Physicians ’ reflections on the personal learning process and the significance of distance learning in family health

The scope of the article is to present the reflections of professionals from the Mais Médicos Program (More Doctors Program) on the significance of the specialization course in Family Health in terms of professional practice and learning the most important concepts. This is an empirically based qualitative study on the statements recorded in the “Critical reflection on their personal learning process” of the final work of the specialization course at the Federal University of Pelotas. For textual analysis, 101 reports were randomly selected from a total of 1,011 reports completed in seven states of the North, Northeast and South of Brazil from June to December 2015. The initial barriers were overcome with tutor support and team integration, with emphasis on teaching tools for the improvement of clinical practice and strategic organization of work and greater understanding of the public health system. Fostering the learning of the Portuguese language and the exchange of experience in the forums were considered valuable positive aspects. Despite the difficulty in Internet access in some municipalities it reaffirmed the central role of ongoing education and the viability of the problem-solving methodology, even from a distance.


Introduction
The shortfall of health workers is a problem that affects over twenty-five percent of the countries in the world, which means that four million new professionals are needed to deal with the shortage in the work force that affects these countries, irrespective of their level of development 1 .
In Brazil, the lack of physicians and their unequal distribution within the country, compounded by the inadequate training profile with regard to the health care needs of the population, make it difficult to implement the Family Health Strategy (FHS), which is considered essential in order to expand and consolidate primary health care in the country 2 .Brazil has only 1.8 physicians available per thousand inhabitants, which is a lower rate than Argentina (3.2), Uruguay (3.7), Portugal (3.9) and Spain (4.0).The National Primary Care Policy reaffirms the important role that primary care coordination is expected to play in organizing the healthcare networks 3 .
The Mais Médicos Program (More Doctors Program) was established with the aim of guaranteeing the provision of physicians in regions that lack professionals, as well as investing in training physicians in the area of primary care, through teaching-service integration, also involving international interchange 4 .In order to meet this expectation, partnerships were established between the Unified Health System's Open University (UNA-SUS) and the Federal Higher Education Institutions (IFES).
The Specialized Family Health Course teaching project, using the distance learning method offered by the Federal University of Pelotas (UF-Pel), is based on a problematization methodology, suitable for the good professional practice of family health and the active search for knowledge, overcoming the traditional way that information is transmitted and emphasizing collective health areas and clinical practice with a systemic and holistic focus on the day-to-day reality of primary health care (PHC) 5 .Learning is centered on the student, encouraging autonomy and developing leadership.Each professional has an exclusive space for dialogue with their tutor about the development of the intervention and outline of the End of Course Paper.In addition, the forums, attended by both students and tutors to enable these to share discoveries, clarifications and discuss situations that occur in their daily routine, help to stimulate the collective learning process.
In this teaching proposal, physicians are asked to conduct a situational analysis of the Prima-ry Health Care Unit to which they are attached.This serves to construct the intervention project, which is focused on improving the coverage and quality of one of the programmatic actions -pre-natal and post-natal period, prevention of cervical and breast cancer, child health, hypertension and/or diabetes and health of the elderly 5 .
The intervention, which lasts for twelve weeks, involves clinical practice training exercises, public engagement, organization and management of services and monitoring and evaluation.The participation of the team, as well as the involvement of the population and municipal management is encouraged.The End of Course Paper is the result of a series of activities carried out during the specialization course, together with a reflection about the learning process, a letter to managers and another to the community explaining the intervention that was conducted and results obtained.The presentation and the defense of the End of Course Paper are the only face-to-face activities included in the course, which, in the case of the others, uses virtual networks with weekly orientation being given, asynchronously, for its activities 5 .
This article aims to present reflections about the significance of the course and the learning process of the Mais Médicos Program experienced during the distance-learning modality of the Family Health specialization course.This article underlines the value of the Mais Médicos Program training, from the point of view of the students, based on the critical viewpoint of those who have had long-term education strongly linked to its application in day-to-day care services.

Methodology
This is a study adopting a qualitative approach conducted with physicians linked to the Mais Médicos Program who had completed their specialization studies in Family Health at the Federal University of Pelotas on the distance learning basis.By December 2015 a total of 1,011 physicians had concluded their specialization courses and most of the interventions conducted were focused on individual care for those diagnosed with hypertension and/or diabetes (n = 433; 44.2%), followed by pre-natal and post-natal cases (n = 176; 18%), prevention of cervical and breast cancer (n = 149; 15.2%), health of the elderly (n = 119; 12.2%) and child health (n = 102; 10.4%) 6 .
With regards to distribution, 41.6% were assigned to the State of Rio Grande do Sul, 12.5% to Rio Grande do Norte, 17% to the State of Piauí, 7.9% to Amazonas, 7.7% to Amapá, 7.3% to Acre and 5.6% to the State of Roraima (Figure 1).
As an empirical base, texts contained in the "Critical appraisal of your personal learning process," which forms the final volume of the End of Course Paper, were used.For this item, it was asked that the professional should reflect on the most relevant aspects of learning they had experienced during their specialization course and what the course meant to the participants in terms of the practice of their profession.
The texts were selected and analyzed during the period between February and March 2016.The End of Course Papers were organized by State and programmatic intervention action, and by means of a systematic leap, 10% of the works were chosen (n = 101), which corresponds to three groups of specialization class students.The reflective texts were identified with a letter and a number in sequential order (M1, M2, M3...).The corpus of the analysis was based on textualized reflections by 51 women and 50 men, distributed between the states of Rio Grande do Sul (n = 41), Piauí (n = 18), Rio Grande do Norte (n = 13), Amapá (n = 8), Amazonas (n = 8), Acre (n = 7) and Roraima (n = 6).Most of the physicians were of Cuban nationality (n = 80), followed by Brazilians (n = 11), Argentinians (n = 2), Venezuelans (n = 2) and one professional from each of the following countries: Bolivia, Uruguay, Nigeria, Colombia, the Dominican Republic and Honduras.
A sequence of three components was established for the textual analysis: the unitization, which corresponds to the phrasal deconstruction of the texts of the corpus of the analysis; classification, which corresponds to relationships established between unitary elements; and capturing emerging issues, which corresponds to a new form of interpretation that has been communicated and validated 7 .
Unitization was independently conducted by three investigators; classification and capturing emerging issues were conducted by means of a consensus between these same investigators.The units of analysis had been previously selected based on the objective of the reflection -"Personal learning process" and "Significance of the course."Units of emerging significance/meaning were obtained in relation to: a) a new method of distance learning; b) strategies that support learning that enable advances to be made in clinical knowledge, in strategic planning and in promoting a better understanding of the principles and guidelines of the Unified Health System (SUS); c) initial barriers to the proposal, which are overcome after exposure to the course; d) the importance of the support of course tutors and teamwork; e) difficulties faced; f) sociocultural gains.
The matrix project of specialization in family health was approved by the Ethics Committee at the School of Medicine, registered under official number 15/12.Authorization was obtained from the students to make use of their reflective texts.

Results and Discussion
The reflective texts show that holding the course using a distance learning methodology represented a new way of learning.Exposure to a distance learning methodology of education was a completely new experience [...] processes were used that were different to the ones we already knew (M73) and with the advantage of flexible hours, which made it possible to organize time according to our needs, which meant I could do my work and fulfill my obligations and access education in the time available to me (M5).Students also acknowledged an improvement in the way they could access education on a permanent basis and overcome geographic limitations where everything can be done and where knowledge can reach even the most distant locations (M10).
The literature highlights the fact that distance learning gives students the advantage of having easier access to improved education and, as a result, professional training, especially for professionals located in the interior of states that are far from the great urban centers, as well as giving them the chance to choose the best time to study 8,9 .
These statements emphasized that the activities offered the necessary tools to provide better care for users and to plan actions that promote preventative healthcare (M94).The course provided questionnaires, spreadsheets, calculators, tests, clinical cases, schedules and a forum, so the student had multiple and differentiated information at his/her disposal for the learning process (M6).
The practical use of materials made available during the course was registered and the importance was emphasized of clinical case studies and reviews of themes to provide up-to-date information on many diseases (M10), are of a practical and applied nature since these make it possible, with interactive cases, to better understand disease management in Brazil (M6).These also helped me to review important issues that I came across on a daily basis during my work at the healthcare clinic (M40).
The forums were acknowledged as being a strategy for the exchange of clinical knowledge and experiences gained in the different states in Brazil, being considered as the best way to interact with the other students and with the University course tutors, through weekly clinical cases and tasks, which helped me to get more in-depth familiarity with Family Health Strategy (M14).When working with teaching-learning strategies, emphasis is given to these forums, since these enable a person to learn about human interaction, providing an opportunity to learn to listen, receive and assimilate criticisms 10 .
Being able to take part in the course represented greater security in my clinical practice and an opportunity to have a totally different overview in relation to Primary Care, since I learned how to work following the protocols established for health care treatment (M33).The use of clinical protocols drawn up by the Ministry of Health to monitor priority groups can help coordinate and reduce types of procedure.In 2002, an investigation was made into the use of these in ten urban centers in the country and it was shown that only in three of these municipalities was the use of protocols considered a concern by local management.(Vitória da Conquista, Vitória and Aracaju) 11 .In 2005, the use of protocols was evaluated by health care teams at the Traditional Basic Health Units (UBS), especially with regards to home care.The protocols for chronic diseases (hypertension and diabetes) and maternal and child-healthcare were not used by a quarter of the teams 12 .
According to statements, the use of protocols helped to overcome my fear of making a mistake (M21), thereby helping to improve my work in the assistance I have provided in dealing with a variety of diseases in accordance with the protocols established by the Ministry of Health (M76).
Based on the situational analysis that was proposed as the assignment for the first few weeks, an opportunity was created to understand the reality of Brazilian life and, especially of the com-munity, making it possible to establish intervention strategies and to assess the impact that these actions have on the population, on the team and also on the community (M13).It was considered essential to use a situational diagnosis as a basis for planning in order to prioritize problems in services, shortcomings in the health care offered, as well as the health needs of the population.The physicians described having learned more skills using the clinical, epidemiological method, implementing the knowledge they had acquired during the course in their daily practice, thereby improving the way their work process is organized in relation to care and decision-making procedures (M30).
The value of using strategic planning as the essential foundation in the organization of health work, also within the scope of services, has been acknowledged in the public healthcare systems in Latin America 13 .The methodological proposal and the educational materials encouraged the autonomy of the professionals in their work to organize the work in the PHCs by providing a complete overview of the work process, and reinforced the fact that health actions should be planned beginning with the diagnosis and identification of the problems of the specific community, by outlining a plan of action and a schedule of activities as well as monitoring and evaluating the actions taken (M70).Thus, actions will be directed towards the needs of the population, so that we can ensure that a profound impact is made on the health-disease process affecting the local population (M70).
Bearing in mind that most of the physicians of this Program come from other countries, mainly Cuba, providing professional distance learning was one way of knowing more about the principles of the Unified Health System (SUS), the rights and responsibilities of the users [...] the problems of this Health System and the deficiencies that exist in our Basic Health Units, the importance of developing an integrated care system, providing universal and continuous access to quality and functional health care services (M22).
The responsibility felt towards the proposal to strengthen primary health care was also explained and since I arrived in Brazil my main objective has been to improve the state of health of the Brazilian population who have so kindly welcomed me and who have made me feel welcome in such a special way (M82).
This focus improved understanding about the organization of the national health system and the role played by social control, with the community participating in the activities of the unit, making it easier to establish inter-relations with the population and with neighborhood leaders (M1).The initiative to establish partnerships with local businesses and other entities in an effort to find solutions to improve the quality of life for the users, promoting the active participation of the community, endorsing new activities that had not been developed before in the units should be highlighted (M5).
This learning process meant overcoming barriers about the proposal for ongoing education linked to the Mais Médicos Program -I have to say that, in the beginning, I found it hard to accept and to understand the importance that this Specialization Course represented, both for me and the rest of my colleagues (M43).There was an understanding that the content would be unnecessary for my training (M21) and that it would offer me absolutely nothing at all (M43) especially in view of the time until graduation and work involved, since I was already a specialist in the area of Primary Health Care with over 20 years of experience and had worked in three other countries (M43).
Exposure over the period of the course made it possible to change my initial opinion when I saw that I had a lot to learn and that there were many gaps that needed to be filled (M21), especially as regards acknowledging that Brazil represents another school in my pathway through life, which has enhanced my medical knowledge, enriched my professional experience and made me a better human being (M43).At the end of the process, even those with broad experience recognized the importance of this initiative as an opportunity to aggregate new knowledge, a process that was made far easier by the individual attention received from my study tutors who were a key element in enabling me to finish the course (M2).
The motivation of the course tutors meant they had the possibility of overcoming problems since they were present at every moment, leading us along the right path (M27).There were times I was disheartened when I really thought it would be impossible to complete my specialization course, however, together with the support of my tutors and a huge amount of personal effort, I was able to fulfill my objectives (M17).
The initial feeling of isolation felt by the physicians could be overcome through team work since in the beginning there was no sense of unity as a team, there was no communication between us (M22).Acknowledging and recognizing the value of a team can be seen as an important strategy that changes the daily work routine and helped reorganize the service within the Basic Health Unit, by changing concepts, even changing ways of working, which thereby showed the real value of primary health care (M11).The duration of the course meant that it was possible for the team to function as a real, articulated and united team (M25).The organization of our work as a team made it possible to offer greater quality of life to those seeking acts of assistance (M8).
In addition to the technical knowledge acquired, this experience was also an opportunity to overcome normal limitations, as highlighted by the fact that I am very happy, since I have really acquired a great deal of knowledge, both clinical as well as managerial, and have also improved my Portuguese and computer knowledge (M68).
Learning the Portuguese language and computer know-how were secondary gains that resulted from this exchange process, together with experience in distance learning and were emphasized for their universal value.For many physicians, this was the first time they had experience of distance learning and Portuguese [...] this is the first time I have worked using Portuguese … it is really difficult to write in another language [...] since I have very little computer knowledge, this was also very difficult for me (M87).
Being able to complete a specialization course gave the physicians personal benefits related to their cultural and social experiences, and also made conceptual and practical contributions on Family Health Strategy.It was a unique experience [...] I gained an understanding far beyond the literature by experiencing the practical side of care and I see how important a physician and the family health team are for the community (M49).Emphasis was on overcoming obstacles as we have broken the barrier of language, of distance, of missing our family and friends, so that we can increase our overall knowledge in another country, that has different customs and different ways of thinking (M10) [...].A willingness to learn was an important issue that involved reflections on life since this is not just a professional experience, but also a life experience, which I will always carry with me [...] it made me grow as a professional and also as a person (M49).
In spite of the expansion of the Internet in Brazil during the last decade 14 , recurring statements mentioned serious difficulties with the internet signal, which made it very difficult to access the university (M47).However, in some case this limitation made it possible [...] to maintain a closer relationship with the managers, who supported me by providing the Internet from the Municipal Health Department (M47).This problem really hampered my work, and often upset me and made me feel discouraged (M14).This affected physicians in the North and Northeastern regions of the country far more, but also affected professionals in the interior of the State of Rio Grande do Sul and [...] although Manaus is a big city, this is the reality that one faces in the Northern region of the country, which bears no resemblance at all to the South of Brazil (M14).
The migratory movement of professional medical personnel is not a recent activity, even though this has changed direction over the last few decades and at this time developing countries contribute a higher number of professionals to fill existing vacancies, both in developed as well as in developing nations.When they migrate, professionals are exposed to cultural differences and need to adjust themselves to local health systems, with all their possibilities and limitations 15 .In the case of temporary migration, as is the case of the Mais Médicos Program, when the host country subsidizes the continued education of foreign physicians, this can help to improve the overall capabilities in their countries of origin 15 .
The specialization course offered was considered to be a required experience, since every nation has its own peculiarities and work protocols (M14) and the ongoing education process represented an opportunity to add a great deal of information that will be shared within my own country (M28) and even though I have been qualified for some time, I don't believe that just because I have been specialized in family health for over 15 years, that I have absolute knowledge, or that there is nothing more that I need to incorporate into my learning process (M28).

Final Considerations
The textual analysis about the personal process of learning experienced by professionals made it possible to see that, despite the mandatory nature of further training courses 3 , taking part in the specialization course meant overcoming obstacles and showing a willingness to learn.These enabled participants to broaden their understanding of the principles and guidelines of the Unified Health System, strengthening the work of the team and improving their clinical practice.
It may be considered that the objectives expressed in the political-teaching project of the Course were reached by means of the problematization methodology based on the situational evaluation.A proactive attitude on the part of the physicians was encouraged in aspects relating to the organization and management of services, as well as monitoring and evaluation, engaging with the public and clinical practice training.
The difficulties encountered in accessing an Internet connection, is still an obstacle that needs to be faced in the distance learning model, especially in municipalities in the interior of the country and in the states in the North and Northeast region of Brazil.In spite of being asynchronous, the course provided and requested that material be submitted on a regular weekly basis and, in the case of difficulties with access to the web environment; there is a risk that it will be impossible to maintain this initiative.
The results obtained by training physicians in the area of primary health care, through a teaching-service integration method, reinforces the viability of the distance-learning process with interventions centered on improving clinical practices, planning and evaluation.Although operating on a grand scale, with over one thousand qualified physicians, the personalized learning process con-nected people, established networks, reduced distances and promoted the exchange of experiences, thereby strengthening the public health system.
The fact that critical reflections about the personal learning process form part of the End of Course Paper may have positively influenced the statements given and be considered a limiting factor for the purpose of this analysis.It is suggested that future studies should explore the issue about the meaning of the course and learning method from the viewpoint of the teachers, the tutors, managers, team and community, so as to enable others involved in the project to register their opinions, either directly or indirectly.
Even though the Internet connection can still present a problem, distance learning has been shown to be an important strategy, which facilitates access to knowledge and, for this reason, needs to be supported and encouraged.This experience made it possible to develop new technologies within the scope of institutions and encourages teachers to offer alternative and easier ways to provide ongoing education.

Collaborations
E Thumé contributed towards the concept, outline, data analysis and interpretation, drafting of the text and critical revision; LS Wachs and UM Soares contributed towards the data organization, analysis and interpretation and drafting of the article; MR Cubas contributed towards the critical revision and organization of data; MEG Fassa, E Tomasi and AG Fassa contributed towards the concept, outline and critical revision; LA Facchini contributed towards the concept, outline, data analysis and interpretation.

Figure 1 .
Figure 1.Distribution of the states and municipalities with students who have specialized in family health for the Mais Médicos Program.Una-SUS -UFPel, 2016.