A formação da identidade do médico: implicações para o ensino de graduação em Medicina

O artigo discute a constituição da identidade do médico tendo como pontos de partida sua escolha e formação profissionais. A partir da experiência das autoras no ensino médico, em especial na disciplina de Psicologia Médica, e da literatura na área são enfocadas: a idealização do papel do médico, as motivações conscientes e inconscientes na opção profissional, as dificuldades dos primeiros anos na escola médica, o início das atividades didáticas no hospital e os mecanismos psicológicos defensivos acionados no contato com pacientes. É muito importante que as Escolas Médicas e seus professores tenham conhecimento desses aspectos, devendo preocupar-se não apenas com questões curriculares e pedagógicas, mas também com o modelo de relação professor-aluno, considerando o seu papel fundamental na formação da identidade médica.

Ligas Acadêmicas e formação médica: contribuições e desafios

Nos últimos anos tem havido um considerável aumento do número de ligas acadêmicas atuantes nos cursos de graduação em medicina no Brasil. Esse fenômeno, no entanto, não vem sendo acompanhado de adequada reflexão sobre seus determinantes, o papel das ligas dentro das instituições, ou mesmo sua função pedagógica. A partir destas constatações, os autores analisam a precária literatura sobre o tema, descrevem a experiência das ligas acadêmicas da Faculdade de Medicina de Botucatu - Unesp e refletem a respeito do papel destas na formação médica, na tentativa de suprir um pouco dessa lacuna e contribuir para esta importante discussão.

Avaliação do estudante: no exercício de avaliação da prática profissional

Este estudo aborda a avaliação do exercício da prática profissional (EAPP) no curso de enfermagem da Faculdade de Medicina de Marília (Famema); tem como objetivo analisar a concepção de avaliação do professor que realizou o EAPP com estudantes de primeira a quarta séries do curso. Trata-se de um estudo qualitativo, modalidade análise de conteúdo e identificação da seguinte temática: as ambigüidades do processo de avaliação. Constata-se que a concepção do professor na avaliação no EAPP aproxima-se muito da abordagem de competência dialógica, que articula e integra resultados, atributos e contexto em situações distintas, com diferentes formas de realizar tarefas essenciais para a formação do enfermeiro. Contradições no processo avaliativo entre os professores, porém, estão presentes e necessitam ser constantemente trabalhadas.

Hospital-dia: para quem e para quê?

OBJETIVO: Estudar prospectivamente a população internada em um hospital-dia (HD) em relação a fatores que poderiam influenciar na melhora e na duração da internação. MÉTODOS: Foram entrevistados, para obtenção de dados sociodemográficos e avaliação da evolução, 34 pacientes internados no Hospital-Dia da Faculdade de Medicina de Botucatu, Unesp, durante um ano. O diagnóstico psiquiátrico foi avaliado pela CIDI (Composite International Diagnostic Interview), a sintomatologia psiquiátrica pela BPRS (Brief Psychiatric Rating Scale) e a incapacitação psicossocial pela DAS (Psychiatric Disability Assessment Schedule). Todos os pacientes foram acompanhados, e seus familiares, entrevistados. RESULTADOS: Predominaram mulheres (76%), jovens (61,8%), sem vínculo conjugal (71%), sem trabalho (82,4%), com diagnóstico de transtornos afetivos (44,1%) e com internações psiquiátricas prévias (44%). Apenas quatro (12%) pacientes apresentavam uma síndrome maior segundo BPRS. Houve considerável incapacitação psicossocial dos pacientes em alguns papéis sociais. Maior renda per capita foi um fator associado à melhor evolução. As internações duraram em média 74 dias. Pacientes com internações prévias tenderam a permanecer menos tempo no HD. CONCLUSÕES: Portadores de transtornos afetivos e quadros não-psicóticos geralmente não necessitam de internação por período integral em hospital psiquiátrico. Contudo, os pacientes deste estudo tiveram um elevado número de internações psiquiátricas prévias, provavelmente por necessitarem de um nível de atendimento além das possibilidades dos ambulatórios. Entretanto, pacientes com maior número de internações -- em tese mais graves -- tenderam a permanecer menos tempo no HD, o que suscita dúvidas quanto à sua adesão a serviços abertos, bem como aos possíveis fatores facilitadores dessa adesão. em um momento de crescimento expressivo no número de serviços de internação parcial no Brasil, como nos últimos anos, mais estudos são necessários a fim de esclarecer para quem e para quê são destinados esses serviços.

AN ULTRASTRUCTURAL-STUDY ON THE ENDOCRINE PANCREAS OF CAIMAN-LATIROSTRIS, WITH SPECIAL REFERENCE TO PANCREATIC MOTILIN CELLS

Pancreatic endocrine cells of Caiman latirostris were investigated by electron microscopy using conventional and immunocytochemical methods. Ultrastructurally, four types of endocrine cells were classified according to the morphology of their secretory granules. Three types of endocrine cells were identified as either glucagon, insulin or somatostatin cells by the presence of such characteristic granules well established in mammals. The remaining endocrine cell type could not be classified by its ultrastructural features alone.Immunocytochemical observations confirmed the ultrastructural classification of glucagon, insulin and somatostatin cells. In addition, endocrine cells immunoreactive for either pancreatic polypeptide (PP) or motilin were identified. Morphometric analysis of PP- and motilin-immunoreactive granules demonstrated that they were the most polymorphous and smallest granules among the pancreatic endocrine cell granules. Although both PP and motilin granules closely resemble each other, motilin granules were smaller in size and more spherical in shape than PP granules.

MOTILIN-IMMUNOREACTIVE CELLS IN THE DUODENUM, PYLORIC STOMACH AND PANCREAS OF CAIMANS (CAIMAN-LATIROSTRIS AND CAIMAN-CROCODILUS, ALLIGATORINAE) - A FURTHER COMPARISON USING REGION-SPECIFIC MOTILIN ANTISERA

Motilin-immunoreactive cells in the duodenum, pyloric stomach and pancreas of Caiman latirostris and Caiman crocodilus were investigated using region specific antisera for porcine and canine motilin molecules. Motilin-immunoreactive cells were found in the duodenum, pyloric stomach and pancreas of both caiman species. These cells were primarily open-type endocrine ones in the epithelium of the duodenum and pyloric stomach. Motilin-immunoreactive cells were observed in both the exocrine and endocrine portions of the pancreas, and frequently exhibited one or more cytoplasmic processes of variable length. Since motilin-immunoreactive cells do not cross-react with serotonin or any of the other pancreatic and gut hormones, they are considered to be cell type independent from any of the other known pancreatic or gut endocrine cells. The molecular similarity between caiman motilin and porcine and canine motilins and the heterogeneity of the motilin molecule in the caiman digestive system is discussed.

Predictors of incorrectness in antimicrobial prescription in the Bauru State Hospital (Bauru city, São Paulo State, Brazil)

The inappropriate use of antimicrobials in hospitals presents a negative impact on patient outcome and is associated with the emergence and spread of multidrug-resistant microorganisms. Antimicrobial stewardship programs (ASPs) have been instituted in order to improve the quality of prescriptions in hospitals. In this setting, the identification of patterns of inappropriate antimicrobial prescription is a valuable tool that allows ASPs to identify priorities for directing educative/restrictive policies. With this purpose, a study was conducted in the Bauru State Hospital, a teaching hospital with 285 beds affiliated to the Botucatu Medical School, São Paulo State University. The hospital maintains an active ASP since it was opened, in 2002. We selected 25% of the requests for parenteral antimicrobials (RPAs) from 2005 for analysis. Prescriptions for prophylactic purposes were excluded. All other RPAs were classified according to a modified Kunin and Jones categories. Univariate and multivariable analyses were performed to identify predictors of general inappropriateness and of specific prescription errors. Prescriptions classified as "appropriate'' or "probably appropriate" were selected as controls in all stages of the study. Among 963 RPAs included in our study, 34.6% were inappropriate. General predictors of inappropriateness were: prescription on weekends/holidays (OR = 1.67, 95% CI = 1.20-2.28, p = 0.002), patient from intensive care unit (OR = 1.57, 95% CI = 1.11-2.23, p = 0.01), peritoneal (OR = 2.15, 95% CI = 1.27-3.65, p = 0.004) or urinary tract infection (OR = 1.89, 95% CI = 1.25-2.87, p = 0.002), combined therapy with two or more antimicrobials (OR = 1.72, 95% CI = 1.15-2.57, p = 0.008) and prescriptions including penicillin (OR = 2.12, 95% CI = 1.39-3.25, p = 0.001) or first-generation cephalosporins (OR = 1.74, 95% CI = 1.01-3.00, p = 0.048). Previous consultation with an infectious diseases (ID) specialist had a protective effect against inappropriate prescription (OR = 0.34, 95% CI = 0.24-0.50, p < 0.001). Factors independently associated with specific prescription errors varied. However, consultation with an ID specialist was protective against both unnecessary antimicrobial use (OR = 0.04, 95% CI = 0.01-0.26, p = 0.001) and requests for agents with insufficient spectrum (OR = 0.14, 95% CI = 0.03-0.30, p = 0.01). In conclusion, the analysis of factors predictive of inappropriateness in antimicrobial prescription allowed us to identify issues requiring intervention. Also, it provided a positive feedback of the ASP efficacy, demonstrating the importance of previous consultation with an ID specialist to assure the quality of antimicrobial prescriptions.

Utilidade dos métodos imuno-histoquímicos para o diagnóstico anátomo-patológico.

In order to determine the value of immunohistochemical staining methods for the morphologic diagnosis, we studied 949 histologic specimens sent for consultation to the Immunohistochemistry Laboratory of Department of Pathology of the Medical School of Botucatu in the period 1984-1989. All case were submitted to the immunoperoxidase staining with the methods PAP or ABC. Immunohistochemical stains confirmed the original morphologic diagnosis in 468 cases (49.3%); made the definitive diagnosis from a list of differential diagnostic possibilities in 244 cases (25.7%); provided contributory information in 74 cases (7.8%); were non-contributory in 114 cases (12%) and rendered an unsuspected diagnosis in 49 cases (5.2%). In some cases with non-contributory information the differences in methods of fixation might have led to suboptimal preservation of tissue antigens. The immunohistochemical staining may provide important and sometimes essential informations for definitive diagnosis. This technique was particularly useful for differential diagnosis between carcinoma, lymphoma and melanoma.

Contribuição do estudo imuno-histoquímico para o diagnóstico anátomo-patológico.

In order to determine the value of immunohistochemical staining methods for morphologic diagnosis specimens of 949 cases received at the Immunohistochemistry Laboratory of the Department of Pathology of the Medical School of Botucatu, in the period 1984-1989 were reviewed. All of them were submitted to the immunoperoxidase staining (PAP or ABC). The main morphologic diagnosis was confirmed in 468 cases (49.3%); the definitive diagnosis was made in 244 cases (25.7%) that had only differential diagnosis, and contributory information was provided in 74 cases (7.8%); the immunohistochemical staining was non-contributory in 114 cases (12%). It rendered an unsuspected diagnosis in 49 cases (5.2%). The analysis of these cases shows that immunohistochemical methods may provide important and sometimes essential informations for definitive diagnosis. This technique is particularly useful for distinguishing between carcinoma, lymphoma and melanoma.

Comorbidity of obsessive-compulsive disorder and personality disorders. A Brazilian controlled study

The aim of this study was to evaluate the presence of personality disorders (PDs) in 40 patients with obsessive-compulsive disorder (DSM-III-R criteria) from the Medical School of Botucatu (UNESP), Sao Paulo, Brazil. It is a case-control study. Patients were 24 women and 16 men, 16-68 years old, referred to our outpatient psychiatric service for treatment. Controls were 40 nonpsychiatric outpatients matched to the cases by sex, age and marital status. The instrument used was the Portuguese version of the Structured Interview for DSM-III-R Personality Disorders (SIDP-R). All interviews (n = 80) were made simultaneously by 2 raters, with independent scoring, so that the interrater reliability of the instrument could also be assessed (kappa statistics). The consensual axis II diagnoses in the OCD group were: avoidant (52.5%, κ = 0.80), dependent (40%, κ = 0.84), histrionic (20%, κ = 0.83), paranoid (20%, κ = 0.74), obsessive-compulsive (17.5%, κ = 0.86), narcissistic (7.5%, κ = 1.00), schizotypal (5%, κ = 0.65), passive-aggressive (5%, κ = 0.79) and self-defeating (5%, κ 0.55). At least one PD diagnosis was made in 70% of the patients, while only 6 controls had a PD diagnosis (p < 0.01). A great deal of diagnostic overlap was found in the OCD group (57.5% had two or more PDs), especially between avoidant and dependent PDs. The features of these two PDs may be secondary to the OCD. The study also suggests that there is not a close relationship between OCD and obsessive-compulsive personality disorder (OCPD). Patients with OCPD or even 3 or 4 O-C traits had significantly less insight into their obsessions and compulsions (p < 0.01).

Hidrocistoma écrino e apócrino na pálpebra - Casuística na Faculdade de Medicina de Botucatu- São Paulo

Background - Hidrocystomas ecrine and apocrine may be observed in the eyelids. Objective - The purpose of this study was to observe the occurrence of eyelid hidrocystoma (eccrine or apocrine), as well as the relation between clinical and histopathological diagnosis. Patients and Methods - 42 patients were selected, with a total of 52 lesions, attended between January 1990 to April 1999, at the Botucatu Medical School, with diagnosis of hidrocystoma confirmed by histopathology diagnosis. Result - Hidrocystoma occurred in 0.07% of patients undergoing lesion removal during this period. Eccrine and the apocrine hidrocystoma were frequently observed in female patients, aged over 40 years. The clinical picture ranged from about 1 to 5 years. The lesions were mainly located in the lower eyelid and presented as a single lesion. The clinical diagnosis agreed with the histopathological diagnosis in 67.31% of the apocrine hidrocystomas, and 9.62% of the eccrine hidrocystomas. Conclusions - Apocrine hidrocystoma was the most frequently observed eyelid hidrocystoma. The correlation between clinical and histopathological diagnosis was higher for apocrine hidrocystomas.

Psicoterapia grupal no transtorno obsessivo-compulsivo

There are few published papers about group psychotherapy for patients with obsessive-compulsive disorder (OCD), and usually restricted psychoeducational, support or cognitive-behavioral approaches. This article describes the experience of group psychotherapy for OCD patients started in 1996 in Botucatu Medical School - Unesp, São Paulo, Brazil. The two-hour sessions occur once a month, with 6 to 10 female patients, and are based on psychodramatic techniques. Psychotropic prescriptions are given after the sessions. In the beginning, aggressive obsessions were more prominent and were reported with much anguish and shame. Gradually, the themes changed from OCD specific issues (symptoms, pharmacological treatment, outcome, need of exposure and response prevention) to deeper and more personal psychodynamic aspects. The psychodramatic approach (techniques of double, mirror, role inversion, search for prymary scenes) has mostly shown: difficulty in accepting their own human mistakes or negative emotions due to excessive personal demands. This seems to generate guilt, low self-esteem, idealization of others, difficulty in enjoying pleasant situations, fear of taking responsibilities and of losing control (madness/aggressiveness). The group has been considered very important by the patients, since sharing experiences helps to diminish feelings of isolation, shame and guilt, stimulates the exposure to feared situations and enhances self-esteem. The fact that all participants have the same disorder favors group cohesion and provides relief, as they see in the others some of their afflictions and are able to share similar feelings and experiences. Many times the burden of the symptoms are dealt with humor. The confidence in such therapeutic setting is helping the identification and resolution of personal conflicts and contributing to the adherence to pharmacological treatment. The group also provides valuable training experiences for resident physicians in psychiatry.

Psychiatric disorders and psychiatric consultation in a general hospital: A case- control study

Introduction: Psychiatric consultation (PC) has been considered an efficient tool to develop research, to track and to give assistance benefiting patients, health professionals and the institution. However, it has not been much used in Brazil. Although 30 to 50% of general hospital (GH) inpatients may present a psychiatric disorder, only 1 to 12% of them are referred to assessment. The aims of this study were: to assess mental disorders in a GH; to identify which of these patients are sent to psychiatric care; to verify alleged reasons for referral to psychiatric consultation, and to examine the relationship between PC and psychiatric learning (during medical school and residence). Methods: A case-control patient study was conducted (47 cases and 94 controls) to analyze in detail the following variables: socio-demographic; clinical; degree of information (about the disease and diagnostic/therapeutic procedures), and relationship between patient and health team. Psychiatric diagnoses were made according to the ICD- 10 criteria. The Self Report Questionnaire (SRQ), the CAGE and Brief Psychiatric Rating Scale (BPRS) were used as well as a specifically designed questionnaire to collect clinical and demographic data. Results: Behavioral alterations, either of elation or of depression, were the main for requesting a PC; 95.8% of the cases and 27.7% of the controls had a mental disorder. Organic mental disorders and alcohol-related disorders were the most frequent diagnoses in group I (cases), while anxiety, depressive and alcohol-related disorders were predominant in group II (controls). Control group patients were better informed and more able to establish an appropriate relationship with the health team than case patients. The logistic regression showed CAGE-positive patients having 12.85 times greater risk of being referred to PC, followed by unemployed patients (2.44 times more PC referrals). Discussion: The SRQ and CAGE were quite useful in the screening of possible patients and might be important for medical students to learn and use as generalists. Further research is needed to verify if and how the newly-established service will improve the diagnostic and treatment skills of our students.