Radiologia Brasileira - Publicação Científica Oficial do Colégio Brasileiro de Radiologia

^IClinical Psychologist, Master Degree in Sciences by the Program of Post-graduation in Radiology at Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ, Brazil
^IIFull Professor at Universidade Federal do Rio de Janeiro (UFRJ), Head for the Service of Radiology at Santa Casa de Misericórdia do Rio de Janeiro, Rio de Janeiro, RJ, Brazil
^IIIPhD in Medicine by the Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ, Brazil

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INTRODUCTION

Medicine is a mix of science and art. As a science, medicineimplies learning and much study, with permanent updating. As anart, it demands a daily bedside experience to discern relevantdata from a tangle of complaints, signs and symptoms, allowingthe diagnosis of a determined pathological condition.

It is known that social variables and inner motivation affectboth the profession choice and the medicine practice. Therelationship of the physician with the practice of his/herprofession plays an essential role in the understanding ofhis/her choice. For Glasser⁽¹⁾, the work is acomponent that defines our lives; we cannot be victims of ourchoices, we must take over the responsibility for them.

The medical residency is recognized as a modality ofpost-graduation, and considered as the ideal course for educationof specialists. In 1889, at the John's Hopkins Hospital, thefirst residency programs coordinated by Halsted and Osler wereimplemented respectively in the areas of surgery and clinicalpractice. In 1945, the first program of medical residency inorthopedics was implemented in the Universidade de SãoPaulo Clinics Hospital, São Paulo, SP, Brazil. In theInstituto de Previdência e Assistência ao Servidor doEstado do Rio de Janeiro (Institute of Social Security andAssistance to the Civil Servants of Rio de Janeiro State), in1948, residency programs were created in the areas of generalsurgery, medical clinical practice, pediatrics, and gynecology& obstetrics⁽²⁾.

Later in the sixties/early in the seventies the number ofthese programs presented a significant increase because of therapid expansion of medical schools. However, several trainingprograms offered to the students graduated from these schools didnot present the required quality for education ofspecialists.

Presently, after finishing their course, medicine graduatestry to enroll in medical residency programs in the areas theyintend to specialize, but not always they succeed due to thestrong competition. Some of them are approved and start theirtraining; other enroll in specialization courses, and part ofthem search for training in the specialty chosen. Another groupis absorbed by the labor market right after graduating.

According to Decree no. 80.281/77, the medical residency is apost-graduation course for physicians, characterized by a workingtraining of the resident physician, whose activities aresupervised on a full-time basis by technically and ethicallyqualified and experienced medicalprofessionals⁽³⁾.

Since 1977, all the medical residency programs in Brazil areunder the competence of Comissão Nacional deResidência Médica (CNRM), which has establishedstandards and criteria for accreditation of programs in medicineclinical practice, general surgery, gynecology & obstetrics,and pediatrics. Subsequently, the requirements for accreditationof other specialties were defined.

According to the CNRM, for programs of medical residency inradiology and diagnostic imaging accreditation, the requiredtraining duration is three years, in the areas of general andcontrast-enhanced radiology, ultrasonography, computedtomography, mammography, bone densitometry, magnetic resonanceimaging, interventional radiology, examination techniques,urgencies and emergencies. The working training must correspondto 80% or 90% of the yearly workload, and theoretical activitiesmust include the following modalities: anatomo-clinical sessions,study of scientific papers, courses, lectures and seminars,bioethics, medical ethics, scientific methodology, among others.The institution also may offer training programs in the followingareas: angioradiology & endovascular surgery,echocardiography with Doppler, neuroradiology, interventionalradiology and angioradiology⁽⁴⁾.

Specialization courses are regulated by the Resolution no.01/01 of the National Council of Education⁽⁵⁾,establishing a minimum 360-hour workload, a minimum 75%-frequencyin scheduled activities, and a teaching staff constituted of atleast 50% of members holding a master degree or PhD obtained inprograms recognized by Capes (Coordenação deAperfeiçoamento de Pessoal de Nível Superior). Forfinal approval of the student, the presentation of a graduatingpaper or monography is required. Upon the end of this course, thestudent will be entitled to receive a graduating certificaterecognized by several medical specialties societies as aprerequisite for granting of a specialist title. This coursemodality has been utilized by certain institutions as areplacement for programs of medical residence, considering thatthere is neither a term for conclusion of the course nor amaximum workload. On the other hand, there is no need to complywith the previously mentioned requirements established in Law no.6932/81, concerning residents' rights⁽⁶⁾.

According Sousa & Koch⁽⁷⁾, the followingrequirements must be met for a program of medical residency to beaccredited: an appropriate infrastructure aiming at assistingpatients, an adequate services dynamics to ensure that thenecessary basic procedures are performed; and a well preparedpedagogical program to achieve the goals proposed during thetraining period.

According to Sousa & Koch⁽⁸⁾,

"Considering the constant scientific developments and the presently demanding world of labor, the assurance of the success of the future specialist in Radiology and Diagnostic Imaging, besides the education traditionally offered by Medical Residency programs, depends on the acquisition of new competencies and specific skills which constitute the profile of an ideal Resident physician, whose main characteristics are the following:

• He/she must consider that mistakes are a natural part of the natural learning process, and should understand that his/her attitude recognizing and trying to learn with them will distinguish him/her from others who harm patients for concealing their mistakes for embarrassment.
• From the best Resident physicians, those who are destined to be leaders in their profession, it is expected that they are willing to help their peers, considering them much less as competitors than as assistants, and to whom they are an example of compliance with working hours, performing their duties with strictness and competence, and remaining in service until they are finished.
• Besides the expectation of a brilliant technical level, some ethical and human qualities must be part of the ideal Resident physician's character: honesty, commitment to keeping the confidentiality of information obtained from patients, generosity with his/her peers, trying to be always open to interact with other health professionals and the public in general.
• The resident must understand that the main goal of the training is to offer a quality assistance to the patient. He/she also must know that the health care requires services in compliance with quality standards, respecting the precepts of Bioethics and Medical Ethics, considering that the resident's responsibility is not limited to the technical act, but includes the resolution of the detected problem.
• The resident must be skilled at developing both verbal and non-verbal communication, besides being skilled at writing and reading interpretation.

  Aiming at ensuring a constant update in the Resident's education, allowing his/her effective participation in the health services rendering, it is necessary that the Education in Radiology and Diagnostic Imaging is periodically reviewed."

It is important to evaluate the differences in thepsychosocial maturity of trainees and resident physicians inradiology and diagnostic imaging to understand their expectationsregarding their future, wages, motivation for choosing medicine,specifically in this specialty, difficulties and facilities facedin the professional practice, idealization versus reality of theprofession, and personal aspirations as radiologists.

According to Taha et al.⁽⁹⁾, the option forradiology and diagnostic Imaging has increased as a result of thedevelopment of imaging methods. This can be observed through ahigher search for courses of specialization and programs ofmedical residency in this specialty.

According to Nogueira⁽¹⁰⁾, some papersapproaching medical residency have already been published onseveral emotional aspects of the resident physicians, theirworking training, stress, their education itself, anxiety,increase in sleep, appetite, anguish, irritability, amongothers.

The norms in force concerning education of specialists inradiology and diagnostic imaging emphasize the technicalcompetence with a little approach to behavioral aspects.Therefore, the trainees self-esteem may be evaluated by means ofthe Rosenberg's scale⁽¹¹⁾, a ten-item test fora self-analysis based on the respondent positive or negativeattitude (Cronbach's alpha = 0.6 and intraclass correlationcoefficient = 0.81). It may be applied to adults and adolescentswith highly consistent results.

The present study is intended for contributing to theunderstanding and knowledge of the profile of the physicianeducating in radiology and diagnostic imaging in abio-socio-cultural context, aiming at better understanding thereasons leading these professionals to choose this specialty.

MATERIALS AND METHODS

A questionnaire was created with 26 questions regardingpsychosocial profile, social factors and inner motivationsinfluencing the choice of the specialty, professional needs andpossibilities of adaptation to the market demands, besides levelof professional satisfaction. Two questions were answered bymeans of a numeric scale (1 – low; 2 – middle; 3 – high). Theparticipation of trainees and medical residents in this study hasoccurred on a voluntary basis. All of them have signed a term ofinformed and free consent.

The mentioned questionnaire was applied in the period betweenFebruary and September 2005, to 44 trainees of thepost-graduation course at Cesanta and PUC, six residentphysicians in radiology and diagnostic imaging at Santa Casa deMisericórdia do Rio de Janeiro, and six residentphysicians in radiology and diagnostic imaging at HospitalUniversitário Clementino Fraga Filho – UniversidadeFederal do Rio de Janeiro (HUCFF-UFRJ). Also, the Rosenberg'sself-esteem test was applied as a part of the mentionedquestionnaire.

RESULTS

Of 56 students interviewed, 85.2% were in the age rangebetween 21 and 30 years. Thirty-one (53.7%) of the respondentswere women.

Self-esteem – Some of the students (21.3%) presentedanxiety, 52% of them at home, 19.2% during classes, and 28.8%during practical activities.

An above average self-esteem was observed in 39.6% of thephysicians who achieved 30 points in the Rosenberg's self-esteemscale. Of the students interviewed, 32.1% presented a higheraverage self-esteem, i.e. 35 points in the mentioned scale. Only17.0% of the students demonstrated a high self-esteem, with 40points in the scale, and 11.3% did not answer this question.

Motivation – For 37.7% of the students, the choice ofmedicine was motivated by aptitude or personal realization; 8.2%did not know the reason of their choice, and 54.1% mentioned anarray of motivations.

The reasons leading them to specialize in radiology anddiagnostic imaging vary. For 42.6% the reason was affinity withthe specialty, and for 53% several reasons were mentioned; 4.4%of the students did not answer this question.

About the level of satisfaction with their professionalchoice, 30.2% marked level 8, and 30.2%, level 10. The remaining39.6% marked levels 5, 6 and 7.

Keeping calm, is the way like 64.8% of these students react todifficult situations in their professional practice. The other35.2% react irritating themselves and swearing.

As regards teachers' expectations, technicalknowledge/professional experience/correct diagnosing/commitmentwere marked at level 3 in the scale by 80.6% of the students.Charisma was indicated by 48.6% at level 2. Good relationshipwith patients/availability/attention/objectivity were itemsmarked by 90.9% of the respondents, at level 3, and ethics, atthe same level by 88.6%.

Professional aspiration – Similarly to the item"motivation", for 37.7% of the students, the choice of Medicineoccurred by aptitude or personal realization; 8.2% do not knowthe reason for the choice, and 54.1% reported an array ofreasons.

The motivation for specializing in radiology and diagnosticimaging varies. For 42.6%, the reason was affinity with thespecialty. For 53% of the students, several reasons wereindicated, and 4.4% did not answer this question.

For 21.7% of the students, the low compensation is thegreatest difficulty for the profession. For the other 78.3%, thegreatest problem is related with stress, high responsibility,excessive workload, absence of resources, among others.

For 31.9% of the respondents, the greatest facility for theprofession is employment opportunity. They said that, despite thelow compensation, there is no lack of work. The remaining 61.1%gave different answers, with less than 4% for each of them.

Students questioned about teachers' expectations in relationto their performance answered the following: technical knowledge,professional experience, correct diagnosing and commitment atlevel 3 for 80.6% of respondents; charisma, at level 2 for 48.6%;good relationship with patients, availability, attention andobjectivity, at level 3 for 90.9%; and ethics, at level 3 for88.6% of the respondents.

As regards their time out, 20.2% of the students spend it inleisure with their families/staying home/seeing someone; theother 78.8%, riding a bicycle, listening music, going to themovies, to the beach, watching TV, reading, browsing in theinternet, among others.

The salary expectation for 54.5% was in the range between R$8,000.00 and R$ 10,000.00 at the fifth year of professionalpractice. The other 45.5% are distributed among salaryexpectations ranging between R$ 3,000.00 and R$ 15,000.00.

Doctor-patient relationship – Likewise as regardsprofessional aspiration, this question was aimed at measuring theteachers' expectations in relation to the students' performance.For 80.6% of the respondents, level 3 was marked for technicalknowledge/professional experience/correct diagnosing/commitment.Charisma was given level 2 by 48.6% of the physicians. Goodrelationship with patients/availability/attention/objectivitywere given level 3 by 90.9% of the respondents. Ethics was markedby 88.6% at level 3.

For 62.5% of the students, the patients ask few questionsabout their diseases, and for 28.6%, the patients ask manyquestions about their diseases. Only 8.9% answered that patientsask no question about their diseases. For 50.9% of thephysicians, the clients understand and assimilate the informationgiven by them, and 49.1% say that they do not.

Of the respondents, 77.4% declared to be able to clarify thedoubts of their patients, and the other 22.6% said they do notfeel comfortable doing so.

As regards the goals to be achieved by the physicians in thisspecialty, level 3 was chosen at highest rates in all theanswers, with the following distribution: a good financialcompensation, 67.6%; to acquire practical experience in thisarea, to learn examination techniques, update and improvement inradiology and diagnostic imaging for 100% of the students;learning to deal with patients, to transmit confidence and bealways available for 77.1%; professional realization for 88.6% ofthe respondents.

DISCUSSION

Technological and scientific developments in the area ofradiology and diagnostic imaging allow the professionalqualifying by the acquisition of new competencies and skillsduring the medical residency and specialization courses,according to the students' expectations provided they are givenopportunities. Therefore, there is a need of a well preparedprogram to provide physicians with an education appropriate forthe future practice of the specialty.

As regards the question about emotional factors afflictingphysicians, 21.3% reported anxiety, and 52.2% alternated sadness,anguish and irritability. These symptoms occur in their majorityat home, after, during classes, and finally during practicalactivities. The reason for 26.5% of respondents not answeringthis question is still to be known. Jaeger⁽¹²⁾says that medicine present more and more surprising developmentsand specialization thus placing the physician at risk of settingthemselves apart of human values. This situation may induceconflicts associated with the professional practice and therelationship with the multidisciplinary team, resulting indifficulty of communication, frustration and disillusion with thechosen specialty.

Rogers^(13–15) highlights the importance ofsensitization, affection and motivation in the construction ofthe knowledge. The emotional background also is extremelyimportant in this context. This becomes clear from the analysisof the Rosenberg's self-esteem test, since 38.2% of thephysicians achieve 30 points in the scale, demonstrating a goodlevel of self-esteem associated with their own positive ornegative attitude.

One can observe that a great part of the students feel secureabout their professional choice. This choice is predominantlybased on aptitude and personal realization. For some physicians,varied motivations were equally marked at low rates. On the otherhand, the reason which has led them to specialize in radiologyand diagnostic imaging is quite variable. For a great part of therespondents the reason was affinity with the specialization. Foranother part of the students, varied reasons were marked atextremely low rates. Also few students did not answer thisquestion.

When asked about difficulties in the medicine practice, lowcompensation is the most mentioned item. On the other hand,employment opportunity was considered as the greatest facility.This uneasiness has been observed byPereira⁽¹⁶⁾, since many Medicine graduates havesought post-graduation courses in the expectation of increasingtheir income as a private doctor and also as a provider of healthcare for private payers (health care plans), including theBrazilian unique health system (SUS – Sistema Único deSaúde).

The present study may bring a great contribution for teachersand advisers in post-graduation programs in radiology anddiagnostic imaging to a deeper understanding and knowledge oftrainees and resident physicians' profile, their innermotivations, personal aspirations, doctor-patient relationship,besides the way they see their profession.

CONCLUSION

With the present study, we could observe that the choice ofthe specialization courses or medical residency programs offeredby Cesanta, PUC, Santa Casa da Misericórdia do Rio deJaneiro, and by HUCFF-UFRJ is due to excellent referencesobtained by candidates on their courses and professors, with agreat influence on their motivation.

These students have chosen medicine by aptitude and personalrealization as their inner motivations.

The students' satisfaction levels related to theirprofessional choice achieved grades 8 and 10, demonstrating thatthey feel satisfied with their option.

Social factor influencing the choice of this specialty were:affinity between students and the methods of diagnostic imaging,and little personal contact with patients, i.e., littledoctor-patient relationship.

Another aspect observed is that, due to the low age andmarital status of the majority of students, many of them can notadmit the lack of free time for themselves resulting in anxietyand uneasiness, despite their above-average self-esteem. Residentphysicians demonstrated a higher assurance level in relation totheir professional choice, and naturally behave with lessanxiety. On the other hand, trainees demonstrate more immaturityand many times insecure in relation to their professional choice.But, professional ethics is extremely important both for traineesand resident physicians who demonstrate their concern withfollowing the rules of Conselho Regional de Medicina (RegionalCouncil of Medicine).

The maturity observed in the psychosocial profile of traineesand resident physicians in radiology and diagnostic imaginginfluences the choice of their subspecialization. In the presentstudy, however, the higher determination of residents in relationto their choice has remained unclear.

Medical residents have said that the value of the scholarshipis very low, considering not only the heavy responsibility load,but also their expectation as regards their income with someyears of professional practice. They have recognized that being aphysician represents a privilege in terms of employmentopportunities, notwithstanding the highly demanding market andthe competition.

It can be observed that the students' desire and willing toadapt themselves to the market demands are not compatible withthe expectation of the ideal versus real in the profession. But,during the interviews, it was possible to observe that thesephysicians are open to changes they have to undergo in their longprofessional career.

Many questions raised in this study could be further exploredaiming at the benefit of those who will be treated by theseprofessionals, as well as the satisfaction of the students whowill continue facing facilities and difficulties during theirwhole professional lives.

REFERENCES

1. Glasser W. Teoria da escolha: uma nova psicologia de liberdade pessoal. São Paulo: Ed. Mercuryo, 2001.        [  ]

2. Ferreira HB. A residência médica no Brasil. Residência Médica 1984;6:2–12.        [  ]

3. Brasil. Ministério da Educação. Secretaria de Educação Superior. Residência Médica. Legislação Específica. Decreto nº 80.281, de 5 de setembro de 1977. Regulamenta a residência médica, cria a Comissão Nacional de Residência Médica e dá outras providências. Diário Oficial da União:Brasília, DF, 6/9/1977. Seção 1, pt. 1, p. 11787.        [  ]

4. Brasil. Conselho Federal de Medicina. Resolução CFM nº 1.763/05. Dispõe sobre a nova redação do Anexo II da Resolução CFM nº 1.666/2003, que celebra o convênio de reconhecimento de especialidades médicas firmado entre o Conselho Federal de Medicina – CFM, a Associação Médica Brasileira – AMB e a Comissão Nacional de Residência Médica – CNRM. [Acessado em 3/10/2005]. Disponível em: http://www.cfm.org.br        [  ]

5. Brasil. Ministério da Educação. Conselho Nacional de Educação. Resolução nº 1, de 3 de abril de 2001. Estabelece normas para o funcionamento de cursos de pós-graduação. [Acessado em: 3/10/2005]. Disponível em: http://www.mec.gov.br        [  ]

6. Brasil. Lei nº 6932, de 7 de julho de 1981. Dispõe sobre as atividades do médico residente e dá outras providências. Diário Oficial da União: Brasília, DF, 9/7/1981. Seção 1, p. 12789-90.        [  ]

7. Sousa EG, Koch HA. A residência em radiologia: o ponto de vista do médico residente. Radiol Bras 2001;34:65–70.        [  ]

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9. Taha OG, Barros N, Cerri GG, Koch H. Estudo das motivações para a escolha da residência médica em radiologia. Radiol Bras 1995;28:7–11.        [  ]

10. Nogueira LA. Residência médica: estresse e crescimento. Psiquiatry on line [Acessado em: 10/10/2005]. Disponível em: http://www.priory.com/psych/resid2.htm        [  ]

11. Rosenberg M. Society and the adolescent self-image. Princeton: Princeton University Press, 1989.        [  ]

12. Jaeger W. Paidéia. A formação do homem grego. São Paulo: Martins Fontes, 1995.        [  ]

13. Rogers CR. Liberdade para aprender em nossa década. Porto Alegre: Artes Médicas, 1985.        [  ]

14. Rogers CR. Sobre o poder pessoal. São Paulo: Martins Fontes, 1989.        [  ]

15. Rogers CR. Tornar-se pessoa. São Paulo: Martins Fontes, 1981.        [  ]

16. Pereira JCM. Medicina, saúde e sociedade. Ribeirão Preto: Complexo Gráfico Villimpress. [Acessado em: 31/5/2005]. Disponível em: http://www. fmrp.usp.br/rms/publicacao/medicina%20 saude%20sociedade%20 alterado.pdf        [  ]

Mailing address:
Glauce Cerqueira Corrêa da Silva
Rua Marquês de Paraná, 62, ap. 401, Flamengo
Rio de Janeiro, RJ, Brazil, 22230-030
E-mail: glauce@centroin.com.br

Received November 16, 2005.
Accepted after revision May 4, 2006.

* Study developed in the Services of Radiology at Santa Casa da Misericórdia do Rio de Janeiro and Hospital Universitário Clementino Fraga Filho (HUCFF) – Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ, Brazil.