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Rev. bioét. 2024; 32: e3751EN 1-8http://dx.doi.org/10.1590/1983-803420243751EN
Update
Revista Bioética
Print version ISSN 1983-8042 | On-line version ISSN 1983-8034
Rev. Bioét. vol.32 Brasília 2024
1
The authors declare no conict of interest.
Development of medical values in the training in
active methodologies
Taane Muniz Barbosa 1, Eduarda Ferreira Merigo 1, Mateus Henrique Silva 1, Paola de Lima 1
1. Centro Universitário para o Desenvolvimento do Alto Vale do Itajaí, Rio do Sul/SC, Brasil.
Abstract
With the growing expansion of medical educaon in Brazil, in parallel with the updang of the
Naonal Curriculum Guidelines (2001, 2014 and 2022), reecon on the teaching-learning process of
ethics and bioethics becomes necessary. The study correlates moral values developed during medical
training with their applicaon during the mandatory internship in a medical course in southern
Brazil. This is a qualitave study with 72 students from the internship classes, and data collecon
consisted of an individual quesonnaire. The results of the content analysis indicate that the moral
values learned during training and the values pracced and considered essenal for internship
experience are respect, responsibility, paence and humility, and discussions and learning about
these moral/social values take place more frequently when educaonal strategies characterisc of
acve methodologies are adopted.
Keywords: Educaon, medical. Ethics, medical. Social values.
Resumo
Desenvolvimento de valores médicos na formação em metodologias avas
Com a crescente expansão do ensino médico no Brasil, paralela à atualização das Diretrizes Curriculares
Nacionais (2001, 2014 e 2022), é essencial reer acerca do processo de ensino-aprendizagem de
éca e bioéca. A pesquisa correlaciona valores morais desenvolvidos durante a formação médica com
sua aplicação no estágio obrigatório – regime de internato em um curso de medicina no sul do Brasil.
Trata-se de pesquisa qualitava, com 72 estudantes das turmas em internato, cuja coleta de dados
consisu na aplicação individual de quesonário. Os resultados, pela análise de conteúdo, indicam que
os valores morais aprendidos durante a formação e os valores pracados e considerados essenciais
para a vivência no internato são respeito, responsabilidade, paciência e humildade, e as discussões e
aprendizados a respeito desses valores morais/sociais acontecem com maior frequência quando são
adotadas estratégias educavas caracteríscas das metodologias avas.
Palavras-chave: Educação médica. Éca médica. Valores sociais.
Resumen
Desarrollo de valores médicos en la formación en metodologías acvas
Dada la expansión de la educación médica en Brasil en paralelo con la actualización de los Lineamientos
Curriculares Nacionales (2001, 2014 y 2022), es esencial reexionar sobre el proceso de enseñanza-
aprendizaje de la éca y la bioéca. Este estudio correlaciona los valores morales desarrollados
durante la formación médica con su aplicación en las pasanas obligatorias en medicina en el sur
de Brasil. Se realizó una invesgación cualitava a 72 estudiantes de las clases de internado, y la
recolección de datos consisó en la aplicación individual de un cuesonario. A parr del análisis
de contenido, los resultados indican que los valores morales aprendidos durante la formación y los
valores praccados y considerados esenciales en el internado fueron el respeto, la responsabilidad,
la paciencia y la humildad; además, las discusiones y el aprendizaje sobre estos valores morales/
sociales ocurrieron con mayor frecuencia cuando se adoptaron estrategias educavas caracteríscas
de las metodologías acvas.
Palabras clave: Educación médica. Éca médica. Valores sociales.
Approval CEP-Unidavi 5.557.178
2Rev. bioét. 2024; 32: e3751EN 1-8 http://dx.doi.org/10.1590/1983-803420243751EN
Development of medical values in the training in active methodologies
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The implementaon of the Naonal Curriculum
Standards (DCN) for medical educaon
1
, academic
training, based on the understanding of the social
determinants of the health-disease process,
aims to provide physicians with a generalist,
humanized, ethical, reflective and critical
educaon
2,3
. This shows how important it is for the
teaching-learning process to create opportunies
for academic experiences founded on an eecve
physician-paent relaonship and in agreement
with the principles of the DCN and the Unied
Health System (SUS).
The traditional teaching model—isolated
subjects, disconnected from each other, with lile
room for social, economic, cultural and ethical
discussions, which alienates students from real-life
health problems and promotes the specializaon
and fragmentation of individuals 2,4—is being
replaced by a teaching-learning process that
integrates active participation and student
autonomy, aiming for reecve acon in which
students become leaders 2. Active learning
methodologies integrate theory and pracce and
insert students in the health system from the
beginning of the course, while recasng faculty in
a mediang role.
In this sense, the pracce of humanized care
should be developed and the doctor-patient
relaonship should be modied 2,4. To impart health
care that is generalist, humanized and eecve,
medical educaon must necessarily address in
the teaching-learning process moral/social values
such as responsibility, respect, paence, prudence,
trust, jusce, compassion, hope, truth, generosity,
humility, charity, harmony, benevolence, courage
and gratude 3.
This study aimed to correlate the moral values
developed during medical educaon with their
application in daily internship activities at a
medical school in southern Brazil.
Method
A qualitave, descripve and cross-seconal
survey was conducted with students from a medical
course that uses acve learning methodologies,
at a higher educaon instuon located in a city
southern Brazil. The research sample consisted
of 72 students (97% condence level) undergoing
mandatory internship in the aforementioned
course (9th, 10th and 11th term) during the second
semester of 2022. Parcipaon in the study was
conrmed by signing an informed consent form,
according to CFM Resoluon 466/2012 5, being
over 18 years old, and regularly enrolled and
attending academic activities during the data
collecon period (second semester of 2022).
Following approval by the university’s
Research Ethics Commiee, data were collected
by administering a quesonnaire adapted from
Marques 3. The rst part of the quesonnaire
related to the sociodemographic idencaon
of parcipants (age, gender, skin color, religion,
marital status and previous undergraduate
educaon), and the second part addressed moral
values and how students perceived them in the
medical course. The students checked mulple-
choice items to idenfy the moral values they
considered important for the internship, those
that were applied in the mandatory internship
program and those developed during the
undergraduate course.
The questionnaire was administered via
Google Forms during weekly clinical meengs that
included all students from each academic term
(9th, 10th and 11th). Each individual answered
the quesonnaire independently, with guaranteed
condenality of responses, anonymity and the
right to withdraw from the study at any me,
minimizing the risk of embarrassment.
The data were processed and grouped
according to the study variables, based on graphs
generated by Google Forms. Subsequently,
data analysis and interpretaon were performed
based on Bardin’s content analysis 6 and supported
by a theoretical framework of the current
technical and crical literature, resulng in four
themac categories: student prole, developed
values, pracced values and essenal values.
Results
Student prole
The study mainly included women students
(68.1%) aged between 22 and 26 (76.4%). Of the
respondents, 87.5% had no prior undergraduate
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Development of medical values in the training in active methodologies
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degree and self-identified as white (98.6%).
Regarding marital status, 87.5% reported being
single, and in terms of religion, most were Catholic
(69.4%), followed by Evangelicals (12.5%).
Developed values
Regarding moral values developed during
the medical course, it was found that respect
(90.3%), responsibility (90.3%), paence (81.9%)
and humility (76.4%) were the most addressed
in academic activities. On the other hand,
compassion (16.7%) and harmony (13.9%)
were the least checked. It is noteworthy that
truth features with 61.1%, which contrasts with
the results in the other categories (pracced
values and essenal values), where it appears
more oen.
Table 1. Developed values
Value %
Respect 90.3
Responsibility 90.3
Paence 81.9
Humility 76.4
Prudence 69.4
Trust 63.9
Truth 61.1
Courage 52.8
Gratude 51.4
Generosity 48.6
Jusce 40.3
Benevolence 37.5
Hope 36.1
Charity 25
Compassion 16.7
Harmony 13.9
Regarding the curriculum units (CU) and
subject areas of the medical course curriculum,
students indicated that discussions and learning
about moral values occur most frequently in
professional skills CUs. These come under the
subject areas of digital health, communicaon
skills and clinical skills and are oered during the
basic and clinical cycles of the course, from the 1st
to 8th term. Communicaon Skills I, in the 1st term
of the course, was indicated by 95.8% of students.
The other professional skills CUs had percentages
ranging from 87.5% to 76.4%, with an emphasis
on the subject areas of communication skills
and clinical skills.
A highlight was CUs related to Integraon
of Health Educaon in the Community (IESC),
oered from the 1st to 8th term of the course.
They comprise theoretical-practical activities
that place students in Family Health Strategy
units (SUS). The percentages ranged from 90.3%
to 75% as CUs that convey knowledge on moral
values, with IESC IV (4th term) and V (5th term)
being the most noted, with 90.3% each. Other
notable CUs included ethics and bioethics in
the 3rd term, with 48.6%, and undergraduate
monograph I and II in the 7th and 8th terms,
with 25%.
In the quesonnaire, students were also asked
to reect on how these topics were discussed
during academic acvies throughout the course,
that is, the educaonal strategies used. Praccal
experience/internships (even observaonal) were
noted by 84.7%, and group discussion instrucon
(small group sessions of problem-based learning)
by 73.6%. Addionally, the reecve porolio
acvity stood out with 43.1%, ranking 8th out
of 11 opons.
Moreover, 63.9% of students believe that
moral values appear implicitly in the CU content/
or subject areas and that horizontal and dialogical
educaonal relaonships between students and
faculty (84.7%) facilitate the teaching-learning
process of moral values.
Practiced values
In this category, the students checked the
moral values experienced during mandatory
internship acvies (9th to 11th term), with the
following standing out: respect, 97.2%; paence,
90.3%; humility, 88.9%; and responsibility, 88.9%.
Conversely, compassion and harmony had the
lowest percentages, 30.6% and 25%, respecvely.
4Rev. bioét. 2024; 32: e3751EN 1-8 http://dx.doi.org/10.1590/1983-803420243751EN
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Table 2. Pracced values
Value %
Respect 97.2
Paence 90.3
Humility 88.9
Responsibility 88.9
Trust 77.8
Generosity 73.6
Prudence 73.6
Trust 68.1
Jusce 59.7
Gratude 59.7
Courage 55.6
Hope 47.2
Charity 45.8
Benevolence 43.1
Compassion 30.6
Harmony 25
Essential values
Regarding the participants’ assessment of
the moral values they deemed essenal for the
praccal acvies of the mandatory internship,
respect, humility and responsibility appeared
with 97.2%, followed by paence (93.1%) and
prudence (86.1%). Benevolence (38.9%), charity
(38.9%), compassion (27.8%) and harmony
(20.8%) were the least checked as important
during internship training.
Table 3. Essenal values
Value %
Respect 97.2
Humility 97.2
Responsibility 97.2
Paence 93.1
Prudence 86.1
Trust 75
Truth 75
Value %
Generosity 58.3
Courage 58.3
Gratude 56.9
Jusce 55.6
Hope 44.4
Charity 38.9
Benevolence 38.9
Compassion 27.8
Harmony 20.8
Discussion
Regarding the profile of the survey
participants, there was a predominance of
women over men, reecng the feminizaon
of medicine, a phenomenon described in studies
such as those by Scheer 7,8, which observe this
trend and predict the increasing involvement of
women in healthcare professions.
Most of the surveyed students are young
adults and self-identify as white. This raises
questions about privileged access to higher
educaon in Brazil. According to a 2021 survey
conducted by the Union of Higher Educaon
Instuons in the state of São Paulo 9, the net
enrollment rate (which esmates the percentage
of young people aged 18 to 24 enrolled in higher
education relative to the total population in
this age group) was only 18.1%—much lower
than goal 12 of the Naonal Educaon Plan,
which aims to reach 33% by 2024.
Due to erratic governmental efforts to
democraze educaon in recent decades, access
to higher educaon is sll reserved for those who
can aord to pay for it. Therefore, it should be
understood that social inequality is embedded
in Brazil’s historical development, impacng the
country’s current student populaon, especially
as access to higher educaon is considered one
of the drivers of accumulated economic, scienc
and cultural human development 10,11.
Another notable aspect of the prole of the
parcipants is the religious aliaon indicated
connues...
Table 3. Connuaon
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Development of medical values in the training in active methodologies
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by the majority (Catholic and Evangelical), since
religious values can be considered moral values
of each individual’s culture 11. Religious morality
can intersect with the outcomes of this survey,
regardless of whether the medical school explicitly
references moral values.
Among the values students deemed to
have been developed during their educaon,
respect, responsibility, patience and humility
stood out. These same values were the most
cited as essenal medical values and as the most
applied in pracce during the teaching-learning
process, varying only in order of importance,
thus corroborating the findings in Marques’
study
3
. However, regarding the values considered
essential for the internship, prudence also
appeared with a higher percentage, potenally
indicang how sensive students are to exercising
praccal wisdom in the pracce of medicine 12.
Prominent among those moral values
was respect, which had not been considered
among the most developed in theoretical
activities, but enjoyed a significant increase
in frequency when participants referred to
essential values and those applied in academic
practice. This perspective supports the need for
healthcare providers to develop interpersonal
skills in their professional practice, providing
harmonious conditions for the performance of
work activities, resulting in effective care and
humanized relationships 13.
In addion, it is believed that this is a sign of a
medical educaon that considers respecul care
a fundamental human atude and presumes
that there must be integraon between care
and respect, recognizing that, in the relaonship
with the physician, the paent is an individual
with intrinsic value and fundamental rights.
In this sense, the teaching-learning process
should include, besides theory, techniques,
and procedures, care and moral respect for
paents’ vulnerabilies 14.
The values of harmony and compassion had
lower percentages than the others and were
not cited as essenal or experienced during the
academic journey of the parcipants. This raises
quesons about the theorecal knowledge and
importance of these values among students,
especially in the current context in which
instuons that view educaonal services as a
commodity are favored 14.
One should also consider the impact of the
lack of values like harmony and compassion
on the education of medical students, since
union of wills, which results in concord,
and conformity of opinions, which leads to
peace, are foundational values for respectful,
humanized and effective care 15. Students may
thus face difficulties to recognize and apply
harmony and compassion on a daily basis
in their work, and healthcare professionals
may struggle to build a more humane and
supportive society 14-16.
Regarding the CUs and subject areas that
enable the students in this study to benet from
the teaching-learning process of moral values, it is
interesng to note that the cited CUs are at the
intersecon of theory and pracce and emphasize
behavior and skills over knowledge. Concerning
educaonal strategies, it is observed that praccal
experiences and internships, as well as group
discussions, are the most cited as facilitators
of moral values, corroborang the ndings of
Marques’ research 3. This indicates that the
development and building of “ethical” (of moral
values) competence depend less on theory and
more on experience, cooperave pracces and
peer learning 16-18, approaches priorized by acve
learning methodologies.
It is noteworthy that the ethics and bioethics
CU (48.6%) and undergraduate research acvies
(undergraduate monograph I and II) (25% and
25%) did not feature prominently among the
main subject areas that promote the teaching
of moral values. This raises quesons about the
point of having a specic moment in the medical
curriculum for ethics and bioethics classes and
the eciency of the research process as a means
to learn about and adopt ethical practices in
knowledge producon. The end-of-term paper
is an assignment directly related to moral
values, given the Brazilian resoluons on ethical
research with humans and animals, which require
experience and understanding of values such as
truth, respect, responsibility, trust and prudence.
Michael Apple’s debate on crical pedagogy 19
describes the development of the educaonal
curriculum not merely as an objecve report but
as condioned by the social group that comprises
6Rev. bioét. 2024; 32: e3751EN 1-8 http://dx.doi.org/10.1590/1983-803420243751EN
Development of medical values in the training in active methodologies
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the classroom, bringing the discussion to its
crical reality. Therefore, it seems evident that
the curriculum units should be addressed so as to
encourage reecon and learning about ethical
and moral values, with a connuous, transversal
and interdisciplinary approach throughout
the course, as a responsibility and critical
commitment of all professors and students,
to smulate reecon in daily real-life pracce.
In this sense, acve learning methodologies
can be more producve than tradional teaching,
insofar as the educaonal strategies employed in
this concepon change the behavior of both faculty
and students. They include immersion in the reality
of healthcare services from the beginning of the
course, the professor’s role as mediator/adviser/
facilitator, student leadership and the development
of abilities that consider levels of knowledge
complexity and socio-emoonal skills 20,21.
The relaonship between faculty and students
in the teaching-learning process inuences the
development of moral/social values. A more
horizontal behavior, as proposed by active
learning methodologies, enables students to
create bonds and develop similar attitudes
when accompanying professionals and engaging
in open relaonships 22. According to research
on characteriscs that contribute to problem-
based learning (PBL), a supporve environment
and open, respecul relaonships are means to
facilitate the teaching-learning process.
Regarding how moral values were studied
throughout medical training, it is observed that
such values, or the lack thereof, may emerge
implicitly in the academic content. This relates
to the hidden curriculum, that which goes
beyond the formal curriculum and is characterized
by interpersonal relationships experienced in
the academic milieu 19,24. Therefore, the fact that
moral/social values are explicit in the course’s
syllabus does not guarantee that they will be
discussed and developed. Moreover, the explicit
content, which generally meets the DCN,
may conict with the hidden curriculum, in which
emerge values, interests, discourses, knowledge
and pracces that also shape medical training
and may serve hegemonic models that contrast
with medical professionalism 24.
Final considerations
In the relation of moral values developed
during medical educaon to their applicaon in the
internship program at a medical school in southern
Brazil, the prole of the invesgated students
shows a predominance of young adult women and
religious aliaon (Catholics and Evangelicals).
Regarding the moral values learned during
medical training and those pracced and considered
essential for the internship experience, it is
noteworthy that the ones most commonly indicated
by students were the same—respect, responsibility,
paence and humility—varying only in order of
importance. Additionally, students report that
discussions and lessons about these moral/social
values occur more oen when strategies typical of
acve learning methodologies are adopted.
The study suggests the need to invest in faculty
development and training to enable professors
and students to legimize the teaching-learning
process as a means of teaching/learning while
caring and of caring while teaching/learning.
Future research on the inuence of the hidden
curriculum on the teaching of moral/social values in
medical educaon may contribute new inquiries to
legimize and indicate new ethical and bioethical
pathways for health care within the SUS raonale.
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24 jan 2024];24:e190572. DOI: 10.1590/Interface.190572
Taane Muniz Barbosa – PhD – taane.barbosa@unidavi.edu.br
0000-0002-3575-1555
Eduarda Ferreira Merigo – Undergraduate student – eduarda.merigo@unidavi.edu.br.
0000-0002-6292-3586
Mateus Henrique Silva – Undergraduate student – mateus.henrique.silva@unidavi.edu.br.
0000-0001-6338-6703
Paola de Lima – PhD – paola.lima@unidavi.edu.br
0000-0001-7647-266X
Correspondence
Taane Muniz Barbosa – Rua Guilherme Gemballa, 13, Bairro Jardim América CEP 89160-932.
Rio do Sul/SC, Brasil.
Participation of the authors
Taane Muniz Barbosa, Eduarda Ferreira Merigo and Mateus Henrique Silva jointly wrote,
researched, analyzed and organized the study. Paola de Lima contributed to designing the
research project.
Received: 1.30.2024
Revised: 5.2.2024
Approved: 5.9.2024