Speech, language and hearing teaching-clinic: waiting list management

ABSTRACT

Teaching-clinics aim to teach-learning, besides promoting free services to the community. These assignments result in a large patient demand and long waiting lists. Our study aimed to analyze the waiting lists management in teaching-clinics of speech, language pathology and hearing sciences. We developed a literature review, through Lilacs database, in which we found 75 articles, three of interest, which reported a large consultation demand and long waiting lists in teaching-clinics of speech, language pathology and hearing sciences. The articles analyzed proposed to referral patients to different reference institutions and the criteria establishment to specific consultation in teaching-clinics. We discussed possible solutions to teaching-clinics, in the sense of not creating waiting lists and solutions for those already existent. Hence, we were able to analyze possible solutions to the waiting list management in teaching-clinics of speech language pathology and hearing sciences, providing the development of activities in research, teaching and extension - which are academic goals, therefore, from the Speech-Language Pathologist and Audiologist formation.

Keywords:
Speech, Language and Hearing Sciences; Ambulatory Care Facilities; Education, Higher; Waiting Lists; Health Services Needs and Demand

RESUMO

As Clínicas-Escolas têm o propósito do ensino-aprendizagem, além de proporcionar atendimentos gratuitos à comunidade. Com tais atribuições, nota-se o alto fluxo de pacientes e formação de filas de espera. Este estudo teve como objetivo analisar o manejo das filas de espera em Clínica-Escola de Fonoaudiologia. Realizou-se uma revisão de literatura, por meio da base de dados Lilacs, em que foram localizados 75 artigos, sendo três incluídos, os quais relataram grande demanda de atendimentos e longas filas de espera em Clínicas-Escolas de Fonoaudiologia. Os artigos propuseram encaminhamentos a outras unidades de referência e o estabelecimento de critérios para o atendimento específico da Clínica-Escola. Foram discutidas possíveis soluções para Clínicas-Escolas, no sentido de não formação da fila de espera e soluções para as já existentes. Portanto, puderam-se analisar possíveis soluções para o manejo da fila de espera em Clínicas-Escolas de Fonoaudiologia, favorecendo o desenvolvimento de atividades de pesquisa, ensino e extensão - objetivos do Ensino Superior, portanto, da formação em Fonoaudiologia.

Descritores:
Fonoaudiologia; Instituições de Assistência Ambulatorial; Educação Superior; Listas de Espera; Necessidades e Demandas de Serviços de Saúde

Introduction

In teaching-clinic there are treatments (focusing on diseases) and, consequently, the student associates practice and theory, guided by teachers, supervisors and even academics. Such knowledge is built through practice- reflexing, by a student's critical positioning faced to the clinical challenges experienced¹.

Health facilities and teaching services present great value for the learning process and the possibility of student to actively build the knowledge towards the clinical practice. The tutor role is also important due to the responsibility of educate and teaching the student as a professional².

Thus, the social responsibility of the teaching-clinics is emphasized: free or low cost consulting the community of low income, under supervision of qualified professionals³.

Add to these aspects the certification of teaching-clinics to addmit patient demand referraled by the primary health care, being in congruence with the current health system in Brazil^2,3. Faced to the wide role of the teaching-clinics, we observe the large demand of patients and also the inevitable waiting lists formation. Consenquently, we verify a longer time between the first require of consultation until getting a space for the treatment required⁴.

The waiting time to patients' admission in the teaching-clinic is related to the severity of the health disorder presented, holding up even more the development of communication abilities, reducing the expectations of a favorable prognostic and a fast solution (regarding the treatment to be initiated)⁵.

Specifically, regarding teaching-clinics in the Speech Language and Hearing area, we often observe the priority of individualy consultation, contributing to long waiting lists and resulting in evasions and treatment delay⁶. These incidences prejudice the consulting, and consequently, patient's and his family's cooperation have direct influence in the evaluation of student's intern discipline⁷.

Since we consider being necessary to verify ways of empowering academic formation and community service, in this study, we aim to analyze the management of the waiting lists in teaching-clinics of Speech Language and Hearing sciences based on specific literature on both subjects.

Methods

Initially, in order to support our discussion, we conducted a literature review⁸ through database Lilacs during January 2016, regardless time delimitation, using keywords in English and Portuguese. We searched crossings in the following DeCS/MeSH keywords in Portuguese. "Lista de Espera" (waiting list) (1), "Fonoaudiologia" (Speech Language Pathology and Hearing science) (2); "Sistema Único de Saúde" (Unified health system) (3); and also we searched the free term "Clinica-Escola" (teaching-clinic) (4). As a result, we applied the search strategies below (Table 1).

Also, we tried out searches on Pubmed and Scopus database, with keywords in English, although there is no success on the search, so they were not considered.

Table 1:
Crossing Keywords and word used in the search strategy

We adjusted as inclusion criteria: Specific studies regarding the situation and possible solutions to waiting lists in health facilities towards higher education in the Speech Language and Hearing sciences scope. As exclusion criteria, we eliminated articles that were not in full text in the system of the University where this research was conducted.

For article selection, we read the tittles and abstracts of papers found (first selection stage) and when the articles satisfied criteria of inclusion, we read them in full text and analyzed objectives, methods, results and conclusion (second selection stage).

The selected articles based our discussion of possible solutions for waiting lists. Also, the information complemented extensive literature, including discussions already existent in other professions.

Literature Review

In sum, we found 75 articles using the strategies previous stablished. Table 2, presents the results, that is, the number of articles found in two selection stages.

Table 2:
Results from the crossing keywords and word used in the search strategy: Articles found, selected by title/abstract and full text Reading

The articles selected that satisfied the criteria of inclusion and exclusion are presented in Figure 1.

Figure 1:
Analysis of the selected articles, according to objective, methods, results and conclusion

The first selected article reported the scene experienced in teaching-clinics of Speech-Language and Hearing sciences related to the great demand of consults and the long waiting list, causing damages to the community and the students. In conclusion, the study brought the characterization of patients' profile of a Speech Language and Hearing sciences teaching-clinic as well as the origin of referrals, as a way to improve the organization of the teaching-clinic. However, researchers did not discuss solutions more reflective on the formation aspect of waiting list⁹.

In the second article, it was verified the high number of patients with Speech, Language or Hearing complaints in the waiting list of a public teaching hospital, whereas part of the demand was addmited by the facility; part waited for consultation; and some subjects were sent back to the original unit. In relation to the demand, researchers also observed the lack of criteria established regarding the severity level. Thus, proposing the creation of regulation models for population access, increasing the solvability and reducing the time in waiting list.

Therefore, their study considers the increase on numer of speech-language therapists and audiologists hired in the teaching-clinic for the assistencial consulting, as well as in the units and cities of origin of the patients, providing a better demand organization in the attention levels. We add to the importance of the creation of regulamentation models for Speech Language and Hearing services according to severity level, by stablishing criteria for the cases that the service is able to take care of, or those that must be referral to other reference facilities¹⁰.

To conclude, the third article displayed a solution applied in a Basic Health Unit, but it could be extended to teaching-clinics aiming to better understand the actual reality of patient demand by developing proper management for actions that optimize waiting lists¹¹.

Next, we eclosed our considerations, raised by extended literature on Speech Language and Hearing sciences and health in general, on possible solutions for waiting lists of teaching-clinics.

Health Promotion

In order to not having constantly development of Speech Language and Hearing problems that are often restrained in the teaching-clinics, it is necessary that teachers in this area stimulate actions of health promotion.

The comprehension of health promotion widely aims subject's autonomy in their sociocultural context, capable to evolve from the individual to collective action, provoking transformations in population's conditions of life¹². Therefore, it is appropriate to stimulate, even in teaching-clinic spaces, the active community participation in maintening health and life quality, emphasizing the social role by improvement of individual and communitary control¹³. In this context, we observed educational actions in health focusing in population's empowering regarding self-care.

When there are Speech, Language or Hearing problems, and the orientation given in the waiting room is important, since it can reach out escorts and the patients themselves, preventing further alterations or aggravation¹⁴. With this dynamic, we expected long-term diminish communication disorders in the population involved in the actions proposed¹⁵.

To this action is added another factor: the training of communitarian health agents, conducted outside the teaching-clinic, that is, in the Primary Attention in Health. The communitarian health agent becomes a strong partner in the health promotion and multiplication of behaviors favorable to health, specifically, in processes and disorders of communication.

Attesting this proposal, studies were developed regarding hearing health¹⁶; aging process and its pathologies related to Speech, Language and Hearing sciences¹⁷; human communication, disorders and forms of intervention¹⁸.

Also, is relevant to emphasize this strategy importance to increase assertive referral¹⁵. Another aspect to be raised is the necessity of continuing these actions, as we verified changes in communitarian health agents personal, as well as of other members that compose health teams, being possibly damaging to continuing the actions developed in the area¹⁹.

Survey of the Demand Profile

Similar to Costa and Souza's study (2009)⁹, this strategy consists on identifying patients' profile who seek the teaching-clinic, regarding sociodemographic and clinical data, so consultings can be adequate to community necessities.

This action becomes essential for health care and follows curricular requirements, that is, it conjoins with the organization of consulting dynamics and optimizes the flexibility of schedules for the consideration on the practical clinic. Moreover, it enables a better organization considering the continuous evaluation of teaching-clinic services, generating a cycle in the adequacies of the service and demand⁶.

The information about users and their complaints must identify the area that presents the higher demand of waiting list⁹ and search the therapeutical process, so it can be traced a specific planning for the singularities of each Speech Language and Hearing area.

Data Management

The importance of the organizational basis of teaching-clinics begins with an efficient program of managing patients demand and professionals involved in this system, in order to all information relative to the patient and the clinic are easily accessed.

Therefore, contributing for the establishment of consulting planning, information systematization, that can contribute to research development, a requirement of academic field²; and also, assist the disponibilization of epidemiologic data contemplating the principles of the Unified Health System (SUS).

Admission

Ever since in teaching-clinics there is a different age public and with individual complaints, and also considering the importance of the National Politics of Humanization principles, for the admission process there is a strategy for handling the waiting lists.

The admission is a guideline that influences in the way to promote health and can be developed in teaching-clinic, even knowing health needs are subjective for each person. According to Costa et al. (2012)²⁰ it is important to embrace, listen, discuss and identify patients demand in order to guide the entrance in the service and the treatment given to users in accordance with the politics cited when adopting an attitude towards user and their necessities, as well as the possibility in reorganizing the team work when receiving the free demand.

There are different ways of embracing, since it is a constructive practice of care associations. A possibility is to apply group embracement which can bring emotional and social benefits by presenting therapeutical function faced to the relation established among the participants in the discussion of their problems, being able to lead them to the confrontation of their difficulties²⁰.

It is also necessary to adjust the environment aiming to guarantee comfort in the spaces for meeting and exchanges, as well as proper and biosecurity conditions in work.

An attitude of qualified listening with the commitment in giving answers to the health necessities brought by user, is possible to provide considering their culture, background and capacity to evaluate risks; targeting the resolutive capacity and directing them, when necessary, to other health facilities, for assistance endurance by establishing the communication with these services, securing the effectiveness of these referrals ²¹.

User-centered practices have to be analyzed by the techonologies in health point of view such as the "soft technologies".

According to Merhy (1997)²², they are in the active live work between workers and users, in the ways of listening and selecting; when dealing with the unpredictable; establishing bonds that reflect in the management of the technologies soft-hard and hard, thus providing the development of welcoming, attaching, accounting actions and making subjects autonomous.

The communication is an essential aspect that guides the moment of embracing, making possible patients to express their expectations in a welcoming and resolutive listening²³. It is in this context that the performance of the speech-language therapist and audiologist as a communication professional should be stimulated.

Different Institutions Partnership

The partnership with other public facilities enables to direct the exceeding demand of the teaching-clinic, avoiding exaggerated waiting for consulting, extending the options for the community and carrying through the treatment at the proper moment for patient⁹.

On the other hand, when the public system is deficit or overloaded, the partnership can be articulated with the private system in favor of the resolubilidade of the difficulties brought by patients. Thus, previous knowledge of the social equipments avaiable in the city becomes necessary.

Clinical Research Activities

The resolution n^o 466 (12/12/2012) of the National Health Council set researchers' responsibility in assuring following, treatment, full assistance and guidance to volunteer subjects in researchs.

As a result, the conduction of clinical trials satisfies the academic and scientific character of a teaching-clinic and, at the same time, enables more consults to be achieved.

To exemplify the development of these studies, there are the on epidemiologic surveys that can assist in population groups' identification, illnesses distribution and factors that influence or determine this distribution²⁴. Consequently, the development of researches in the context of teaching-clinics enables the improvement of Speech Language and Hearing actions as those related to prevention and therapeutical measurements, besides providing fund to the designation of public politics in health.

In the same thought, it is reasonable to emphasize the importance of scientific research dissemination⁵, as well as the organizational systems of teaching-clinics and experience reports (since there are not many studies in this theme) guiding new practices optimizing waiting lists.

Shorter Visits

The practice of long visits with the therapist is very common in teaching-clinics of Speech Language and Hearing sciences. Although, due to the large demand and current findings of therapeutical proposals, the therapy must be reorganized with faster therapeutical sessions²⁵, admitting more patients by student and also focusing in home activities⁵, allowing more experience of the contents approached during the therapy, and involving family in the therapeutical process.

Intervention Groups Consulting

Group consulting contributes for the solution of demand and waiting lists in teaching-clinics, and also for student formation, since it does not shows only the personal assistance, demonstrating in practice, how to contribute the interpersonal relations in a different environment of the binomial therapist-patient²⁶.

Group dynamics consists in an education and therapeutical practice, positive in the re-signification of symptoms, besides promoting changes in the subjects relations. The group is a "moment" of cultural experiences exchanges and sharing knowledge that take individuals to the confrontation of difficulties. It is a tool of health promotion and prevention of illnesses that can be carried through in public or private institutions ^26,27.

Thus, such dynamics can present effectiveness as much in the promotion and prevention of the health as in clinical consulting ²⁷.

The moment of patient's evolution in therapy and the objectives proposed must be taken in consideration²⁸ on the definition of performing therapy in group or not. Individual needs must be prioritized to reach the independence or the empowerment of patient's communicative abilities.

Relative and /or Carers Group Consulting

The consults with relatives and/or carers aim to diminish the anxiety of the waiting lists, providing sharing of experiences and difficulties²⁹ and prevent evasion due to delay on starting therapy.

Along with, it is a chance to take the participants to considerations and confrontation of anxieties, as well as the o their empowerment, since it maximizes the subjects' potential in the prevention of illnesses and worsening. As an example of this type of intervention, there are the practices and researches in which relatives are therapeutically treated becoming active agents in the therapeutical process of their children ³⁰.

Consults Performed by Students of the First and Second Year of Graduation

There is a proposal in the Psychology area of consults performed by students of the first and second year of graduation, with recreative context and not therapeutical, aiming higher envolvement and practice with the role to be developed. Results revealed important prevention of the evasion in teaching-clinics³¹. These methodologies are supported by the intention of critical thinking on the practice, through a progression of the abilities and learning required with difficulties faced³².

In Speech Language and Hearing sciences, such aspect can be studied in order to verify the viability of the students' participation of the first years, under supervision of professors and assitance of students from senior years of the graduation.

Conclusion

By literature review we were able to observe that, generally the teaching clinics of Speech Language and Hearing sciences have presented great demand of consulting and long waiting lists. The solutions raised were to assigned patients to different reference institutions and the establishment of criteria to specific consultation in teaching-clinic.

The possible solutions discussed meet the fundaments of the University: research, education and extension. Reaching a balance in the execution of activities that contemplate the triad, may guarantee a new reality in the teaching-clinics, mainly regarding waiting lists.

It is evident that the fragility experienced by the effective health system and the political aspects of each territory will influence in Speech Llanguage and Hearing demands. Consequently, managing waiting lists should by guided by partnerchips among people involved, in order to provide better guidance to patients and solvability of the presented problems.

Referências

• ¹
  Oliveira BSA, Pedrozo CAZP, Macedo HO. Como receber pacientes numa clínica-escola de Fonoaudiologia: uma nova proposta. In: Lagrotta MGM, César CPHAR. A fonoaudiologia nas instituições. Ed Lovise. 1997. p. 55-60.
• ²
  Maravieski S, Serralta FB. Características clínicas e sociodemográficas da clientela atendida em uma clínica-escola de psicologia. Temas psicol. 2011; 19(2):481-90.
• ³
  Peres RS, Santos MA, Coelho HMB. Perfil da clientela de um programa de pronto-atendimento psicológico a estudantes universitários. Psicol estud. 2004;9(1):47-54.
• ⁴
  Danziger BCO, Biazin RR. A psicanálise no contexto da clínica-escola. Anais V CIPSI - Congresso Internacional de Psicologia. Universidade Estadual de Maringá [serial on the Internet]. 2012 [access 2016 May 10]. Available from: http://www.eventos.uem.br/index.php/cipsi/2012/paper/viewFile/731/402
  » http://www.eventos.uem.br/index.php/cipsi/2012/paper/viewFile/731/402
• ⁵
  Bazzo LMF, Noronha CV. A ótica dos usuários sobre a oferta do atendimento fonoaudiológico no Sistema Único de Saúde (SUS) em Salvador. Ciênc Saúde Coletiva. 2009;14(suppl.1):1553-64.
• ⁶
  Gauy FV, Fernandes LFB. Um panorama do cenário brasileiro sobre atendimento psicológico em clínicas-escola. Paidéia. 2008;18(40):401-4.
• ⁷
  Pinheiro NNB, Darriba VA. A clínica psicanalítica na universidade: reflexões a partir do trabalho de supervisão. Psicol Clín. 2010;22(2):45-55.
• ⁸
  Cook DJ, Mulrow CD, Haynes RB. Systematic reviews: synthesis of best evidence for clinical decisions. Ann Intern Med. 1997;126(5):376-80.
• ⁹
  Costa RG; Souza LBR. Perfil dos usuários e da demanda pelo serviço da clínica-escola de fonoaudiologia da UFBA. Rev Ciênc Méd Biol. 2009;8(1):53-9.
• ¹⁰
  Mandra PP, Diniz MV. Caracterização do perfil diagnóstico e fluxo de um ambulatório de Fonoaudiologia hospitalar na área de Linguagem infantil. Rev Soc Bras Fonoaudiol. 2011;16(2):121-5.
• ¹¹
  Lemos M. A integração ensino-serviço no contexto da formação do fonoaudiólogo: um relato de experiência da prática de ensino-aprendizagem no estágio de saúde coletiva. Rev Baiana Saúde Pública. 2012;36(4):1068-76.
• ¹²
  Dalmolin IS, Faria LM, Perão OF, Nunes SFL, Meirelles BHS, Heidemann ITSB. Dialogando com Freire no círculo de cultura: uma estratégia de promoção da saúde. Rev enferm UFPE. 2016;10(1):185-90.
• ¹³
  Wallerstein N. Powerlessness, empowerment, and health: implications for health promotion programs. Am J Health Promot. 1992;6(3):197-205.
• ¹⁴
  Reis FV, Brito JR, Santos JN, Oliveira MG. Health education in the waiting room - case studies. Rev Med Minas Gerais 2014;24(Supl 1):S32-S36.
• ¹⁵
  Diniz RD, Bordin R. Demanda em Fonoaudiologia em um serviço público municipal da região Sul do Brasil. Rev Soc Bras Fonoaudiol. 2011;16(2):126-31.
• ¹⁶
  Alvarenga KF, Bevilacqua MC, Martinez MA, Melo TM, Blasca WQ, Taga MF. Proposta para capacitação de agentes comunitários de saúde em saúde auditiva. Pró-Fono R Atual. Cient. 2008;20(3):171-6.
• ¹⁷
  Arakawa AM, Sitta EI, Maia Junior AF, Carleto NG, Santo CE, Roosevelt S. et al. Avaliação de um programa de capacitação em fonoaudiologia para agentes comunitários de saúde na Amazônia brasileira. Distúrb Comun. 2013;25(2):203-10.
• ¹⁸
  Brites LS; Souza APR; Lessa AH. Fonoaudiólogo e agente comunitário de saúde: uma experiência educativa. Rev Soc Bras Fonoaudiol. 2008;13(3):258-66.
• ¹⁹
  Cáceres JV, Pacheco AB, Fedosse E, Mello JG. A potencialidade do sistema de informação de atenção básica para ações em fonoaudiologia. Rev. CEFAC. 2014;16(5): 1723-9.
• ²⁰
  Costa JC, Giustti SA, Murofuse IS, Gumz AL. Acesso ao serviço de fonoaudiologia: a implantação do acolhimento no município de Toledo-PR. Rev. CEFAC. 2012;14(5):977-83.
• ²¹
  Brasil. Ministério da Saúde. Secretaria de Atenção à Saúde. Núcleo Técnico da Política Nacional de Humanização. Acolhimento nas práticas de produção de saúde / Ministério da Saúde, Secretaria de Atenção à Saúde, Núcleo Técnico da Política Nacional de Humanização. 2. ed. 5. reimp. Brasília: Editora do Ministério da Saúde, 2010.
• ²²
  Merhy EE, Chakkour M, Stéfano E, Stéfano ME, Santos CM, Rodríguez RA. Em busca de ferramentas analisadoras das tecnologias em saúde: a informação e o dia a dia de um serviço, interrogando e gerindo trabalho em saúde. In: Merhy EE, Onocko R (Orgs.). Agir em saúde: um desafio para o público. São Paulo: Hucitec, 1997. p.113-50.
• ²³
  Oliveira A, Silva Neto JC, Machado MLT, Souza MBB, Feliciano AB, Ogata MN. A comunicação no contexto do acolhimento em uma unidade de saúde da família de São Carlos, SP. Interface Comun Saúde Educ. 2008;12(27):749-62.
• ²⁴
  Gordis L. Epidemiologia. Revinter. 4ª ed. 2010.
• ²⁵
  Melo DP, Ramalho MSSC, Perillo VCA, Rodrigues LC. Terapia fonoaudiológica intensiva e fissura de palato: relato de caso. Rev. CEFAC. 2013;15(4):1019-102.
• ²⁶
  Sideri KP, Botega MBS, Chun RYS. Population profile of the Evaluation and Prevention Group of Language Disorders (EPGLD). Audiol Commun Res. 2015;20(3):269-73
• ²⁷
  Souza APR, Crestani AH, Vieira CR, Machado FCM, Pereira LL. O grupo na fonoaudiologia: origens clínicas e na saúde coletiva. Rev. CEFAC. 2011;13(1):140-51.
• ²⁸
  Cernescu RP, Leite CAG, Lessa WM. Reabilitação fonoaudiológica em grupo de pacientes afásicos. UNOPAR Cient, Ciênc Biol Saude. 2000;2(1):77-91.
• ²⁹
  Cardoso AM, Munhoz MLP. Grupo de espera na clínica-escola: intervenção em arteterapia. Rev SPAGESP. 2013;14(1):43-54.
• ³⁰
  Machado M, Berberian A, Massi G. A terapêutica grupal na clínica fonoaudiológica voltada à linguagem escrita. In: Guarinello A, Santana A, Berberian A, Massi G (orgs.). Abordagens Grupais em Fonoaudiologia: contexto e aplicações. São Paulo: Plexus; 2007. p. 58-79.
• ³¹
  Guerrelhas FF, Silvares EFM. Grupos de espera recreativos: proposta para diminuir o índice de evasão em clínica-escola de psicologia. Temas Psicol. 2000;8(3):313-21.
• ³²
  Mitre SM, Siqueira-Batista R, Girardi-de-Mendonça JM, Morais-Pinto NM, Meirelles CAB, Pinto-Porto C, et al. Active teaching-learning methodologies in health education: current debates. Ciênc. saúde coletiva. 2008;13(Suppl.2):2133-44.

Publication Dates

• Publication in this collection
  Sep-Oct 2016

History

• Received
  03 Nov 2015
• Accepted
  06 June 2016