Formação para o trabalho no ensino das graduações em saúde

Resumo Este artigo revisa as transformações no ensino médico e no ensino da saúde, impulsionadas, de um lado, pela reforma sanitária e consolidação do Sistema Único de Saúde e, de outro, pelas Diretrizes Curriculares Nacionais, que fomentaram a interdisciplinaridade, a interprofissionalidade e a intersetorialidade das políticas indutoras para a consolidação da Educação Interprofissional em saúde (EIP). Nesse percurso destacam-se as contribuições da professora Regina Marsiglia, tanto em suas produções como em sua militância, na incansável articulação entre teoria e prática.


Introduction
The recent history of Brazilian higher education is being marked by new identity traits regarding the conception of professional training in the field of health. From the establishment of the Brazilian National Curriculum Guidelines (Diretrizes Curriculares Nacionais -DCN) in 2001 for medical undergraduate programs, growing efforts have been made to achieve a better harmony between teaching and social needs: The objective of this work is to understand the meaning of the concept of care […] a concept of education focused on the development of the autonomy of subjects, considering the educational thought of Paulo Freire. Such teaching concept focuses on the aspects related to the critique of banking education and the proposition of a liberating education, whose objective is the humanization of individuals, resulting from an educational and formative process that considers critical reflection as a link between the individual and the world. (Rosito;Loterio, 2012, p. 126) Therefore, health education must contemplate not only diseases, but also human life. Advances provided by technology and scientific knowledge must be recognized, but humanistic training becomes essential for its mode of application. This change of paradigm necessarily assumes an ethicalpolitical commitment, as described in article 3 of the DCN: "Undergraduate Courses in Medicine have as the profile of the egress/professional the doctor, with a generalist, humanist, critical and reflexive education, trained to act based on ethical principles, on the health-disease process in its different levels of care" (Brasil, 2002, p. 1).
Among the many contributions of authors who have studied this subject, such as Almeida (2003), Batista, Vilela, and Batista (2015), Marsiglia (1995Marsiglia ( , 2011Marsiglia ( , 2013Ibañez;Ianni, 2010) and Peduzzi (2001;Oliveira, 2009;Peduzzi et al., 2013), we can identify that the training of health professionals covers subjective aspects, the production of specific technical abilities and knowledge of the Brazilian National When analyzing the Brazilian proposals, Marsiglia (1995) states that IDA projects have broadened the understanding of teaching-work integration and the possibilities of transformations and insertions of pedagogical practices in health practices, in which students, teachers and workers choose the health/illness situations and living conditions of users of greater social and epidemiological relevance, jointly problematizing responses for the construction of promotion and prevention actions, thus evidencing the connection between theory and practice. IDA projects achieved greater reach during the 1980s, both in Brazil and Latin America.
The 1960s were critical when surfacing the problematization of medical training and its relationship with practice. The movement of integral medicine emerges in this context, focusing on the fragmentation of medical practice, the polarization between basic and clinical education, and the disciplinary approach of programs. Seeking to overcome this scenario, propositions to restructure educational institutions were formulated, with the creation of departments by areas of knowledge rather than isolated disciplines, so students were accompanied from their first years until boarding school, being guided by a biopsychosocial approach of the patient (Aguiar, 2006;Mota, Schraiber, Ayres, 2018).
The movement for preventive medicine was also important in this process, leading to discussions about teamwork in health, initially in curricular proposals for medical education, and later in nursing courses (Arouca, 2003;Oliveira, 2009).
Teamwork refers to health care, administration and professional training, requiring commitment from health professionals and administrators of the health system, educators, and even students, who need to be prepared/trained for interprofessional practice. For such, the articulation with the health care network is crucial, being transformed into teaching-learning environments (Peduzzi et al., 2013).
In the 1980s, the World Federation for Medical Education (WFME) and its regional associations held meetings to set goals for improving the quality of medical education. The results of these meetings contributed to the elaboration of the principles in the Edinburgh Declaration (WHO, 1988), which had strong influence on the debate on medical education and its necessary curricular reforms, particularly in Brazil (Martins, 2008).
From the implementation of SUS since 1990, changes in medical education in Brazil are driven by the need to reorient the new health care model. Thus, in 1991 the proposal "A new initiative for the training of health professionals: unity with the community: UNI Project" (Uma nova iniciativa na educação dos profissionais de saúde: união com a comunidade: Projeto UNI), with financial support from the W.K. Kellogg Foundation, was implemented in some Schools of Medicine: of Marília (SP); of Botucatu of the Universidade Estadual de São Paulo; of the Universidade Estadual de Londrina (PR); of the Universidade Federal do Rio Grande do Norte (RN). The UNI Project sought to integrate school-servicecommunity, using the service as an environment for teaching and learning, for new forms of structuring the curriculum, models and pedagogical methods (Tempsk, Borba, 2009). Peduzzi et al. (2013) drew attention to the importance of the referred changes in the administration of interprofessional education, in which the integration of disciplines in the same professional field strengthens each profession and the multiprofessionality of health teams, favoring interprofessionality and collaborative practices, concepts that updated the notion of teamwork.
Although there is no consensus on the best moment to initiate interprofessional education, the introduction of these programs in the health area has been stimulated and promoted by universities and government agencies in different countries. For example, in the United Kingdom interprofessional education programs have been funded in undergraduate and graduate courses, with investments in research on the field since the 1990s (Carpenter, 1995;Hind et al., 2003;Horsburgh;Lamdin;Williamson, 2001;WHO, 1988).
This movement for changes in medical training and the implantation of the new health system in Brazil determined the new DCN for undergraduate courses in health, which were approved between 2001 and 2004, incorporating as general competences to be acquired: health care, decision-making, communication, leadership, administration/ management and permanent training; these are common elements of health education that are complemented by the specific skills and abilities required for each course/profession. Curricular flexibility is a fundamental premise of these guidelines, it gives higher education institutions greater autonomy and diversification of training paths, as well as the conception of the specific competences of each area through discussions between committees of teaching specialists and consultation of various documents , such as the 1988 Federal Constitution, the Law on Guidelines and Bases (Lei de Diretrizes e Bases) and the Final Report of the 11 th National Health Conference (Relatório final da 11ª Conferência Nacional de Saúde) (Almeida, 2003).
Since 2003, through the installation of the Department of Labor Administration and Health Education (Secretaria de Gestão do Trabalho e da Education em Saúde -Segets) in the Ministry of Health, discussions on the relationship between health practices and higher education in Brazil became broader, being articulated alongside MEC. Government initiatives that sought to stimulate and promote curricular changes became common, emphasizing training oriented to work with multiprofessional health teams and integration among courses (Brasil, 2005).
Among the joint policies conducted by MEC and MS for changes in professional training we can highlight (Alves et al., 2013, Brasil, 2002, 2005:

Program for Incentives to Curricular Changes
in Medical Courses (Promed, 2002): program of internships in university hospitals and public network services to enable the training of medical students when caring for the new health realities of the population and health system, starting from primary health care.

National Program for the Reorientation of
Professional Training in Health (Pró-Saúde, 2005): initially aimed at undergraduate courses in medicine, nursing and dentistry, the program sought to promote and integrate teaching-service, the reorientation of professional training based on an integral approach of the health-disease process and the insertion in Primary Health Care, to promote transformations in the services provided to the population.  (PET-Saúde, 2008): promotion of intersectoral actions, assuming the integration between teaching-service-community and presenting, among other objectives, the promotion of introduction to work and experiences for health students according to SUS's needs (Brasil, 2008). In August 2018 a new decree for PET-Saúde was proposed with the theme "Interprofessional Health Education" (Pinheiro, 2018). 4. More Doctors for Brazil Program, 2013: rearrangement of the number of spots for medical courses and medical residency. The program recommends the rearrangement of curricula, proposing the fulfillment of at least 30% of the workload in Primary Care and Emergency services, respecting the minimum time of two years of medical internship during undergraduate education. Batista, Vilela, and Batista (2015) point that a triangulation between teaching-learning-care will always exist in the health area. For Marsiglia (2011Marsiglia ( , 2013Ibañez;Ianni, 2010), inductive policies seek to cover idea: (1) interdisciplinary knowledge; (2) health work focusing in the centrality of interprofessional education; (3) strengthening the relations between IES and SUS. In this context, interdisciplinarity, multidisciplinarity and transdisciplinarity emerge as devices to integrate knowledge, building new theoretical and methodological frameworks, in addition to attributing new meanings to the field of health practices (Peduzzi et al., 2013).
Health work presents peculiarities that make it different from other works in society. The recognition of its complex nature requires a greater range of knowledge and professional diversity that determine several health practices, the incorporation of technology and organization of services of the area. Technical divisions point to differentiated degrees of professional interrelationship, requiring collaborative action and being guided by the autonomy and complementarity of each profession (multiprofessional), as well as the establishment of competencies and attributions (uniprofessional). However, such conditions are not consolidated in health education, thus requiring Interprofessional Education (Educação Interprofissional -EIP) processes focused on producing effective health care practices for the population (Coster et al., 2008;Norman, 2005).
EIP acts on the health, education and work interfaces, allowing the integration of knowledge and practices through intersectoral and interinstitutional scenarios. Considering this idea, Centers for Training and Continuing Education for Family Health (1998Health ( -2002 and Centers for Permanent Education in Health (2003)(2004)(2005)(2006)

Final remarks
Regina Marsiglia was the great mentor of Pró-Saúde and PET-Saúde at the Faculdade Ciências Médicas da Santa Casa de São Paulo (FCMSCSP), facilitating the dialogue and discussion between this institution and São Paulo's Municipal Health Department to create a collaborative training network that resulted in the development of a cooperation system between the Basic Units in São Paulo downtown and the specialized services of the central hospital of the Santa Casa de São Paulo.
Students of medical, nursing and speech therapy undergraduate courses participated in health promotion actions that were collectively constructed. One of its most emblematic projects discussed the culture of violence and accident prevention, concepts rooted in the different social groups that live in downtown São Paulo (Marsiglia, Ibañez;Ianni, 2010).
Considering the pedagogical perspective, this opportunity was used to update faculty members of the FCMSCSP regarding the theoretical basis, pedagogical approach and professional practice, constructing modules in which the contents of social, psychological and clinical disciplines were articulated to highlight the complex nature of health problems and their social determinants.
Brazilian studies on interprofessional education in undergraduate courses in health and its effects on health practices are more recent and refer to specific experiences, thus requiring a more rigorous and systematic approach that compares the results of uniprofessional and interprofessional education. In this perspective, analyzing the practices of students with different learning experiences during their training can contribute and increase knowledge about interprofessional education.