Atualmente o vídeo tem sido considerado por alguns autores o padrão-ouro para ensino de habilidades de comunicação e o vídeo feedback (VF) tem se mostrado eficaz no treinamento de habilidades em várias áreas profissionais. Entretanto, há poucos estudos sobre os efeitos das diferentes metodologias de VF. Este estudo propõe explorar as potencialidades, desafios e efeitos do VF de filmagem de consultas em contexto real, para uma avaliação formativa em habilidades de comunicação, com médicos residentes, em um programa de Atenção Primária. Foi conduzido um estudo pré e pós teste com um grupo controle. A intervenção constituiu-se de sessões de revisão do vídeo em pequenos grupos, na metodologia de entrevista baseada em problemas, com feedback por colegas (peer-feedback) e com um facilitador. Os 54 (cinquenta e quatro) médicos residentes responderam questionários quantitativos e qualitativos e dois avaliadores externos analisaram em vídeo, randomicamente e às cegas, cerca de 200 (duzentas) performances dos residentes com pacientes-simulados, antes e após a intervenção. Para análise dos dados foi usado ANOVA two-way de medidas repetidas e para análise qualitativa foi usado análise temática de Braun e Clarke. A metodologia de VF utilizada para avaliação formativa mostrou ser bem avaliada pelos participantes e com potencial de gerar mudança de atitudes no entrevistador. Na análise qualitativa, as principais potencialidades identificadas na metodologia foram autopercepção e o feedback por pares, e as principais mudanças na prática clínica foram a melhora da comunicação não-verbal, mudanças de comportamento, abordagem mais centrada no paciente e incorporação de prática reflexiva. Houve aumento de escores, entre os tempos, relacionados à decisão compartilhada, aviso de alerta de comunicação de má notícia e disposição para apoio ao paciente. Os desafios foram a dificuldade do facilitador em conectar o vídeo feedback com o referencial teórico e o estresse inicial para gravar-se e assistir-se em vídeo. Observamos que a análise qualitativa dos dados revelou mais informações sobre os efeitos nos participantes que a análise quantitativa. Os dados observados nos resultados qualitativos não tiveram o mesmo impacto nos resultados quantitativos. Devido à dificuldade observada em encontrar instrumentos adequados e validados para avaliar habilidades de comunicação, foi realizada em uma etapa posterior, a tradução e adaptação transcultural para o português falado no Brasil do instrumento Calgary-Cambridge Observation Guide (CCOG), com análise psicométrica. Concluímos que há uma dificuldade nos questionários em mensurar competências atitudinais e aspectos mais subjetivos de comunicação. Sugere-se mais estudos com aprofundamento na definição de parâmetros dos itens subjetivos de avaliação, conforme as competências exigidas para cada fase da formação médica. Concluímos também que para uma metodologia de VF efetiva é importante estimular a autoavaliação com uma prática reflexiva, feedback por pares focado em reforço positivo na busca de estratégias, além de um facilitador cuidadoso em relação a psicologia do aprendiz, com habilidade de conectar o feedback com uma teoria de comunicação abordada previamente. A versão brasileira do CCOG mostrou confiabilidades aceitáveis nos indicadores psicométricos, incluindo no modelo multifacetas de Rasch e assim, um instrumento adequado para auxiliar no ensino e avaliação de habilidades de comunicação no Brasil / Currently, video recordings of medical consultations have become the standard teaching approach to communication skills, and video feedback has shown to be effective in skills training in many professional areas. However, researches on the effects of different video-based feedback methodologies remains scarce. This study proposes to explore the potentials, challenges, and effects of video-based feedback methodology in real contexts for the formative assessment of communication skills of medical residents in a primary health care program. We conducted a pre/post study with a control group. The intervention was video feedback sessions with peer-feedback. Before and after the intervention, medical residents 54 (fifty four) answered quantitative and qualitative questionnaires and two raters blind assessed about 200(two hundred) video-recorded clinical examinations with simulated patients, who also scored the performances. For the data analysis, we used ANOVA two-way and for the qualitative analysis, we used the Braun and Clarke framework for thematic analysis. This video feedback methodology showed to be a well-accepted formative assessment. The main potentialities identified were self-perception and peer-feedback. The main effects in the residents\' medical practice was a better patient-centered approach, with increased scores mainly in good listening, decision-sharing, and patient support. Improvements were reported in non-verbal communication, behavior changes, and incorporation of reflective practices. Some of the challenges were the difficulty of the coordinator to link the video feedback with theoretical references and the initial stress to record and watch oneself in video. During the study, we did not find adequate and validated instruments to assess communication skills, and so in stage 2 we developed the translation and transcultural adaptation to Brazilian Portuguese of the Calgary-Cambridge Observation Guide (CCOG). This study did not find instruments that completely answered the assessment necessities regarding training in clinical communication. Further researches about assessment tools are thus required, as discussion about competence parameters in subjective items in assessment. The qualitative analysis revealed more information about the effects in communication skills than the quantitate analysis. We observed that there is a difficulty in questionnaires assessing attitudinal competences and subjective aspects in communication. We conclude that for an effective video-based feedback it becomes important to promote self-evaluation alongside reflective practices, peer-feedback focused in positive reinforcement and pursuing strategies, and a supervisor attentive to the leaner\'s psychology and able to relate the feedback with a well-defined communication theory. The Brazilian CCOG version showed acceptable reliability in the Rasch model indicators and could be part of a systematic assessment of communication skills in Brazil

In einer repräsentativen Querschnittsuntersuchung wurden 1219 Multiple Sklerose Betroffene in Deutschland zu den Auswirkungen der Multiple Sklerose auf deren Lebenssituation und ihrer Einschätzung der medizinischen Versorgung befragt. Schwerpunkte der Untersuchung, die auf einem integrativen Konzept der Patientenorientierung beruht, waren: Soziale Auswirkungen, Krankheitswahrnehmung, Alltagsbewältigung, Lebensqualität, Patienteninformation, Arzt-Patient-Beziehung, Therapieentscheidung und das ACT Programm in der medizinischen Versorgung. Negative Auswirkungen der Multiple Sklerose auf die untersuchten Lebensbereiche sind nachweisbar, aber die Einschätzung differiert in Abhängigkeit von der konkreten Lebenssituation und der Persönlichkeit. Der Schweregrad der körperlichen Einschränkungen steht nur bedingt in Beziehung zur subjektiven Einschätzung der Auswirkungen. Es bestätigt sich außerdem die besondere Bedeutung des nahen persönlichen Umfeldes als wichtigste Quelle der Unterstützung Multiple Sklerose Betroffener. Professionelle Unterstützung wird nur in geringem Maß in Anspruch genommen. Die Anforderungen der Befragten an die medizinische Versorgung sind sehr hoch. Negative Bewertungen der medizinischen Betreuung zeigen sich sowohl bei kritischeren Befragten und als auch bei ausgeprägten Autonomiebedürfnis. Die befragten Multiple Sklerose Betroffenen nutzen überwiegend objektive Informationsquellen als allgemeine Informationsbasis und zur Therapieentscheidung. Subjektives Erfahrungswissen wird meist nur ergänzend herangezogen. Veränderungsbedarf besteht in der medizinischen Versorgung im Bezug auf die Integration kritischerer, informierterer, selbstbewussterer Multiple Sklerose Betroffene und in Bezug auf den Zugang zu den vorhandenen Informations-, Unterstützungs- und Beratungsangeboten. / In a representative study 1219 people with multiple sclerosis in Germany were asked about the impacts of multiple sclerosis on their living situation and their estimation of the medical supply. Main topics were: social impacts, perception of the disease, coping with everyday life, quality of life, patient information, doctor-patient-relationship, shared decision making and the ACT programme as tool in the medical supply. Negative impacts on all analysed areas of the living situation could be proved, but the estimation differs in dependence on the specific living situation and the personality. Unlike the physical disability isn''t a predictor of the individual estimation of the impact. People with multiple sclerosis get their main support by relatives and friends. Professional services are rarely used in relation to the aid by the individual social environment. People with multiple sclerosis have very high expectations on the medical supply. The estimation of the situation is relatively negative if the people are more critical as well as if they have a great need for autonomy. The interrogated people with multiple sclerosis use basically and for their therapy decision mostly objective, medical information. Most of them use subjective knowledge based on experiences only additionally. Medical supply should be optimised by better integrating people with multiple sclerosis who are more critical or self confident as well as better informed. Usability and access of the existing offers to inform, support and counsel people with multiple sclerosis have to be improved.

Made available in DSpace on 2016-04-26T20:26:19Z (GMT). No. of bitstreams: 1 Christiane Cavalcante.pdf: 1437083 bytes, checksum: a73d416438445333a439ea317e0a64b5 (MD5) Previous issue date: 2007-12-17 / Coordenação de Aperfeiçoamento de Pessoal de Nível Superior / In recent years, under the liability, grew too much in the number of indemnities demands against private hospitals, especially under the allegation of medical mistakes. The doctor makes mistakes because he is human and makes mistakes because he had a poor training, because it is lacking residence for all graduated from schools of medicine, because he works too and has no time for study and research. Whatever the cause, the fact is that their conduct affects directly the entities hospital because the medical services provided by hospitals derive from the performance of professional doctor, which is the only authorized to practice of medical act. Though there is a close relationship between the hospital and medical liability and it is treated differently between the doctrine and jurisprudence, for the first, in the field of liability and subjective, for the second, objective. It is not the objective responsibility out of the hospitals, but only when acting as simple hospital service providers; outside that event, the hospital responds by attesting that the doctor acted with fault, as well as its own doctor. The proposal of this work is reflecting on the responsibility of private hospitals, particularly on the nature and various forms. In rich, the issue goes beyond the material aspect, so goes through some procedural peculiarities, which directly influences the indemnities demands such as evidences and third-party complaint / Nos últimos anos, no âmbito da responsabilidade civil, cresceu em demasia o número de ações indenizatórias contra os hospitais privados, notadamente sob a alegação de erro médico. O médico erra porque é humano, erra porque teve uma formação deficiente, porque falta residência para todos os egressos das escolas de medicina, porque trabalha demais e não tem tempo para estudo e pesquisa. Seja qual for a causa, o fato é que sua conduta influencia diretamente as entidades hospitalares porque os serviços médicos prestados pelos hospitais decorrem da atuação do profissional médico, que é o único habilitado à prática de ato médico. Apesar de existir uma estreita relação entre a responsabilidade médica e hospitalar, encontra-se na doutrina e jurisprudência tratamento diferenciado, para o primeiro no campo da responsabilidade subjetiva e, para o segundo, objetiva. Não se descarta a responsabilidade objetiva dos hospitais, mas somente quando atuam como prestadores de serviços meramente hospitalares; fora dessa hipótese, o hospital responde mediante a comprovação de que o médico agiu com culpa, assim como o próprio médico. A proposta do presente trabalho é refletir acerca da responsabilidade dos hospitais privados, em especial quanto à sua natureza e diversas formas. De tão rico, o tema não se esgota no aspecto material, por isso pincela algumas particularidades processuais, que diretamente influenciam as demandas indenizatórias, tais como a prova e a denunciação da lide

Submitted by PPG Direito (ppgdir@pucrs.br) on 2018-06-04T13:38:03Z No. of bitstreams: 1 Andrei_Ferreira_de_Arau?jo_Lima_DIS.pdf: 2336908 bytes, checksum: 566fe92260d6a118f2a36da3cfd3cc73 (MD5) / Approved for entry into archive by Sheila Dias (sheila.dias@pucrs.br) on 2018-06-11T13:15:40Z (GMT) No. of bitstreams: 1 Andrei_Ferreira_de_Arau?jo_Lima_DIS.pdf: 2336908 bytes, checksum: 566fe92260d6a118f2a36da3cfd3cc73 (MD5) / Made available in DSpace on 2018-06-11T13:29:04Z (GMT). No. of bitstreams: 1 Andrei_Ferreira_de_Arau?jo_Lima_DIS.pdf: 2336908 bytes, checksum: 566fe92260d6a118f2a36da3cfd3cc73 (MD5) Previous issue date: 2018-03-27 / Coordena??o de Aperfei?oamento de Pessoal de N?vel Superior - CAPES / This work is the result of an interdisciplinary study between the Science of Law and Bioethics. It aims to understand the ethical and legal limits of the possible right to die, specifically euthanasia. In order to achieve that goal, we will investigate the conflict and the conformation between the fundamental right to life, to human dignity and the autonomy of the will, taking into account both doctrine and national and international jurisprudence. The main reason for the reincorporation of the subject of euthanasia into the medical and legal debate (both academic and jurisprudential) refers to the fast-moving and efficient evolution of medical science, developing treatments that can prolong the patient?s life, possibly, depending on the sickness, forever. In face of this reality, one can perceive the alteration of certain paradigms of Bioethics, such as the breaking of the paternalistic relationship between doctor and patient, the principle of beneficence according to what would be best for the patient, and the removal of unreasonable obstinacy, based on the autonomy of the will and in human dignity. In this scenario, the patients? rights are increasingly debated and new contour to the state?s duty to protect life are being given, especially when in conflict with the dignity and autonomy of the patient. In this scenario, it?s debated a possible right to die with dignity. This right promotes numerous questions, especially concerning the ethical and legal limits in cases of euthanasia, requiring the establishment of clear criteria, having as a basic principle the maximum protection of the patient?s dignity. It is emphasized that, in spite of the varied forms of assisted death, as well as the recent incorporation of ortotan?sia (term in Portuguese used for terminal patients who decline useless treatments and have their right to die granted) as legal conduct in medical ethics in Brazil, the work seeks to solve questions related to euthanasia. First classifying it, in order to avoid any form of semantic confusion. In the following points it will be discussed as a possible establishment of legal criteria as well as the practical developments, taking into account both the medical deontology and the patient?s fundamental rights. / O presente trabalho de disserta??o ? fruto de um estudo interdisciplinar entre a Ci?ncia do Direito e a Bio?tica, buscando compreender quais s?o os limites ?ticos e jur?dicos relativos a um poss?vel direito ? morte, especificamente ? eutan?sia. Para tanto, se investigar? o conflito e a conforma??o entre os direitos fundamentais ? vida, ? dignidade e ? autonomia, levando em considera??o tanto a doutrina quanto a jurisprud?ncia nacional e internacional. Elucida-se que o principal motivo para a reincopora??o da tem?tica da eutan?sia no debate m?dico e jur?dico (tanto em n?vel acad?mico quanto jurisprudencial), se refere ? r?pida e eficaz evolu??o da ci?ncia m?dica, desenvolvendo tratamentos que possam prolongar a vida de um paciente, por vezes, de modo ad eternum. Frente a essa realidade, se percebe a gradativa altera??o de determinados conceitos da Bio?tica, como a quebra da rela??o paternalista entre m?dico e paciente, o princ?pio da benefic?ncia de acordo com o que seria melhor para o paciente, e o afastamento da obstina??o irrazo?vel, todos calcados na autonomia da vontade e na dignidade da pessoa humana. Nesse cen?rio, os direitos dos pacientes s?o cada vez mais debatidos e o dever de prote??o da vida por parte do Estado passa a receber novos contornos, impondo-se limites ? dimens?o objetiva do direito fundamental ? vida, podendo prevalecer, em casos espec?ficos, a dimens?o subjetiva desse mesmo direito. Dessa rela??o entre vida, dignidade e autonomia, fala-se em um poss?vel direito ? morte digna. Contudo, restam in?meras quest?es quanto aos limites desse direito, tanto em um sentido ?tico quanto jur?dico, pois por mais que se conclua pela exist?ncia de um direito ? morte, necess?rio ser? o estabelecimento de crit?rios, limitando a autonomia dos pacientes, tendo como norte a prote??o m?xima de sua dignidade. Frisa-se que, em que pesem as mais variadas formas de morte assistida, bem como a recente incorpora??o da ortotan?sia como conduta legal na ?tica m?dica brasileira, o trabalho buscar? resolver quest?es relacionadas ? eutan?sia. Primeiro classificando-a, de modo a evitar qualquer forma de confus?o sem?ntica, para nos pontos seguintes estabelecer os crit?rios jur?dicos, bem como os desdobramentos pr?ticos calcados na deontologia m?dica.

Ce travail de recherche s’appuie sur un corpus de cinq ouvrages de médecine, publiés entre 1532 et 1558. Ces ouvrages sont porteurs d’une dimension polémique en opposant deux corporations médicales : les médecins et les apothicaires. En 1532, un célèbre médecin lyonnais, Symphorien Champier, fustige les erreurs des apothicaires sur les simples médecines dans son Myrouel des appothicaires. En 1553, un médecin poitevin, Sébastien Colin, dénonce à son tour, dans sa Declaration des abuz et tromperies que font les Apothicaires, le manque de connaissances des apothicaires et s’indigne de leur peu de moralité. Face à l’animosité de cette deuxième attaque, l’apothicaire Pierre Braillier s’attèle à défendre l’honneur de ses pairs. Il publie en 1557 sa Declaration des abus et ignorances des Medecins, […] Pour responce contre Lisset Benancio dans laquelle il reprend point par point les accusations de Colin pour les retourner contre les médecins. En 1558, le médecin Jean Surrelh cherche alors à redorer l’image écornée de sa corporation dans son Apologie des medecins contre les calomnies, & grand Abus de certains Apothicaires. Pierre Braillier lui répond quelques mois plus tard dans ses Articulations […] sur l’apologie de Jean Surrelh. En parallèle du projet d’édition des cinq textes du corpus qui constituent le second volume de cette thèse, le premier volume propose une analyse de cette polémique médicale. Nous avons voulu observer comment le discours de chacun de ces quatre auteurs est influencé par son appartenance à la corporation des médecins ou bien à celle des apothicaires. Pour ce faire, nous avons privilégié trois angles d’analyse : un premier sur l’ancrage du discours des auteurs dans le contexte scientifique et idéologique de la Renaissance, un deuxième axé sur les divergences des pratiques entre ces deux corporations concurrentes et un dernier davantage orienté sur l’intérêt lexical et linguistique de cette polémique corporatiste. La contextualisation a ainsi permis d’observer comment chaque auteur se positionne en tant que professionnel par rapport aux principes fondateurs de l’art de médecine. Chacun revendique la vertu et la grandeur de sa corporation en s’appuyant sur la référence des auctoritates ou sur la Bible, ou bien au contraire en dénigrant les sources citées comme autorité par l’adversaire. Par la même occasion, chaque participant à cette polémique cherche à se construire un ethos positif tant comme professionnel que comme auteur, tout en discréditant les membres de la corporation adverse. Si l’apothicairerie est distincte de la médecine à la Renaissance – tant au niveau des pratiques, que du domaine d’intervention et du cadre légal d’exercice des professionnels – les pratiques concurrentielles entre médecins et apothicaires perdurent à la Renaissance et entachent les relations de ces collègues. Dans le corpus d’étude, l’intérêt du patient devient un objet secondaire du discours puisqu’il s’agit pour chaque auteur de blâmer la corporation adverse afin de défendre la légitimité de la sienne. Le lecteur se voit par la même occasion attribuer une place de choix puisqu’il est présenté comme juge de cette querelle, dans un double intérêt. En plus de revendiquer à la face du monde la reconnaissance sociale méritée, chaque auteur se justifie des traitements reçus, enjoignant de facto de potentiels patients à préférer sa corporation. L’appartenance corporatiste marque également le lexique scientifique et technique. Nous avons aussi interrogé le rapport de chaque auteur à la langue latine, tenue encore comme langue européenne du savoir à la Renaissance, et au français, langue dominante du corpus. Si les médecins utilisent encore un lexique scientifique en latin, l’apothicaire Pierre Braillier revendique l’usage exclusif du français, circonscrivant par la même occasion le latin à un usage parodique. / This research is built on a corpus of five medicals books, published between 1532 and 1558. The corpus takes a polemical dimension by opposing two medicals guilds: the doctors and the apothecaries. In 1532, a famous doctor from Lyons, Symphorien Champier, criticizes the apothecaries’ errors concerning the simples in his book, Myrouel des appothicaires. In 1553, a Poitevin doctor, Sébastien Colin, in his Declaration des abuz et trumperies que font les Apothicaires, also denounces the apothecaries’ absence of knowledge and deplores their lack of ethics. Facing the hostility with this second offensive, the apothecary Pierre Braillier wants to defend the honour of his peers. In 1557, he publishes his Declaration des abus et ignorances des Medecins, […] Pour responce contre Lisset Benancio. In his book, he takes the same criticisms as Colin has, but in order to charge the doctors. In 1558, doctor Jean Surrelh wants to restore the doctors’ reputation in his book, Apologie des medecins contre les calomnies, & grand Abus de certains Apothicaires. Pierre Braillier responds to him a few months later in his Articulation […] sur l’apologie de Jean Surrelh. In parallel with the edition of the five texts which constitute the second volume of this research, the first volume is a global study of this medical polemic. We have wanted to examine how the discourse of each of these authors is impacted by his corporate belonging. To that end, we have chosen three focuses: the first is about the anchoring of the authors’ discourse in the scientific and ideological environment, the second is focused in the divergent practices between the two guilds, and the third is about the lexical and linguistic interest of this corporate polemic. The contextualisation reveals how every author positions himself as a professional against the founding principles of the art of medicine. Building on the auctoritates or Bible references or denigrating the sources referred to by the opponent, everyone claims the morality and the greatness of his corporation. At the same time, each author wants to build a positive image of his corporation, discrediting the members of the opposing corporation. During the Renaissance, the apothecary is distinct from the medicine, concerning the activities as well as the legal framework of the exercising of the professionals. Indeed, the competitive practice between doctors and apothecaries continues and tarnishes the relations between these colleagues. In the corpus, the interest of the patient becomes a secondary object of the discourse, because every author wants to blame the opposing guild, in order to defend the legitimacy of her own. The reader is then assigned an important place because he’s presented as a judge in this polemic with a double interest. In addition to relying on the well-deserved social acknowledgement, every author wants to justify his treatments and enjoins the future patients to turn over his corporation. The corporatist affiliation also haunts the scientific and technic lexicon. We have also examined the relationship of every author with the Latin, still considered as the European language of knowledge in the 16th century, and the French, prevailing language in the texts’ corpus. The doctors use a scientific lexicon in Latin, but the apothecary, Pierre Braillier, claims the exclusive use of the French and he confines the Latin to a parodic use.

Doctor protection vs. patient protection. This diploma thesis deals with the medical law, namely the protection of physicians and the protection of patients, and their mutual comparison as entities standing more or less against each other. The main objective of the thesis was to analyse the protection of both sides; the practical example provides describes a controversial situation which may happen in reality, also gives better understanding of the issue for readers. The aim was to capture the complex and also very extensive legal regulation of the topic, focusing on the touchpoints between the medical and civic laws. In view of the wide range of the topic in question, I consider specifically some sections of the thesis as the most important. At the beginning, the thesis provides a specification of the elementary legislation regulating the medical law. This is not a comprehensive list of resources, due to the enormous extent of the legislation regulating the medical law. Individual chapters describe the topics of informed consent and the protection of personal data, the provision of healthcare without the patient's consent and the special arrangement concerning the consent of underage patients, the relationship between the physician and the patient, the confidentiality duty, previously expressed...

Submitted by Silvana Teresinha Dornelles Studzinski (sstudzinski) on 2016-05-18T15:12:54Z No. of bitstreams: 1 Daniela Negraes Pinheiro Andrade_.pdf: 3094213 bytes, checksum: 9a9e3f421a0d29eb223c0be2ccb4462d (MD5) / Made available in DSpace on 2016-05-18T15:12:54Z (GMT). No. of bitstreams: 1 Daniela Negraes Pinheiro Andrade_.pdf: 3094213 bytes, checksum: 9a9e3f421a0d29eb223c0be2ccb4462d (MD5) Previous issue date: 2016-02-26 / CAPES - Coordenação de Aperfeiçoamento de Pessoal de Nível Superior / FAPERGS - Fundação de Amparo à Pesquisa do Estado do Rio Grande do Sul / Esta tese resultou da investigação sobre o programa educacional para boas práticas de saúde que um hospital da rede privada localizado no sul do Brasil, nomeado na tese como Maxcárdio, realiza com portadores/as de Síndrome Coronariana Aguda e Insuficiência Cardíaca Congestiva. Adotou-se o aparato teórico – metodológico da Análise da Conversa (SACKS, 1992; SACKS; SCHEGLOFF; JEFFERSON, 1974) para analisar 25 interações ocorridas entre pacientes e profissionais médicos/as e não médicos/as – enfermeiros/as, nutricionistas, fisioterapeutas e psicólogos/as – integrantes da equipe multidisciplinar responsável pelas orientações aos/às pacientes. As interações foram gravadas em áudio e em vídeo e transcritas segundo Jefferson (1974). Os objetivos da tese foram: (a) verificar como os/as profissionais de saúde responsáveis pela efetuação do programa educacional recomendam ou prescrevem boas práticas de saúde no turno a turno de modo a discutir quais maneiras de falar mostram-se mais (potencialmente) particularizadas ou generalizadas em relação às necessidades demonstradas (ou não) pelos/as pacientes na interação e, a partir dessa discussão, apontar tendências de (não) adesão aos autocuidados recomendados ou prescritos por parte dos/as pacientes; (b) apresentar um percurso empírico representativo do programa educacional concernente à maneira como os/as participantes negociam, no turno a turno, direitos e obrigações de saber (domínio epistêmico) e de dizer (domínio deôntico) (HERITAGE, 2012; STEVANOVIC, 2011) o que (não) pode e/ou (não) dever ser feito em termos de boas práticas de saúde e, assim, discutir as implicações interacionais e práticas relacionadas às negociações entre os/as participantes em torno de direitos e obrigações de recomendar ou prescrever boas práticas de saúde; (c) discutir os modos de organização de prestação de serviço de orientação para boas práticas de saúde à luz do princípio da integralidade (BRASIL, 1998; MATTOS, 2005a). No que toca às maneiras de falar dos/as profissionais verificou-se que a particularização tende a ocorrer quando os/as profissionais instauram cursos de ação de modo a: (a) (tentar) remover empecilhos ao aceite do/a paciente à recomendação em favor de alguma boa prática de saúde; (b) desviar da ação de prover informações contidas nos manuais de boas práticas de saúde dos programas e demonstrar conhecimento sobre aspectos peculiares ao estado de saúde do/a enfermo/a; (c) justificar a indicação para a adoção de certa medida de cuidado de saúde. No que se refere à maneira como profissionais e pacientes negociam domínios epistêmicos e deônticos, observou-se que: (a) os/as profissionais não médicos/as colocam-se na posição de alguém com direitos e obrigações de saber e de dizer como pacientes devem controlar seu quadro de saúde; (b) os/as pacientes não ratificam os direitos e obrigações desses/as especialistas não médicos/as de saberem e poderem dizer-lhes como proceder no pós-alta; (c) os/as profissionais médicos/as abordam boas práticas de saúde em turnos de fala em formato de lista, o que conflita com a expectativa dos/as pacientes de discutir tais tópicos de maneira pormenorizada. Por fim, apurou-se que o modo de organização de prestação de serviço de orientação a pacientes que participam do programa Maxcárdio aproxima-se de ações assistenciais integrais (AYRES, 2004) à medida que os/as profissionais produzem falas capazes de estabelecer uma sequência de demonstração de necessidade de orientação a partir de solicitações de informações sobre se e como o/a paciente cuida de sua saúde. A contribuição teórica desta tese traduz-se na proposta de inclusão do aspecto modo de organização sequencial de tópico na descrição do princípio de fala ajustada (SACKS, 1992; SACKS; SCHEGLOFF; JEFFERSON, 1974). O modo como as sequências de tópicos são organizadas na interação mostra-se relevante para o grau de particularização que as falas dos/as interlocutores podem alcançar na conversa. Em termos aplicados, visto que ofertar recomendações ou prescrições ajustadas às necessidades dos/as pacientes interlocutores/as locais implicar saber se e como os/as doentes controlam seu estado de saúde, sugere-se que se parta da ação de solicitar informações acerca das experiências de sucesso e das dificuldades que os/as pacientes encontram para cuidar da saúde para, então, ter material interacional para orientá-los/as de forma particularizada. / This dissertation resulted from the investigation of educational programs into good health practices that a private hospital located in the South of Brazil accomplishes with Acute Coronary Syndrome and Congestive Heart Failure patients. Conversation Analysis theoretical and methodological approach (SACKS, 1992; SACKS, SCHEGLOFF, JEFFERSON, 1974) has been adopted to analyze 25 interactions occurred between patients and medical doctors or other health providers – nurses, nutritionists, physiotherapists and psychologists – members of the multidisciplinary team responsible for the patients’ orientation. Interactions were audio and video recorded and transcribed according to Jefferson (1984). The present dissertation aimed to: (a) verify how the health professional responsible for accomplishing the educational program recommend or prescribe good health practices in the turn by turn of the interaction so as to discuss which ways of talking appear to be more (potentially) particularized or generalized in relation to patients` (not) displayed needs in the interaction and, from such discussion, to point out tendencies of (non) adherence to good practices recommended or prescribed by patients; (b) present an empirical trajectory representative of the educational program concerning the ways participants negotiate, in the interaction turn-by-turn, rights and obligation of knowing (epistemic domain) and saying (deontic domain) (HERITAGE, 2012; STEVANOVIC, 2011) what can (not) and/or must (not) be done in terms of good health practices so as to discuss the interaction and practical implication related to the negotiation around rights and obligations of recommending or prescribing good health practices; (c) discuss the ways of organizing provision of orientation to good health practices in the light of principle of integrality (BRASIL, 1998; MATTOS, 2005a). Regarding more or less particularized ways of talking concerning patients’ orientation needs, it has been verified that the professional members’ talk appear to be more particularized in situations in which they implement courses of action in such a way as to: (a) (try to) remove obstacles so that patients may accept professional members’ recommendations in favor of good health practices; (b) deviate from the action of providing information included in the manuals of good health practices of the programs and display knowledge regarding patients’ peculiar health conditions; (c) justify the indication of certain good health practice. In relation of the ways professional members and patients negotiate epistemic and deontic domains, it has been observed that: (a) non-medical members assume the position of someone who has rights and obligations of knowing and saying how patients must control their health conditions; (b) patients do not ratify these professionals’ rights and obligations of knowing and saying how they should proceed in the post-discharge; (c) medical doctors talk about good heath practices by list-formatting their turns at talk, which conflicts with patients’ expectations of discussing these topics in a minutely detailed way. In the third one, a comparing analysis between two interactions has been done. Finally, it has been verified that the way of organizing service of orientation to patients approximate integral assistance actions (AYRES, 2004) insofar as professional members produce talk capable of establish a demonstration sequence of orientation need from information solicitation concerning if and how the patient takes care of their health. The theoretical contribution of this dissertation may be translated into the proposal of including the aspect topic sequential organization mode in the description of the principle of recipiency-designed (SACKS, 1992; SACKS; SCHEGLOFF; JEFFERSON, 1974). The way topical sequences are organized in the interaction displays relevance to the degree of particularization interlocutors’ talk may reach. In terms of applicability, as providing recipient-designed recommendations or prescriptions to situated interlocutors’ needs implicates knowing if and how patients control their health conditions, we suggest that professional members depart from the action of soliciting information regarding patients’ successful and failed experiences and their difficulties in heath-caring so that interactional material may be generated and patients’ orientation may be done in a particularized way.

Made available in DSpace on 2016-04-28T20:39:20Z (GMT). No. of bitstreams: 1 EDUARDO GOLDENSTEIN.pdf: 870373 bytes, checksum: 3d2e971540a9c347550f42beab244033 (MD5) Previous issue date: 2006-08-25 / Coordenação de Aperfeiçoamento de Pessoal de Nível Superior / From the end of the Second World War on, medicine started to develop clinically and surgically in a way hitherto unknown. Due to more accurate diagnoses, new therapeutic resources and the development of new drugs and technological procedures that allowed physicians to risk major surgeries, sicknesses simply became extinct or controlled and life could start earlier and end later. But all this technological development ended up causing two new problems and two new challenges: the increase of sicknesses without well-established physiopathological bases, such as psychosomatic anxieties and illnesses, and a kind of deconstruction of the humanistic face of medicine -- a deconstruction that came to be known as the dehumanization of medicine. Perhaps this dehumanization of medicine should be understood as a need to reformulate the humanistic bases of the same, adapting to current technological advances, which certainly have changed the training and the performance of the physician as he exercises his profession. The focus of our attention during this research was to go back to the previous matter: the double concept of dehumanization-humanization of medicine, especially in hospitals. Theoretical support for understanding these concepts will be presented in the introductory chapters. The objective of this research has been to analyze the experience of the clinical practice of ICU pediatricians in a humanized hospital. We, therefore, adopted a specific qualitative research methodology based on the phenomenological-existential approach of Heidegger, Boss and Buber. Interviews were made and analyzed with five ICU pediatricians that work in a humanized children s hospital The doctors accounts reveal different views on: how to deal with death, with anxiety and with guilt; the presence of mothers in the ICU and the effect on hospital routine and medical clinical practice; the recognition (or non-recognition) of the physician s work by the parents and ICU professionals; (positive or negative) aspects of the physical environment of the ICU and of working conditions. Starting from the data collected, a profile can be made of the clinical experiences of those interviewed, emphasizing the strategies used by them to deal with the difficulties and adversities generally present in ICUs. The analysis of these experiences has revealed the importance of listening to the physicians and including the voice of the doctor in the humanization process of medicine and hospitals. New research fronts, in which are heard the voice of other doctors, other professionals, the mothers and the children too, have shown themselves to be important / A partir do final da Segunda Guerra Mundial, a medicina tomou um impulso de desenvolvimento clínico e cirúrgico até então desconhecidos. Por conta de diagnósticos mais precisos, de novos recursos terapêuticos, do desenvolvimento de novas drogas e de procedimentos tecnológicos que propiciaram aos médicos se arriscarem em cirurgias de grande porte, doenças foram simplesmente extintas ou controladas, a vida pôde se iniciar mais cedo e terminar mais tarde. Entretanto, toda esse desenvolvimento tecnológico acabou por gerar dois novos problemas e dois novos desafios: a expansão de doenças sem bases fisiopatológicas bem estabelecidas, tais como ansiedades e doenças psicossomáticas, e uma certa descaracterização da face humanística da medicina, descaracterização essa que passou a ser conhecida como desumanização da medicina. Possivelmente essa desumanização da medicina deva ser entendida como uma necessidade de uma reformulação das bases humanísticas da mesma, numa acomodação com os avanços tecnológicos vigentes, os quais certamente mudaram a formação e a atuação do médico no exercício de sua profissão. O foco de atenção nessa pesquisa se volta para essa última questão: o binômio desumanização humanização da medicina, especificamente dos hospitais. Subsídios teóricos para a compreensão destes conceitos estão apresentados nos capítulos introdutórios. O objetivo desta pesquisa foi analisar a vivência da prática clínica de médicos pediatras intensivistas de um hospital humanizado. Adotou-se, para tanto, uma metodologia específica de pesquisa qualitativa referenciada pela abordagem fenomenológica-existencial de Heidegger, Boss e Buber. Foram realizadas e analisadas entrevistas com cinco médicos pediatras e intensivistas que trabalham em um hospital infantil humanizado. As falas dos médicos revelaram diferentes visões sobre: o lidar com a morte, com a angústia e a culpa; a presença das mães na UTI e suas decorrências na rotina hospitalar e na prática clínica médica; o reconhecimento (ou não-reconhecimento) do trabalho médico pelos pais e profissionais da UTI; aspectos (positivos ou negativos) do ambiente físico da UTI e das condições de trabalho. A partir dos dados colhidos, pôde-se traçar um perfil geral das vivências clínicas dos entrevistados, com ênfase nas estratégias por eles usadas para lidar com dificuldades e adversidades em geral presentes em UTIs. A análise dessas vivências revelou a importância de se ouvir os médicos e englobar a voz dos médicos no processo de humanização da medicina e dos hospitais. Novas frentes de pesquisa, nas quais se dê voz a outros médicos, a outros profissionais, às mães e às próprias crianças revelaram-se importantes

Being a lecturer and serving in the Higher Degrees Committee of the Department of Public Administration and Management at Unisa for several years, gave me exposure to master’s and doctoral candidates’ scholarly work. I realised that the doctoral candidates, in particular, were facing methodological challenges. This realisation triggered my curiosity in the methodological preparedness of doctoral candidates. My scholarly curiosity prompted me to undertake a preliminary literature review which has identified a number of scholarly contributions on the quality of research in Public Administration. These studies have not established or attempted to establish conceptual frameworks for understanding this phenomenon. I deduced that the lack of scholarly contributions on the methodological preparedness of doctoral candidates indicates a knowledge gap that compromises scholarly understanding of methodological preparedness, both as a concept and a phenomenon. The main purpose of this research was to generate theory, by means of the development of a conceptual framework, in response to the identified knowledge gap in the literature. Consequently, a qualitative theory generating research design was chosen and actualised in three interrelated research phases. Phase 1 provides a theoretical perspective by turning to the scholarly literature and institutional documents to obtain a deepened understanding of the concept methodological preparedness relevant to Public Administration doctoral candidates. This phase serves, firstly, to provide an overview of the characteristics of the doctorate in Public Administration as an immediate context for methodological preparedness, and secondly, to do a concept analysis to identify and describe the meaning of the concept methodological preparedness with reference to a doctoral candidate. Phase 2 aimed to make sense of the methodological preparedness of Public Administration doctoral candidates at Unisa by exploring, through an Interpretive Phenomenological Analysis (IPA), how doctoral candidates and supervisors make sense of this phenomenon. This study makes a methodological contribution by employing the IPA for the first time in the South African Public Administration fraternity. Phase 3 generates a conceptual framework for understanding the methodological preparedness of Public Administration doctoral candidates at Unisa. The framework contributes to the understanding of the under- vi researched concept and phenomenon methodological preparedness of doctoral candidates in Public Administration. This study has shown that a candidate’s methodological preparedness (the state of being competent to independently make a methodological decision relevant to his or her doctoral research project), is not a once-off gate-keeping phenomenon, but an ongoing and fluent state of being. / Public Administration / D. Litt. et Phil. (Public Administration)

Embora sejam grandes os progressos com a promulgação da Constituição de 1988, que garante constitucionalmente a saúde como direito de todos e dever do Estado, esse direito não tem sido assegurado no mesmo nível e com a mesma qualidade de atenção, em especial, para a população negra. Depois de uma revisão sobre a história a influência das teorias racialistas e de gênero como categoria de análise na medicina, discute-se uma síntese da história recente das práticas médicas no Brasil e a reflexão critica sobre essas práticas centradas no tecnicismo. O objetivo deste estudo, parte da linha de pesquisa Pesquisa Psicossocial da Desigualdade: Relações Étnico-raciais, foi descrever que sentidos e significados médicos e médicas conferem aos temas médico-sociais na sua trajetória e formação, especialmente como concebem os determinantes sociais de gênero e raça Foram entrevistados 25 médicos (13 médicos e 12 médicas) que orientam e são preceptores de alunos da residência médica em um hospital universitário. O roteiro abordava o perfil sócio-demográfico e sua trajetória profissional; o seu nível de conhecimento e contato com os determinantes sociais (pobreza, gênero, cor/raça, nacionalidade, religião dos diferentes grupos populacionais) durante a formação acadêmica; que fatores consideravam relevantes para uma boa relação médico-paciente; seu conhecimento sobre Direitos Humanos e os princípios do Sistema Único de Saúde; as experiências na relação médico-paciente e de cuidado. Depois de um aquecimento propiciado pela situação da entrevista, entre os resultados, o estudo permitiu observar como os médicos entrevistados reconhecem alguns marcadores sociais da diferença que se transformam em desigualdade, os lugares sociais diferentes para homens e mulheres, brancos, amarelos e negros, lugares de maior ou menor privilégio e de obstáculo para o sucesso técnico. As diferenças e desigualdade de gênero foram mais fáceis de serem explicitadas e os entrevistados articulavam um repertório levemente maior para o tema. Todos os entrevistados, em algum momento, usaram o discurso sobre o instintivo e natural, e a maior parte deles compreende o masculino e o feminino de um modo muito conservador, com problemas para encontrar definições para perguntas supostamente simples. No caso da desigualdade racial, observamos que houve uma polarização: de um lado a negação das desigualdades entre brancos e não brancos, do outro temos a valorização da identidade branca, compondo bem com o racismo à brasileira. O contexto social foi associado à pobreza mais que qualquer outro indicador da desigualdade social. Cenas de racismo e sexismo institucional foram frequentes. Os poucos entrevistados que tinham uma noção mais sofisticada sobre gênero e raça eram aqueles que contaram com a oportunidade de desenvolver uma atividade de extensão, a iniciação científica ou que tiveram uma formação mais generalista, mais social. A trajetória trilhada na faculdade contribui, portanto, para a formação / Brazil\'s 1988 Constitution grants health as a human right to all and a duty of the State. Although great progress has been made since its enactment, this right has not been ensured at the same level and with the same service quality, particularly with regard to Afro-Brazilians. With close attention to history and the influence of racial and gendered theories, this article discusses the recent history of medical practices in Brazil and provides critical reflection on those practices that are centered on technique. The main purpose of this study, a part of the Psycho-social research on inequality: ethnic-racial relations research line, is to describe the meanings and significance that doctors give to medical social issues in their education. Special attention is given to their conception of the social determinants of gender and race. Twenty-five doctors (13 men and 12 women) were interviewed. All of them mentor medical students pursuing their residency at a University Hospital. The interviews script centered on their socio-demographic profile, their professional path and the degree of knowledge or contact with social determinants (poverty, gender, race/color, nationality, religion of the different population groups) during their academic formation, the factors they considered as relevant to a good doctor-patient relationship, their knowledge of Human Rights and the principles of the Sistema Único de Saúde (SUS) and their experiences in the care and doctor-patient relationships. Among its results, the study shows how the interviewed doctors recognize several social markers of difference that convert into inequity, the different social places for men and women, the white, the people of Asian descent and the black, places of greater or lower privilege and obstacle for technical success. The gender differences and inequalities were more easily explained and respondents articulated a slightly larger repertoire for the topic. All of the interviewees, at some moment, used the discourse on the instinctive and the natural, and most of them have a very conservative comprehension of the feminine and the masculine, and encountered problems in finding definitions for apparently simple questions. With regards to racial inequality, there was a polarization: on the one hand, the denial of inequalities among the white and the non white, on the other, a consistent evaluation of white identity, linked to the Brazilian racism. The social context was associated with poverty rather than any other indicator of social inequality. Evidence of racism and sexism were frequently observed in the interviews. The few interviewees that had a more sophisticated notion of gender and race were those who had had the chance to develop an extracurricular activity, the scientific initiation, or those who had had a more generalist and social education. Thus, the experience acquired during university contributes to the formation of their notions of social determinants in health