Perception about the medical Internship at Federal university of rio de Janeiro by the Service’s Preceptors in Primary Health Care: a Case Study

– Medicina. ABSTRACT Introduction: A preceptor is understood as a health care professional with an important role in introducing students and recently graduated doctors into professional practice. However, studies into medical teaching in the Family Health Strategy (FHS) have shown inadequacies in the quality, training and time spent by the tutors with students. In the municipality of Rio de Janeiro (RJ), the expansion of the FHS was belated, resulting in a vacuum of medical students being inserted into the network. Objective: To understand the perception of Family Health Strategy physician preceptors regarding their performance with medical student interns from the Federal University of Rio de Janeiro (UFRJ). Methods: This is a case study which employed a qualitative method and took place in the city of Rio de Janeiro (RJ). Semi-structured interviews were conducted between September 2011 and March 2012, with 15 preceptors from six Family Clinics receiving UFRJ medical interns. Interviews were recorded, transcribed, read and subjected to thematic content analysis, resulting in the establishment of five categories: encouragement and motivation; appreciation; training; real world versus academic world; teaching-service integration. Results: The preceptors report that they feel recognized and encouraged by the students, but do not feel appreciated by the service coordinators, who fail to allocate adequate space and time to their preceptorship activities. A good relationship is established with both tutors and students. The preceptors would like to be trained in preceptorship and to strengthen their ties to UFRJ. They view their time with the students as both precious and challenging, because it stimulates them to rethink their care practices. They recognize in the internship the opportunity for students to gain practical experience of what has been learned in theory. Conclusion: The preceptors’ work is supported by the good relationship established between preceptors, tutors and students but efforts are needed to value the professionals who perform this practice.


INTRODUCTION
Since the Declaration of Alma-Ata, in 1978, the World Health Organization (WHO) has recommended the strengthening of the Primary Health Care (PHC). In Brazil, the Ministry of Health has recommended the Family Health Strategy (FHS) as a model of PHC since the 1990s. In order to prepare the human resources for performance in this new scenario, the National Curricular Guidelines (NCG) for the Medicine courses of 2001, albeit late, have begun to recommend that much of the doctor's training be given in the PHC 1 . This recommendation was emphasized in the NGCs published in 2014. The broadening of scenarios of the practical activities for the graduation course oriented by the NGC of 2014 brought the need for preceptors in this scenario 2 .
The preceptor is understood as the care network professional who plays an important role in the insertion of the students and the fresh graduate in the professional practice. However, studies about the teaching of medical practice in the FHS have shown inadequacies in the quality, training and time allocated by preceptors to the students [3][4][5][6] . In particular, in the city of Rio de Janeiro (RJ), the FHS expansion occurred belatedly, starting in 2008, which resulted in a vacuum of the insertion of the student of Medicine in the network 3 . Therefore, this experience was little studied in the municipality [3][4][5][6] .
The objective of this study was to know the perceptions of the health professionals of the FHS regarding their work with the medical interns of the Federal University of Rio de Janeiro (UFRJ).

METHODS
It is an exploratory research, of the case study type, with a qualitative approach. In the qualitative research, the researcher must try to understand phenomena according to the perspective of the participants of the studied situation. It is a procedure rich in descriptive data, which has an open and flexible plan, and focuses reality in a complex and contextualized way 7,8 .
The research scenario was the six Clinics of the Family of the municipality of Rio de Janeiro which receive junior doctors of Medicine from the Federal University of Rio de Janeiro (UFRJ), which were participants in the National Program for Restructuring Professional Training in Health (Pró-Saúde), whose objective is to encourage and develop the integration teaching-service to contribute to the organization of the practice of preceptory 9 .
The research individuals were the 15 doctors of the clinics, preceptors of the UFRJ residents, who were invited and accepted to participate in the study.
Data were collected from september 2011 to march 2012. The technique applied was the semi structured interview, carried out with the help of a script with structured questions related to the profile and professional training, and open questions, regarding their perceptions about their role, activities, facilities and difficulties as preceptors.
All the interviews were recorded and transcribed integrally by the main author, responsible, at the Municipal Health Secretariat of the city of Rio de Janeiro (SMSRJ), by the covenants for the internship with the different IES. None of the interviewees knew the interviewer at the time of the first approach. To guarantee the anonymity of the individuals, all answers were systematized and presented in the section of results identified by the letter P (preceptor), followed by an arabic numeral, according to the order of execution of the interviews.
Data were submitted to thematic content analysis, which is a set of communication analysis techniques that uses systematic and objectives procedures to describe the content of the messages 10 .
After the transcription, a floating reading was performed to establish contact with the speeches. Subsequently, the material was explored and organized into categories recognized in the statements, both in agreement and in contradictions.
The research was approved by the Ethics Research Committee of the SMSRJ (CAAE: 0250.0314.000. 10), and all the interviewees signed the Free and Informed Consent Form.

RESULTS AND DISCUSSION
The sociodemographic, training and professional characteristics of the participants are arranged in Table 1.
It is observed that most of the interviewees attended residence and have training in the area of Family Medicine/Community. Of the four stricto sensu graduation degrees, two had as concentration area this specialty. Only six (40%) declared having had some training for the preceptor activity.
From the speeches, the following categories emerged: stimulus and motivation; valuation; training; academic world versus real world; teaching-service integration.

Stimulus and Motivation
The preceptors interviewed expressed that the work with the student is motivating and keeps them stimulated for the search of new knowledge. They also consider that the changes during the follow-up process contribute to the better develop- ment of their medical activities, providing the qualification of their practices. They also report that the preceptory flows with harmony when the preceptor is stimulated by the student who questions, stimulating the study and the search for updating so that he can, at the same time, stimulate and encourage the student to practice in the FHS 11 .

Appreciation (and lack of appreciation) of the preceptory
The preceptor activity is not valued enough, even though the student gives the preceptors, in relation to the preceptor-student relationship in patient care, more qualities than the teachers themselves 4 . In the following speeches, the preceptors confirm that their work, although recognized by the students, is not recognized as a work of teaching activity of their routine, not stimulated by the IES, nor by the head of the service. When the trust between the student and the preceptor is established, the approximation between both facilitates the teaching process 12 . The exercise of the preceptor function provi-des elements that can subsidize the teaching and service unit in the improvement and valorization of the work. For this, there is a need for professionalization and creation of specific legislation for preceptorship, among other proposals for valorization 13,14 .
The lack of valorization is also reflected in the absence of adequate physical structure to this activity and in the unavailability of time dedicated to it. The interviewees consider the physical space of the health unit small, insufficient and limiting for the fruitful development of the preceptory activities.
What hinders is the physical space. For example, there is a room there that is for the accommodation of the mother and the baby, but we improvise it as a consulting room. So, they [internals] must take turns, sometimes they even stand still. The residence time of the students in the health unit is also considered by the preceptors as a detrimental factor to the preceptory process.

Another thing that hinders is time, they complain. It seems to me that the length of internship is limited. It is small. (P7)
One part that makes me sad is that this is a short-term relationship. (P14) Also among the aspects of availability, the high workload was mentioned, since preceptors perform other activities within the preceptory period, which, in addition to clinical care, involves the bureaucracy of the service. This fact restricts the preceptory, especially when the number of students is excessive.

Training
To exercise the preceptory activity, specific training is not always offered. As observed in previous studies 4 , the main demand of the preceptors interviewed resided in the provision of training and continuing education processes that enabled them to improve their pedagogical skills. The absence of permanent technical training causes them discomfort and feelings of inadequacy. The request for training and refresher courses is, undoubtedly, an assignment that the IES should not wriggle out of complying with, stimulating the qualification of the professionals of the service network.

Real world versus academic world
The preceptory in health is a pedagogical practice that occurs in the work environment and professional training, at the moment of the clinical exercise, conducted by professionals of the assistance, with position of professor or not, with the objective of constructing and transmitting knowledge related to each area of acting as well as assisting in the ethical and moral formation of the students, be they the junior doctor or resident, stimulating them to act in the health-disease-care process at different levels of attention, with social responsibility and commitment to citizenship 16 . The interviewees evidenced that, by acting as trainers, in addition to the technical question in the FHS, the real experience, the reflection, the tools of the specialty, the social context, the practice and the interdisciplinary relationships are examples to be followed by the students. The preceptor must be able to transmit the best evidences and experiences, always valuing the ability to learn from practice. Among the competencies of the preceptory function are: having responsibility, integrating, transferring knowledge, being ethical and stimulating the development of skills and attitudes for the training of the student 5 .

Teaching-service integration
During the interviews, the preceptors have spoken about the relationship and the dialogue established with the educational institutions, especially about the position of the tutor.
For the most part, there is an important movement of information exchange, which greatly facilitates a feedback system, necessary for the identification of deficiencies in the teaching process.
For some preceptors, the relationship is good, but the dialogue is limited because there is no greater articulation that subsidizes the planning of the activities or, also, because the moments of discussion of the tutor with the students also occur in working hours, precluding the participation of the preceptor. The participation of the preceptor in the process of discussion between tutors and students is sometimes made unfeasible by the need of the service. There is a need for flexibility between managers and IES so that this meeting is facilitated, and the mission of permanent education can be accomplished with less difficulty.
A closer approximation of the IES through the more constant presence of the tutors in the health units could give a more specific focus to the preparation for the teaching of these preceptors, giving higher quality to the professional performance. The IES could invest in continuing education, with periodic updates on current topics and research methodology courses, preparing them for in-service research. The university should be committed to stimulating the construction and exchange of knowledge, as well as permanently capacitate the entire team of the unit 9 .

FINAL CONSIDERATIONS
In this study, it was sought to give voice to the preceptors of the Family and Community Medicine internship of the UFRJ, of the PHC network of the SMSRJ.
The practice of preceptorship is supported, according to the interviewees, by the good relationship established with tutors and students. For them, the time with the student is precious and challenging, since it stimulates the rethinking of their care practice, and can also become a moment of learning and qualification of their practices.
Many factors making it difficult to the performance of their teaching practice, such as lack of capacity for this activity, limited physical space, sometimes excessive demand, execu-tion of administrative activities and short time of permanency of the students in the units, preventing a more continuous work, since it is Need time to develop the skills of the family doctor.
Despite the perception of having their preceptor work recognized by the students and the IES, there is still little recognition by the head of the service and insufficient encouragement to the development of this practice. There is, on the part of the preceptors, a clear demand for better integration with IES to enable them for this activity and also for training in research and academic in general.
It would be important to give voice and analyze the perceptions of other actors involved in the preceptory processstudents, service managers and professionals of the IES -that were outside the scope of the present study.