preceptores de CM. Constituíram-se seis grupos focais, dois com os internos, dois com residentes e dois com docentes, com perguntas semiestruturadas que identificaram as percepções, por meio da metodologia empregada, na qualidade da avaliação e eventuais repercussões para o processo de ensino-aprendizagem. Resultados: No grupo focal dos internos, o momento de feedback da avaliação foi considerado essencial para o processo de aprendizado embora a avaliação a beira-leito tenha se mostrado tensa pela presença do tutor. Os residentes relataram que a avaliação foi válida, pois os levou a revisar alguns pontos da literatura médica, além de estimular o raciocínio clinico diante de uma situação real. Os preceptores validaram a importância do feedback para os avaliados e identificaram a avaliação a beira-leito como momento de melhor análise das individualidades. Conclusão: Por meio das percepções dos grupos em foco, identificamos o Mini-CEX como ferramenta fundamental para o processo de ensino-aprendizagem de todos os envolvidos e a necessidade de estruturação do momento de feedback para um resultado mais eficaz. Durante a avaliação a beira-leito, foi identificado o estímulo ao raciocínio clínico como ponto positivo e o estranhamento, a ansiedade e a tensão como pontos negativos.

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BACKGROUND: There are plenty of options for evaluating medical students and medical residents' clinical skills. Objective structured clinical evaluations (OSCEs) have emerged as a powerful and reliable tool for assessing multiple cognition domains of clinical expertise. In the same way as OSCEs have emerged to assess clinical skills, objective structured teaching evaluations (OSTEs) have come to light as promising and unbiased interventions for evaluating the act of clinical teaching. DESIGN AND SETTING: Narrative review developed at Universidade Federal de Uberlândia, Brazil. METHODS: We searched the literature regarding OSTEs using the MEDLINE (via PubMed) and LILACS (viaBiblioteca Virtual em Saude) databases. The SciELO library was also searched for Brazilian papers. Systematic reviews, reviews and randomized controlled trials specifically assessing how OSTEs performed in relation to development of academic staff and medical residents were then selected. RESULTS: Our search retrieved 178 papers, of which 40 were considered eligible for intensive review. Most of the studies selected reported positive effects from OSTE activities. However, there was little quantitative data to gauge the impact of OSTEs on improvement of teaching skills. CONCLUSIONS: Considering that OSCEs have become a widely used tool for assessing medical students' and residents' clinical skills, it is high time to incorporate OSTEs for evaluating teaching skills in Brazil. Encouraging data to support implementation of this assessment tool in this country is available from abroad. The net benefit from this would possibly encompass medical students, residents and academic staff, through bringing awareness about the importance of excelling in teaching skills.

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This paper aims to describe and analyze medical education in Brazil, a history of over 200 years. As in most European countries and influenced by the Flexner Report, an undergraduate medical course in Brazil takes 6 years. Recently, medical education research has been advocating a shift from a teacher-centered and hospital-based approach to student-centered and community-based education. Nevertheless, a huge variation exists among Brazilian medical schools. The physicians' supply program known as "More Physicians" has strongly impacted the number of medical schools in Brazil, which is growing rapidly. Professors of medicine from several institutions and other stakeholders have alerted authorities to the risks of operating so many schools without adequate time to prepare teachers, clinician-educators, curricula, and sufficient pedagogical structure to ensure quality medical education. The possibility of an imminent catastrophe in medical education has united stakeholders in pursuit of a guarantee of quality maintenance. This effort has resulted in the creation of an independent accreditation system approved by the World Federation of Medical Education. The study of the unbalanced relationship between stakeholders in medical education in Brazil until now has provided valuable information concerning the importance of having their roles and limits clear. It is possible that these findings might be replicable around the world.

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RESUMO A residência médica, instituída legalmente no Brasil em 1977 pelo Decreto nº 80.281, é considerada a melhor estratégia de ensino em cenário de prática, sendo o padrão ouro da especialização médica. A característica mais marcante da residência é o treinamento em serviço, que articula ensino no cenário de prática, além de construir um perfil profissional. Os residentes desenvolvem também a função docente. Pesquisas americanas estimam que exerçam tal função em boa parte de suas atividades, chegando a um quarto do período total de tempo de seus programas de residência. Esse processo de ensino-aprendizagem durante a residência ainda é pouco estudado, principalmente no Brasil. O objetivo deste estudo foi realizar uma ampla revisão narrativa sobre RaT (Resident as Teacher), tema pouco explorado na literatura brasileira, avaliando historicamente o processo de ensino-aprendizagem dos programas de residência médica. Foi realizada uma revisão na literatura acerca do processo de ensino-aprendizagem da residência médica no Brasil e no mundo. Diversos países estão implementando treinamentos formais de ensino denominados programas de Resident as Teacher (RaT). Somente nos EUA, mais de 50% dos programas de residência têm alguma forma de treinamento RaT. Vários programas foram desenvolvidos e se diferenciam no conteúdo, na duração e no formato, porém são baseados em atributos de ensino considerados essenciais ao ensino. No que diz respeito ao conteúdo, os programas RaT enfatizam predominantemente o modelo preceptor minuto (One Minute Preceptor - OMP), a estrutura de ensino clínico do Programa de Desenvolvimento da Faculdade de Stanford ou os domínios mostrados por Irby como essenciais à excelência em ensino clínico. Em conclusão, sugere-se que os programas brasileiros de residência médica invistam em estudos e, consequentemente, em estratégias efetivas para aprimorar as técnicas de ensino para médicos residentes.

ABSTRACT The medical residency program, legally established in Brazil in 1977, is considered the best practical teaching strategy and it's a gold standard to physician specialization. Resident, house officer and registrar are synonymous to refer to post medical training after internship, who attending a program or programme, depends on the region of the globe you are. The teaching of the residency training program is conducted during patient care in all settings (i.e., bedside teaching), which brings together teaching in a practical setting and the improvement of a professional profile. Residents also develop their teaching skills. American researchers estimate that residents acts as teachers in almost one quarter of their residency programs. This teaching-learning process hasn't been thoroughly studied, especially in Brazil. The aim of this study was to do a narrative review about Rat (Resident as Teacher), an issue not explored in the Brazilian literature, evaluating the teaching-learning process in the medical residency programs. A review in the Brazilian and worldwide literature was conducted. In many countries, several formal training courses are being implemented worldwide under the "Resident as Teacher - RaT" denomination. In the United States, more than half of the residency programs have RaT training. The developed programs are different in their approach, duration and format. However, they are all based on attributes considered fundamental for teachers. Regarding content, RaT programs emphasize the One Minute Preceptor (OMP) model, the clinical teaching structure of the Stanford Faculty Development Program, or the domains shown by Irby to be essential for the excellence of clinical teaching. In conclusion it would be important for Brazilian programs to develop studies and, consequently, effective strategies to improve RaT.