Estudantes de Medicina em Roda: os Diálogos da Extensão Popular com os Indígenas Potiguara Medical Students in a Talking Circle: the Popular Extension Dialogues with Potiguara Indigenous People

Introduction: University extension projects with socially excluded populations can be a strategy for the training of professionals in the cultural and social diversity of the Brazilian population. The practice of Popular Health Education (PHE) through university extension is one of the possibilities to foster dialogic interactions between teaching and the community and has been a space for the development of health education with social commitment. The Îandé Gûatá Extension Project was created in Paraíba in 2013, based on the principles of PHE and Popular Extension, focusing on the meeting between Potiguara indigenous people and Medical students. This study aimed to evaluate the learning built by this project students’ for their medical education. Method: Therefore, a qualitative approach research was developed through the analysis of discursive practices, using the talking circle technique at the end of the project cycle. To analyze the material, linguistic repertoires were identified from the subjects’ speech and three sets of meanings were built: extension university as a counter-hegemonic space of medical education; building skills for the future doctor; relations between health and culture in care. The linguistic repertoires were discussed based on theoretical references, such as popular health education, indigenous health and competences in medical education. Results: According to the students, this project allowed them gains in the attributes of: knowledge, as it allowed reflections, identification of gaps and greater understanding about the health-disease process in the context of the indigenous population; allowed gains in the ability of making and receiving criticism, teamwork and dialogue between different cultures; and allowed gains in attitudes, broadening the attitude of professionalism, the comprehension and performance on ethical issues and the construction of social commitment. Conclusion: Therefore, they highlight both the development of general competences for the future doctor, but also more specific ones, such as cultural competence. Moreover, the challenge of dialoguing in the polarity: aiming to reduce the distances within the same institutional space; cultural conflicts; and understanding and acting


INTRODUCTION
The complex dynamics of Brazilian health requires the training of health professionals who have, in addition to ethics and the capacity to work at different levels of care, respect for citizenship and the knowledge/ experience of commitment and social responsibility in the health-disease process 1 . Therefore, university extension in the training process can enable dialogic interactions with the exchange of knowledge, overcoming the idea of academic hegemony and building solutions with society 2 . In this context, the practice of Popular Health Education (PHE) is one of the possibilities to foster the connection between education and the community, since teachers, students and professionals can collectively promote a more equitable Unified Health System (SUS, Sistema Único de Saúde), focused on social participation and longitudinality of care 3 .
Socially excluded populations -such as quilombolas, river communities and indigenous peoples -are made invisible in the curricular matrices of most undergraduate medical courses. University extension projects with these groups can be a strategy towards approximating the cultural and social diversity of the Brazilian population 4 . There are descriptions of extension experiences with indigenous populations, based on the mapping of indigenous health policies and services 5 , in specialized outpatient clinics in the urban space with the objective of working in the care networks and construction of intercultural practices 6 , or even in the experience with the primary health care service in villages 7 and in the daily lives of indigenous families 4 . Other initiatives also work with the concepts and practices of health of indigenous peoples in the curricula or elective courses, with emphasis on the presence of indigenous university students in these experiences. Taking as reference the current National Curriculum Guidelines for Undergraduate Medical courses 1 , activities in these contexts can identify ways to build competences to respect human singularities and social groups where ethnic-racial issues are present. Therefore, the Îandé Gûatá Extension Project was developed by two professors, a family and community doctor and a sanitarian physical therapist, and 19 students from different periods of the medical course at School of Medical Sciences of Paraíba (FCM/PB). Its guiding principles were the PHE and Popular Extension. The activities focused on the encounter between the indigenous population and extensionists, allowing the construction of dialogic relationships and a sense of community work. The choice of working with the indigenous population was favored by the experience of one of the teachers when working as a doctor of the multidisciplinary team of indigenous health in the Potiguara villages 8 .
The monthly meetings with the Potiguara people took place between the years 2013 to 2015, on Saturdays, with activities from 7 am to 5 pm, when students experienced the daily life of the village with the indigenous people. Moreover, there were weekly theoretical-reflective meetings at the medical school, with discussions and extended material based on experiences 4,8 . The Potiguara people live on the north coast of the state of Paraíba and have a population of about 19,000 indigenous individuals 9 . They are in a constant process of social and cultural reorganization, triggering important achievements, such as the demarcation of their lands; political and institutional representativeness (City Halls and City Councils, indigenous school education, health policies, environmental and development policies) and a renewed interest in traditional cultural expressions (toré ritual, Tupi language, body painting, book and video productions) 10 .
At the university level, the Popular Extension is a starting point where students, teachers and technicians are allowed an immersion into the social reality, through a participative and shared construction, experiencing its dynamic and complex processes, their pains and joys and establishing a dialogue with the protagonists of the reality 11 . This was the understanding of extension that guided the activities of the Îandé Gûatá Project, whose name means "Nossa Caminhada" (Our Walk) in Tupi.
Considering the closure of the activity cycle of this extension project, it was necessary to analyze the group' s experiences, and the study presented in this manuscript was carried out, with the objective of describing the lessons learned by the extensionists.

METHODOLOGICAL PROCEDURES
This is a study with a qualitative approach, carried out with participants from the Îandé Gûatá Extension Project. As a theoreticalmethodological framework, discursive practices and the production of meanings were used 12 , which seeks the production of meanings through ordinary language and everyday conversations.
For the construction of data, the use of the 'talking circle' 13,14 technique was chosen, due to the approximation with Popular Extension principles, based on shared constructions of knowledge in dialogue spaces. Therefore, the talking circle used as a research technique makes it possible to understand the inclusion of researchers in their field and the work experienced in daily life 14 , because in this case, it is interesting that the subjects be active in the production of knowledge, functioning as a strategic methodological device supported by the radicalization in the construction of a democratic science, seeking to demystify the neutrality fallacy 13 . Characterized as a space for spontaneous conversations and without a script of pre-established questions 15 , this research technique allows greater exchange of information between researchers and participants, starting with the exposure of a topic to the group, followed by discussions, developments and stances of those present 16 . The talking circle has its principles based on the logic of Popular Education 17 and works in a dialogic way, focused on the collective construction between knowledges.
For this research, a talking circle was held with the 13 medical students who were extensionists at the end of the Îandé Gûatá Project. It was supervised by the two coordinating teachers of the extension project, lasting 2 hours and 17 minutes. In the beginning, the objectives of the research were explained, reinforcing the voluntary participation, in addition to the need to agree with the Free and Informed Consent form. It was suggested to the participants to evaluate the Îandé Gûatá Extension Project and discuss remarkable experiences and learning. In the conversation, the group rescued their own experiences, defending their positions and presenting their convergences and divergences, with brief interventions by the two facilitators. It should be noted that this talking circle took place specifically to carry out this research.
The talking circle audio was recorded, and the researchers transcribed the material in its entirety, seeking guidance from the naturalist transcription 18 , replacing the names of the participants by codes and guaranteeing the confidentiality of identities. A Dialogic Map was created for the initial analysis process to bring the researchers closer to the materials and discourses, dialogic interanimation and ruptures 19 . In this context, we sought to associate the research objectives and the subjects' speeches, allowing the recognition of the linguistic repertoires that emerged during the talking circle.
Linguistic repertoires are the first unit of discourse analysis, characterized by the set of terms, descriptions and multiple ways of talking about the experience 20 . Based on this material, statements, voices, interpretative repertoires, times and ruptures were identified 21 . The analysis of the linguistic repertoires from the Dialogic Map made it possible to focus on the positions, relationships and controversies arising from it 21 .
Before starting the investigations, this study was approved by the Research Ethics Committee of FCM/PB, with CAAE number 44662015.7.0000.5178.

RESULTS AND DISCUSSIONS
Three sets of meanings, related to the experience of participating in the Îandé Gûatá Extension Project, were defined: (1) University Extension as a counter-hegemonic space of medical training; (2) the development of general competences for the future health professional; (3) the encounter between different cultures in the extension experiences. The discussions of these results were carried out based on theoretical references of the PHE, indigenous health and competences in medical education.
Set of meanings 1.: University Extension as a counter-hegemonic space of medical training "Here is a place that is exactly for you to open that closed mind of yours".
In this first set of meanings, students' speeches are presented in a reflection on university extension as a counter-hegemony strategy in medical education. The current paradigm in most medical courses is the biomedical one, based on the Cartesian model of science, conceiving the body in a biomechanical way, with intense specialization and separation between normal and pathological, biological and social 22 .
In medical education, the biomedical model considers the clinical aspects as the most important to produce a good professional, with the mastery of other skills considered less relevant, such as sociocultural skills. At this point, it is important to highlight the challenge when meeting this dominant paradigm while addressing social issues, as they operate from different epistemological principles. While the first works in an exclusive logic, where a new technique, procedure or product must replace the previous one, Social Sciences operate with distinct and complementary schools of thought, so as not to be excluded and thus, persist 23 . The extensionists' speeches showed that the university extension allowed the approximation of these two fields: Here we can get to know, experiment the different.
The extensionists stressed that it is important to experience dealing with different people and that the social reality is related to the extended conception of health. In the community, the experience of daily life and health conditions required a dialogue of knowledge that goes beyond the technical training in health 24 , including political and social perspectives 11 . They also brought in their speeches the resistance by other college students when talking about this experience, which reinforces the hegemony of the biomedical model in training: The biomedical model admires the homogeneity between the diseases and also the ways the students think, dress and act, with attitudes that are different from the majority being little accepted. In contrast, popular extension values diversity and demonstrates that its protagonists are open to changes based on the experiences they have had 4 , while the traditional model tends to suppress these practices.
In popular extension, there is a contribution to the formation of health professionals who are more empathetic, ethical and committed. This approximation between academia and social reality generates mutual strangeness, restlessness and leads those involved to a critical reflection on their position in the world 25 .
In the statements below, the students reflected on the space of extension as a possibility to produce diversity: There is not just any group in college that is so mixed, so full of different people. The university extension was associated with expressions such as: local reality, knowing, living with the different, life enrichment, a differentiated look, dealing with the patient, opening your closed mind, mixed group, countless learnings. When referring to students who had no contact with the extension, they associated them with expressions such as: not prepared to live with the different, resistant to the new, focus on workload. In this comparison, the impact of popular extension on the creation of criticism was evident, beyond the biomechanical and technical training 11,22 .
Taking a university extension while attending a Medical course with its strenuous workload was considered a challenge, requiring effort from students and teachers. Thus, horizontal relationships and the exercise of understanding were necessary for the group to be able to grow together, in a relationship between educator and students, in which everyone taught and everyone learned 17  The understanding of the extension project as a space for exchange and, above all, the construction of knowledge, was only possible due to the stimulus to the extensionists as protagonists. In this case, teachers acted as triggers for an identity learning process, where students had an active production. This was evident in terms as: working with autonomy; do different; take over; have faith in yourself; motivate you; light the fire. After that, the students brought elements to their speeches that denote the achieved autonomy: If we want this to work, we will have to do it in a different manner.

I put in my two cents' worth.
Along this path, an aspect highlighted in the speeches is the fact that the project' s administration was carried out through shared management, using the talking circle method 23 . They addressed the division of tasks, but also the camaraderie between colleagues and the energy of new members in moments of extension fragility, along the path of the collective construction: I learned here to fully share the roles.
When someone was discouraged, someone did something.
Because everyone has to want it, let's make this thing work.
Thus, the extensionists showed in their speeches that, through the dialogue in the talking circle, the closure of the extension cycle was a natural process, with movements constructed by themselves and the mediation carried out by the teachers. The students elucidated the educational leaps they achieved with the university extension. We used the concept of inclusive and dialogic competence 26,27,28 as a reference for presenting and discussing the results of this set of meanings.
Professional competence is the habitual and judicious use of communication, knowledge, technical skills, clinical reasoning, emotions, values and reflection in daily practice for the benefit of the individual and the community 25,29 . The perspective of the dialogic approach works based on two ideas that complement each other: the combined development of attributes/performances (cognitive, psychomotor and affective) that follow different ways of performing essential tasks and characteristics of professional practice; recognizes and considers the history of people and societies that legitimize the attributes and expected results in that particular professional area 28 .
In this sense, the students brought in words that were repeated or emphasized, such as: growing up, looking, learning from mistakes, opinion, more open mind, (towards the different and to criticism), adaptation, learning: I think everyone here will have a much more comprehensive look in relation to anyone who arrives.

You will know that behind that person there is a history and a whole life and context.
The speeches pointed to the constant need to practice reflection for the professional future, since they need to be open to criticism, to different opinions and to have a sensitive look for the integral care of people. These aspects corroborate the idea that competence is context-dependent, being a statement of the relationship between a skill, a task (in the world, service or health system) and the context in which these tasks occur 27 .
This explanation allows a more open process of exploring the different conceptions, interests, values and ideologies that invariably rule and determine the intentionality of educational processes 28 . Therefore, the use of problematization as a methodological strategy made it possible for students to be in the real-life spaces of indigenous people and, in the following stages, to reflect on the practice and return to reality with a more grounded and debated reading of the world 17 .
The students assessed that the university extension organization model favored the members' autonomy and teamwork. The group showed strength in being open to discussions in the perspective of growth and continuous and active learning: This is a group where I think everyone knew how to respect the other. Shared management, this equity made all the difference, because that way I felt that everyone there was responsible.
The evaluation of students in relation to the shared management of the project stimulated performances, from three perspectives: 1. collaborative learning perceived by the group' s cohesion, while respecting the different opinions and feeling of belonging; 2. acquisition of an attitudinal attribute of teamwork; 3. meaningful learning.
Working in small groups and investing in an extension format in which management is everyone' s responsibility and task facilitated the interaction and made collaborative learning possible. Moreover, learning through practice allowed the acquisition of knowledge, skills and the development of attitudinal attributes essential for adequate future professional performance 30 .
When the learning process is triggered by everyday life, meaning is built according to your motivation to learn and the potential value that new knowledge has in relation to its use in personal and professional life. Therefore, the process that favors meaningful learning requires an active and critical posture, on the part of those involved in learning 31 .
The group thought it was noteworthy the development of scientific works and their presentations, which allowed the development of other potentials by the extensionists. They described an improvement in the capacity to write, to use the tools available for that purpose, of communication in oral presentations and expressing themselves on a daily basis. The distance between the practices that a person already masters and the new ones acquired can be reduced by the interaction of different people and skills, named by Vygotsky 32 as a zone of proximal development.
In the students' evaluation, the challenge of breaking the excessive fragmentation of knowledge and expanding ethical awareness in the production of new knowledge 33 was important to build a better performance in the cognitive field and in written and spoken communication skills.
Moreover, meeting the learning needs of everyone involved in an educational initiative guarantees respect, acceptance, inclusion and commitment 34 . Without a doubt, this is not a simple and romantic process, so it is essential to highlight that the teachers' mediation was a critical success factor. This analysis was made by the students themselves and reflected in the research talking circle: they understood that the teachers, even though they were not the center of the process, had a fundamental role in the intentionalities, in the articulation of different points of view and as a support in times of group crisis.
This set of meanings allowed a glimpse of competence gains, in a dialogic perspective, for the construction of students' identity and role in a future professional life. As a complement, it reinforced the role of university extension, based on adult learning and education as the practice of freedom and autonomy 17  In this last set of meanings, we present, based on the extensionists' speeches, the encounter between different cultures in the approximation between Medical students and Potiguara indigenous people. Thus, it is necessary to understand that, at the same time, an evolutionary understanding, with a strong Eurocentric character still persists, which influences Brazilian society, favoring the imaginary that the native peoples are primitive and little evolved. The fact is that the historical process about the concept of culture in Europe during the Illuminist period, with the description that each society would go through the same stages until it became a more developed society, still favors the understanding that to be evolved is to be closer to the European society 35 . The students' speeches brought what echoes in the voice of society: One day, I was there at the hospital, then a Potiguara shaman arrived to see his brother who had had a stroke, or something like that. Then I heard one of the surgeons saying: 'Ah, these indigenous people, they are primitive, I don't know what else, This posture had an impact on the initial contact relations between the indigenous people and the students, who were uninformed and insecure when they first arrived at the village, which was deconstructed over time:

You fall into a place while you are wearing a blindfold and you don't know what you're doing. Then, with the visits, we have learned.
In their speeches, they demonstrated a surprise that the reality did not correspond to the initial expectation about the villages -closely related to the romantic view of the generic indigenous individual -when faced with customs and practices similar to those of their own daily lives: We immediately lose that illusion that we had, that we would find them dressed in the characteristic way, wearing a headdress.
We were very surprised with the history of pay-TV packages that were sold in the village. We still had that idea of an indigenous individual closed to the world.
In this context, it is clear that ruptures occurred, in a construction of learning based on what is lived, while being open to be transformed by experience and the affections caused by it, in a direct relationship between knowledge and human life 36 . Thus, the extensionists began to question their own ethnocentric viewpoint through cultural relativism, considering the diversity of forms of community and family organization, and overcoming the evolutionary nature of culture by incorporating the idea that it is dynamic, and not static 35 .
I remember that leader, on that first visit, who sat there at the foot of the stairs at his house and surprised us with such intelligence, that we could never imagine.
We found out that the flour mill house had a community function and that you paid for it. It showed us a vision that we had not been able to have.
The students' speeches focused on the process of experiencing and overcoming prejudices, which was made possible through the experience with the different, in a process of recognizing the conflict and making it into a strength in the relationship. In the students' speeches, having their skin painted with indigenous drawings was repeatedly disclosed as an experience that generated conflicts and disagreements, but also knowledge. Consequently, they built new understandings that could not be developed based on activities that were strictly planned and that would prevent something unforeseen and spontaneous from happening 36 .
In the approximation between the different cultures, the students' speeches demonstrated the respect and tolerance made possible by the recognition of specificities related to habits, customs and beliefs. They also emphasized the understanding that they come from a different culture, but not a hierarchically inferior one 37 . In an indigenous assembly in which they were able to participate, they recognized differences regarding the organization and the relationships between people: One of the most interesting things I saw was that they kept shaking the maraca so that the person would not stray from the subject. But this is different when you are an elder. They respected the elder and did not shake the maraca. He had the preference. It was the respect he had, that a lot of people don't have in the city! There was the general population that did not have any specific position and they were there! Also fighting and saying that they were following, that they wanted to go to Brasilia when they went to fight. I found it very organized. If it were me, I wouldn't even know what that was about. I used to see it as if they were taking advantage of their historical condition to get everything. And I realized that this is not it, understand? They have their own ways when they fight. It is one of their strengths, they are not just oppressed people.
Therefore, the possibility of recognizing that a culture is different from yours and that it must be respected appeared in the speeches, bringing an important learning: cultural competence. Cultural competence means the capacity to understand and effectively respond to the cultural needs brought by patients, horizontally, without hierarchizing values and practices, overcoming prejudices 38 .
I always saw them saying that they had to show their culture and that they didn't have to feel ashamed, that they had already acquired a lot, but they should never be ashamed of dancing the toré. I thought that was beautiful. When identifying and working with a different culture in the health field, it is possible to recognize it as a set of symbols and meanings that allow individuals from a group to interpret the experience and direct their actions. This definition of culture as intertwined systems of interpretable symbols, within which social events, behaviors and institutions can be intelligibly described, makes it possible to understand health (and, moreover, illness) as a system that is social and cultural in its origin, structure, function and meaning 39 .
Therefore, similarly to other studies, it is clear that medical education must address the needs of patients from culturally heterogeneous populations and, for that, it is necessary to take Medical students to these different scenarios, including remote and indigenous areas, and that the university extension can be one of these spaces in the path of the training of doctors that are more aware of the different socioeconomic and cultural realities of Brazil 40,41 .

FINAL CONSIDERATIONS
Based on the analysis of the extensionists' speeches, it is observed that the evaluations in the Îandé Gûatá Extension Project occurred as a continuous and systematized strategy to redefine the practices and possible changes in the learning path. Therefore, the attitudes of running a project under permanent evaluation, of building it in a shared manner with the indigenous people and of using diversified strategies in their daily lives, were recognized. These attitudes favored gains in the attributes of: knowledge, allowing for reflections, identification of gaps and better understanding of the health-illness process in the context of the indigenous population; skills to make and receive criticism, of teamwork and dialogue between different cultures; and attitudes, expanding the attitude of professionalism, understanding and acting on ethical issues and the construction of social commitment. Therefore, they highlighted the development of general competences for the future doctor, but also more specific ones, such as cultural competence. The completion of the talking circle at the end of the cycle, part of this study, confirms this information, as well as highlights the previous procedural evaluations as very expressive from the point of view of the power in the mobilization of students.
Additionally, they disclosed the understanding of university extension as a counter-hegemonic training space, in the encounter between different cultures and in the development of competences. They pointed in the direction of social commitment, reinforcing the power of the Popular Education perspective in the training of health professionals.
On the other hand, they demonstrated that their training was still impregnated by the technical dimension of the work and included in the curriculum "grid" of the course. In all these aspects, there is the challenge of dialoguing in the polarity in order to approximate the distances in the institutional space; in cultural conflict; and between understanding and action. Moreover, with the clashes, criticism, flexibility, sharing and hope also appeared.
Or maybe "to hope"? According to Freire' s ideas 42 , to hope is to "go after, to join, to not give up. It is being able to refuse what rots our capacity for integrity and our active faith in works". This collective of students, within the limits of this experience, hoped, together with an indigenous community, to approximate these distances, in a collective commitment to produce change and social transformation.