Implementation of a Mental Health internship in a higher education institution

The approval of the More Doctors Program has triggered a number of readjustments of the National Curricular Guidelines (DCNs) for Medical Education, like the creation of a mental health internship integrated into the health service and community. Due to this demand, the higher education institutions have been encouraged to innovate in their teaching-learning methodologies in order to guarantee a generalist, humanistic and critical professional education. We report the experience of a private higher education institution in the implementation of a mental health internship in consonance with the new DCNs. We present all the steps of the implementation, reporting the participation of students, supervisors, preceptors and managers. We show that a mental health internship linked to different levels of healthcare promotes learning conditions capable of favoring the decentralization of care and application of the community/family approach.


Introduction
With the increase in the prevalence and severity of mental disorders in the Brazilian and world populations [1][2][3] , the mental health area started to play a fundamental role in the education of the generalist doctor, posing new challenges for higher education institutions.In addition, Law no.12871 of 2013, which instituted the More Doctors Program (PMM) focusing on primary care, demanded a restructuring of the National Curricular Guidelines (DCNs) for Medical Education.One of the changes was that Mental Health was removed from Medical Clinic and became a specific area adjusted to the program's principles 4 .
In light of this scenario, the new DCNs establish that 70% of the number of internship hours must include essential aspects of the Mental Health areas, as well as of Medical Clinic, Surgery, Gynecology-Obstetrics, Pediatrics, and Collective Health 5 .Thus, education in Medicine includes, as a stage of the undergraduate course, an obligatory and supervised curricular internship for in-service education, performed at the institution's own health services or through partnerships under an Education-Health Public Action Organizational Contract (COAPES) entered into with Municipal and State Health Departments.This contract guarantees access to all the health establishments as practice scenarios for education in the sphere of undergraduate courses and residencies in the area of health, and establishes the parties' duties related to the functioning of the teaching-service-community integration 6 .
The curricular alterations highlight fundamental contents to medical education focusing on the health-disease process of the citizen, family and community, guided by the epidemiological reality of the higher education institution's space of action, enabling comprehensive care and having the determinants of the health-disease process as the transversal aspect 5 .However, the new guidelines do not explain how to implement mental health in the new curriculum, leaving this responsibility to each education institution.Usually, this responsibility is assigned to those in charge of the disciplines of Psychiatry and Medical Psychology.
With the approval of Directive no.3088/2011 7 , which instituted the Psychosocial Care Network (RAPS), mental health was integrated into all care levels and spaces in the Brazilian National Health System (SUS).This expanded considerably the scenario of the teaching-learning process and requires that higher education institutions provide effective conditions for the medicine student to experience all situations.Furthermore, as the RAPS is based on the principles of autonomy, respect for human rights and exercise of citizenship, it is expected that the structuring of the academic curriculum of the Medicine course prioritizes teaching strategies that approach issues related to the promotion of equity and to the recognition of the social determinants of health-disease-suffering-care processes, undoing stigmas and prejudices.
Thus, some questions arise: How can we articulate the spaces of the mental health network so that students can access all of them?How can we make mental health learning become significant and humanized, in consonance with the profile of a generalist doctor?In view of the need to adjust medical education in Brazil according to the new DCNs, we report, in the present article, the experience of implementation of the mental health internship in a private higher education institution.

Methodology
This is an experience report on the implementation of a mental health internship, a curricular component required by the DCNs for medical education, at a private higher education institution.The institution is located in the city of Maringá, in the northeast of the state of Paraná (Southern Brazil).This city's planning and urbanization is recent.It is the state's third largest city and the seventh most populous in the South region of Brazil.According to the United Nations Development Program (UNDP), Maringá is one of the state's two cities that are among the 50 cities with the best municipal human development index of the country.
The Mental Health Network in Maringá has a Public Psychiatric Emergency service with 26 psychiatric beds at the Municipal Hospital, which is the reference unit for the cities of Maringá and Mandaguaçu, one Psychosocial Care Center for alcohol and drugs (CAPS-AD II), one Psychosocial Care Center (CAPS II Canção), one Psychosocial Care Center for Children (CAPSi), two Therapeutic Homes for men and one for women.In May 2015, Maringá's Mental Health Complex was inaugurated and the specialized services were placed in an adequate building (CAPSIII, CAPS-AD and CAPSi).
The implementation of the mental health internship during 2016, in the fifth year of the medicine course, followed three stages: 1) diagnosis and viability of the city's mental health network; 2) planning and development of the teaching process; 3) evaluation of the effectiveness of the internship in the medicine student's education.In the last stage, the evaluation sheets filled in by students about the discipline were analyzed.The answers were transcribed and analyzed in the software IRAMUTEQ (Interface de R pour les Analyses Multidimensionnelles de Textes et de Questionnaires) 8 .
Word cloud was used for data processing.Words were grouped and organized graphically according to their frequency, facilitating their identification based on one single file, which contained the texts originated by the answers given in the evaluation sheets.Thus, each sheet characterized one text and the set of these texts constituted the corpus of analysis.Based on the most frequent words provided in text segments, the program performed a lexical analysis, whose vocabulary was identified and quantified in relation to frequency 9 .This vocabulary was submitted to statistic calculations for its subsequent interpretation 10 .
Our experience report is organized as a narrative of the internship implementation stages, involving the action of different actors -students, supervisors, preceptors and health managers -, as well as a qualitative analysis of this activity's repercussions on medical education.Therefore, an adjustment model for medical education in consonance with the new DCNs is assumed, and this process' influences on medical education are discussed, based on the students' perspective.

The context of the course
The first class of the Medicine course initiated its studies in 2012.The course, offered in the baccalaureate modality and in a grading regime, lasts six years, opening 186 seats per year.Its integrated curriculum totals 8,289 hours: basic education/ professional education (4,820 hours), obligatory curricular internship (3,000 hours), and complementary activities (469 hours).
It uses a transformative pedagogy with active teaching-learning methodologies, prioritizing evidence-based medicine, the understanding of reality and the exercise of reflection, according to the standards of adult education (learning based on the solution of problems, problematization, team-based learning and in-service learning).The course adopts diagnostic evaluation, which enables to correct its directions, and follows the DCNs for the Medicine course 5 .
The course has two coordinators, one from the medical area and another one from the pedagogical area.They conduct the activities together.As a management strategy, the organization and conduction of the course's activities were shared with subcoordinators for each year of the course.Pedagogical and administrative discussions, fundamental to the implementation and development of the course, are carried out by the Structuring Teacher Nucleus (NDE) and the board of the Medicine course.
In view of the need to implement the mental health internship during the year of 2016, in the fifth year of the course, the NDE started to discuss the hiring of a teacher to organize and articulate the conduction of the internship.It was decided that this teacher must be a medical professional working in the area of psychiatry of the city's health network.He or she must have a PhD degree and teaching experience.
After the selection of the teacher responsible for the internship, the group established work stages: diagnosis and viability of the city's service network, definition of the teacher profile for the hiring of professionals, and planning and development of the teaching process.

The diagnosis and viability of the city's mental health network: integrating school and service
For the submission of the internship proposal, first the coordinator contacted the city's Advisory Body for Health Workers' Education and Permanent Qualification (CECAPS).CECAPS is responsible for the procedures, distribution and norms related to internships in the services connected with the Municipal Health Department in primary and secondary care.It is also in charge of the development of COAPES, which, in the city, is still ongoing.
After the authorization was obtained, a survey of the services of the city's mental health network was performed.The network is composed of a General Hospital with hospitalization beds and emergency care in psychiatry, CAPS-AD, CAPSi, CAPS-III and Primary Care Units (UBS).
Efforts were made to put the internship coordinator in touch with the services' coordinators, so that they could discuss the student's role in each service and designate professionals to receive the students.
Here, it is important to highlight that many negotiations and clashes occurred concerning students' inclusion and action in the services.Issues like the physical space to welcome students and their action in all the network's points, with the aim of including them in primary care units, were discussed.However, when the moment of implementation of the internship arrived, it had not been possible to decide on the units and activities that could be performed yet, because, as the proposal is new, it needs to be further discussed within the network.
Regarding teacher profile, it was decided that these professionals should have a generalist vision targeted at mental health and not at illness; moreover, they had to be working in the municipal network.Six doctors-teachers were hired: two PhDs to work 40 hours per week, one MSc and one specialist to work 24 hours per week, and two specialists to work 12 hours per week.With the purpose of complementing the assistance provided for students in internship fields, two scholarships were offered to specialist doctors who had been hired by the city to work in the municipal network.
With the faculty formed, new meetings and discussions were held, this time to plan and develop the teaching and learning process.

The planning and development of the teaching process
Based on the discussions, it was possible to outline that the mental health internship's objective is to qualify Medicine students to assist individuals undergoing mental and behavioral suffering, approaching the necessary aspects for a generalist medical education.At the end of the internship, the student is expected to: Develop managerial competencies, such as: the organization of mental health services in the city of Maringá; the public policies developed by the Ministry of Health; and the importance of the healthcare network, interconnected with the social work and education networks.
Develop individual and collective care competencies, working in different types of mental health services, in different complexity and emergency levels, and participating in multidisciplinary meetings, modelling communication in a clear way, mastering the skills of synthesis, discussion of diagnostic hypotheses and leadership, respecting the other team members and their forms of action; Develop general skills of anamnesis and physical examination/mental state examination in psychiatry, encompassing: using propaedeutic and therapeutic resources in a conscious way; perceiving the biopsychosocial nature of mental illnesses (with social, cultural, behavioral, psychological, ecological, ethical, and legal determinants); understanding the utilization of forms to prescribe controlled medications; discussing clinical cases evaluated during the internship period; exercising the capacity to read medical records critically and write/synthesize clinical cases; formulating individual therapeutic plans involving the individual and collective spheres; reflecting on the individual psychopharmacological therapeutic plan, understanding the role of psychotropic drugs, their risks and benefits; using basic principles of scientific methodology to choose therapeutic options; having a humanistic understanding of the individual who looks for medical help, recognizing him/her as a subject in whom biological, psychological and social aspects are integrated; reflecting on the importance of their (the students') own physical and mental health for the practice of the medical activity; and other ethical principles of medical practice, in addition to the ones mentioned above.
Thus, the internship was organized in groups of 15 students who, subdivided into two groups, alternate in two cycles at the internship fields (CAPS-AD, CAPSi, CAPS-III, a general hospital with hospitalization beds and emergency care in psychiatry, and a realistic simulation laboratory) (Table 1).As a teaching strategy, students provide clinical care individually, in pairs and in groups for hospitalized patients, patients under semi-intensive monitoring and patients in outpatient clinics, including care for family members and actors of the simulation laboratory.In addition, they conduct clinical case studies in groups and observe waiting environments.
In the Community Psychiatry internship, they perform referral and counterreferral contacts, as well as matrix activities to other services of the health, social work and education networks.At the CAPSi and in the ward of the general hospital, they observe models of multidisciplinary meetings.A clinical meeting is held on a weekly basis, with seminars given by the students themselves about specific themes in mental health.
Furthermore, there are three longitudinal programs throughout the seven weeks of the internship: in the first, called "Medical relationship", participants discuss aspects related to transference, countertransference, doctor-patient bond, and basic techniques of supportive psychotherapy and of brief psychotherapeutic interventions.The second, called "Simulation laboratory", takes place in the realistic simulation laboratory with actors in situations of psychomotor agitation, alcohol withdrawal, abused children, suicidal ideation, and panic attacks.
The third, "Human area", is a space reserved for students where they can develop their artistic skills.During the seven weeks, there is a scheduled time for this purpose, and the result is presented to the supervisors at the end of the internship.In addition, students are stimulated to write a life narrative in order to reflect on the reasons why they are where they are and are who they are.These activities are not obligatory; they add a bonus to the final grade for those who perform them.Even so, they have students' active participation.
Psychiatrists hired by the higher education institution supervise the activities.In some fields, like CAPS-AD, CAPSi, at the Psychiatric Emergency and Psychiatric Ward, the service's physician assistant him/herself welcomes students.
The evaluative process of the internship is composed of two stages: a formative and a cognitive evaluation.The formative evaluation is subdivided into attitudinal evaluation and practical evaluation of clinical skills.Both are performed at the institution's specialties medical offices.The first is carried out throughout the entire internship and corresponds to 40% of the total grade.The second evaluation also corresponds to 40% of the grade.Cognitive evaluation, in turn, is composed of multiple choice questions, corresponding to 20% of the final grade.The questions approach psychiatry themes included in cases and situations found in the five large areas: Pediatrics, Collective Health, Gynecology-Obstetrics, Surgery, and Medical Clinic.

Reflections on the mental health internship
The proposal for the implementation of the internship in different health services was authorized by the city's Health Department by means of a contract.Thus, the population and the service benefit, as it fosters a significant increase in the number of assistances in the entire mental health network, as well as the professionals' permanent education.
To some services, the institution hired a preceptor, which generated approximately two hundred specialized consultations per month to the city, reducing the waiting period for specialized care.It is important to mention that the institution became responsible for one of the five regions of reference in mental health belonging to the city of Maringá.
In other services, students accompany doctors from the health network, helping in the consultations and observing conducts and patients' progress.In these experiences, the user, the service and the professional benefit, due to informed and evidence-based decision-making.
However, it is important to highlight that the implementation in primary care units is still being discussed and represents a great challenge, as it requires a detailed planning of priorities, with defined and established objectives and strategies, participation of all the actors involved, and discrimination of the tasks and responsibilities of each professional, not to mention the training of professionals, continuous support provided by specialists, and specialized reference equipment and medicines 11 .
This does not involve only administrative and curricular organization.It requires a collective effort of the school and the service to recognize the importance of the articulation between mental health and primary care, so that, together, they can promote discussions among teachers, students, professionals and community about the importance of this articulation, as this strategy can significantly reduce the burden of diseases produced by mental disorders 12 .
At the end of the mental health internship, students evaluated the strengths and weaknesses of the process.They realized that the opening of this internship front allowed them to experience new situations, strengthening their capacity for embracing users and exchanging experiences with them, and enabling students to reflect on the quality of their own mental health and to search for ways of improving it.
In addition, it was possible to perceive, in students' evaluations, that there was an expressive reduction in the "stigma against mental illness and the person undergoing mental suffering", as many of them could reflect on humanization of care.Furthermore, they had the possibility of questioning, caring for and referring to the specialized service, searching for more natural methods and centering the activities on the person and not on procedures.This was identified in the word cloud (Figure 1).
The focus on the "patient" (Figure 1) shows that the significance of the student's learning increases as the prejudice against people with mental disorders decreases.In addition, it is possible to perceive that the users accept the students' presence well.
Discussions about the stigma against mental disorders and humanization of mental healthcare in Brazil are not recent.The fight against oppressive practices that violate human rights has been stimulated since the Brazilian psychiatric reform in the 1970s 13 .The change in the healthcare model, targeted at decentralization and the community/ family approach, to the detriment of the traditional, centralizing model, has been grounded on the National Humanization Policy -HumanizaSUS 14 -, and strengthened by RAPS.It is in this new scenario that the DCNs for the Medicine course are included, inspiring the method of clinical teaching centered on the person and on their experience of illness in an integral, participatory, realistic way, aiming at health promotion 15 .In this profile of care, contexts of life and the feelings involved are recognized, which guarantees an openness for the individuals with mental disorders to find themselves in their possibilities 16 .Therefore, we believe that the education of doctors for the development of mental health services in primary care must focus on the doctor-patient relationship, teamwork techniques and practices, and on the development of the capacity for listening and communicating 17,18 .
However, in some services, in spite of the negotiations and interactions that were performed, we noticed a certain resistance of the team in relation to the students, which can be attributed to the lack of a familiarization process with the students' presence in these environments.This fact requires integrative actions that enable the exchange of experiences and knowledge about mental health, as well as challenges, advances and future perspectives in the context of the service and of teaching.
Anyway, the experience of implementation of the mental health internship reported in the present article is positive: it showed that academia and the service can maintain a good relationship, revealed in the openness to dialog and in the students' possibility of acting in different points of the mental health network.The non-insertion of students in primary care units to act in mental health was due to the fact that this new field requires integrated actions planned in the medium and long term, involving countless actors, interests and strategies so that an effective adaptation and integration occur.

Final remarks
On a broader level, the report on this experience enables us to perceive that the DCNs have triggered changes beyond the education of Medicine students.In the field of medical education, we found that these changes play a role in the acquisition of skills in different competence areas of medical practice.Concerning healthcare, besides other aspects approached in the DCNs, the inclusion of a specific internship in mental health has enabled to advance, by means of verbal and non-verbal language, in the communication with users, families and members of professional teams, with empathy, sensitivity and interest, preserving confidentiality and guaranteeing understanding and patient safety.
In addition to these effects on education, the fulfilment of what is prescribed in the DCNs has enabled the intensification of the teaching-service partnership, with consequent impacts on the health network and on the quality of the care provided for users.The competencies recommended by the DCNs lead to the need of using different teaching and learning scenarios, as we described here with a practical example.Thus, the student can experience varied situations of medical practice, of the organization of practice and of multiprofessional teamwork, acting as a protagonist.As a broader effect, the DCNs direct the medical-academic education to social health needs, with emphasis on the SUS.Overall, we can conclude that the structuring of a mental health internship connected with different points of the healthcare network provides teaching and learning conditions capable of promoting the decentralization of care and the community/family approach, to the detriment of the centralizing model.

Figure 1 .
Figure 1.Word cloud resulting from the evaluations of students from the medicine course about the mental health internship.

Table 1 .
Rotation scheme of the mental health internship groups according to premises and weekdays