We investigated the subjects' experience in the management of T2DM cases. In this context, symbolic meanings concerning T2DM and the clinic management emerged from the subjects; and the description of the medical role assumed in the scenario and how it was seen by the patient-actor and their group colleagues.
To understand our findings, we resumed the efforts of medical graduates to the T2DM clinic in PHC. They focus on developing in students the skills, knowledge and attitudes for the prevention, monitoring and balance of glycemic level and reducing of hyperglycemia risks. This approach aims to reduce the impact of T2DM on the health of with it and the burden on health services and systems arising from the numerical increase in cases and their chronicity (Buckley A and Colagiuri R 2008; Gorrindo et al. 2014; Johnson et al. 2017; Krok-Schoen et al. 2017; Lavorato-Neto and Parisi 2017; Lee et al. 2016; MacEwen et al. 2016; Maria Medina-Figueroa and Atzimba Espinosa-Alarcon 2007; Patil MM et al. 2013, 2013; Rizvi A. 2009; Whitehouse et al. 2021).
The clinical TP approach includes prescribing oral medications and insulin, offering advice on healthier lifestyle habits. This approach focuses on DPR as an element of joint continuous construction and TP review grounded on the motivational education of people with diabetes to their engagement in self-caring and clinic visits schedule where barriers on caring may be mitigate and risk complications are screened and reduced (Forouhi and Wareham 2019; Gorrindo et al. 2014; Johnson et al. 2017; Lee et al. 2016; Organization 2018; Remus et al. 2016; Whitehouse et al. 2021).
When comparing educational trends and clinical guidelines (Forouhi and Wareham 2019; International Diabetes Federation 2008; Organization 2018) with our findings, we found distinct contrasts that should receive necessary educational attention, especially in TL strategies based on reflection. Starting with the symbolic meanings about T2DM and management, we highlight the students' difficulty in naming T2DM. They describe it as "damage greater than death", a "thing you wouldn't want to have" or a "something that kills you" (Rosa), and that "affects several parts of the body" (Bomba). Regarding the diagnosis, it has a “huge impact on the person's life” (Girassol). The meaning of “impacted” is enhanced by the expressions “bring the hammer down” (Lampa) or like a “stamp… as if you were a judge giving a sentence” (Édipo). “Hammer” and “stamp” are instruments that operate by impact.
Denominating T2DM and its treatment as “impact” represents the anguish of students’ feelings about this condition and how to cope with it. These conceptions can intervene in the outcome of attitudes towards establishing the DPR that depends on communication, and therefore, on the success in the construction and conduction of the TP, dialogic with the effort of the educational examples available (Gorrindo et al. 2014; Hibbert et al. 2013; Krok-Schoen et al. 2017).
The “hammer” (the subject's metaphor about the conclusion of the diagnosis) is the instrument of a judge's authority. In line with the expression adopted by another subject, the “stamp” (to communicate the diagnosis to the affected person), a medical instrument to authenticate prescriptions, aligns diagnosis and treatment at the level of prescribing a conviction to the affected person – communication about the diagnosis and therapy appear negatively. The doctor's explanatory words can be a sentence and are "powerful words" to penalize. Words and treatments can be poison to the affected person: “it is a medicine and a poison” (Rosa); “words are powerful… the patient will remember it for the rest of his/her life” (Rosa).
This power can make the student uncomfortable, and requires responsibility: “a great power, but, at the same time, it brings a great responsibility” (Édipo). Here the subject shows a moral identification. Words, prescriptions and explanations are a moral challenge: it is “very bad for the patient to leave his appointment, receiving a diagnosis and not knowing exactly what he has […] you have to explain it to the patient” (Kari); “I need to know how to explain things better” (Taiga). It is difficult to level this responsibility: “would just a change in lifestyle, diet or physical activity be enough, or should I use… Metformin?” (Édipo). The symbolic question permeates the ideal of the TP's set of behaviors, counterbalanced by the perception of competence to prescribe this set.
Concerning the treatment and its possibilities, the subjects demonstrate questions that deal with the theme of "to be or not to be" efficient - conducive to the theatrical platform of TL. That is, knowing or not knowing the set of therapeutic procedures, which has a symbolic relationship with the sufficiency of medical performance: “I knew I needed to prescribe insulin…, but… should I keep oral medications?” (Leia); the “what I told her was enough to convince her that it was ok to use insulin, even though it was a bit annoying” (Leia); “a subject I knew even less about” (Girassol).
The lack of student confidence is discussed in the literature in the following contexts: studies that analyze the phenomenon articulated to levels of knowledge (MacEwen et al. 2016; Mumtaz et al. 2009); or with the intention of developing it through strategies that anticipate clinical practice (immersion teaching) in the pre-clinical stages of the course (Nieman 2007); or through digital simulation, which allows beginners to deal with the limits of their skills and knowledge (Diehl et al. 2015). Despite the need for such objective questions, there is a gap in the literature: the consideration of the set of symbolic and subjective questions of students that affect the lack of confidence in the management of T2DM. As an example of this, we show here these symbolic aspects of how T2DM and its management can be conceived as an anguish, damage, a condemning and unpleasant sentence to be communicated.
This responsibility of dealing with the management of a chronic health condition that causes “damage greater than death” (Rosa) touches the idealization that students have about their role in the management. Part of this idealization captures moral identification – a “great power … brings great responsibility” (Édipo). This is a latent concern that students have about the perception that patients form about them as doctors, in addition to self-judgment about performance.
The predominantly negative impressions used by students are antagonistic to the established guidelines (Forouhi and Wareham 2019; International Diabetes Federation 2008; Organization 2018; WHO [Organization] 2019). They aim at treatment encouraging a healthy physical and mental state, recommending habits that improve the quality of life of people with T2DM, as well as medication to keep glycemic balance (American Diabetes Association 2021; Inzucchi et al. 2015; Organization 2018).
Students justify the negative view with ideas: “I am someone who really likes sweets. I really like eating. So, I wonder, if, by chance, I were to have a illness like this, how much it would affect my life” (Bomba) – The predominant view is the restrictive one due to the recommendations of not consuming glucose and ultra-processed foods, needed in the caring of the T2DM condition. These ideas are imposed in the name of idealized pleasurable satisfaction and overwrite the conception of health gains in the pleasure of healthy – consuming foods with better nutritional value (Adams et al. 2010; Pérez-Cornejo et al. 2021). Treating the condition implies eating quality food and practicing physical activity to provide physical and mental gains (American Diabetes Association 2021; Inzucchi et al. 2015). The point is to reflect on the educational problem to develop student clinical skills in such way they reach a reasoning to help in promoting new ways in health improvement and quality of life through healthy practices to people with T2DM (Eilat-Tsanani et al. 2015; Gorrindo et al. 2014; Krok-Schoen et al. 2017; Patil MM et al. 2013; Remus et al. 2016; Rizvi A. 2009).
Medical education is concerned this field (Hoang and Lau 2018; Nieman 2007; Remus et al. 2016). However, attention should be paid to the reasons that justify the phenomenon that positive learning about healthy things does not change students' convictions, fantasies and identifications with the negative-restrictive content related to T2DM. Diagram 2 summarizes the contrast between the symbolic conceptions (frequent difficulties in approaching this clinical situation among students) and the recommendations for the treatment of the person with T2DM. Future studies should address this phenomenon.
Concerning the performance of the medical role of patients and colleagues, students reported feeling inhibited when being observed. Asking questions in front of someone causes a certain paralysis of actions or memory and results in some failure, even when there is care in the clinical approach. For example, trying to remember as much conceptual information as possible to track the effects of hyperglycemia on target organs does not prevent the lapse in taking the medical history – “it was my fault” (Kari). The context is not having identified that the patient's mother, in the plot, had died from consequences of T2DM.
Failure is a frightening for students: “if we can treat it, what did we get wrong for the person to get to this point?” (Rosa); “what scared me was talking, inducing the person…” (Beriba). This causes indignation and highlights the idealized clinical role that, at this point in training, is opposed to the perception of performance in the responsibility of clinical management of a chronic health condition. An ideal that, in the face of patients or the observation of colleagues, is difficult to achieve. It is a hard process to get out of the role: “It took me a while to get out… I was afraid of getting out of there, of being humiliated… I didn't know how to deal with it…” (Barth).
Diagram 2 - Students' Perceptions of Recommended Policies: Points of Attention and Educational Intervention
[Diagram2.docx]
A safety point for students, in the role they play in coping with the condition, is to keep blood glucose level and avoid evolution of complications: “doing the best… complications… that's it!” (Kari). Another safety point is articulating a plan to adopt healthy habits: “tell her to join her family to go jogging” (Lampa). Regarding this role, it is aligned with the need to know how to better explain the condition to the affected person and consider in the clinical role the attention to the entire complex set of details that involves T2DM. These last two points are represented with insecurity and concern: “I need to know how to explain it better” (Taiga); “I was kind of lost… Do I have to play this role [handbook and prescription available in the scenario]; Should I or shouldn´t I play the role?… I was kind of…[lapse]” (Taiga). The final expression, “I was halfway through”, is symbolically pertinent to this conflicting point between the level of performance and the ideal necessary to face the condition. The student feels in the middle – between doing and not doing, “Do I have to play the role?” – Should I write and act thinking about the task, or “I shouldn´t I?”.
The symbolic conceptions that we gathered about T2DM and its treatment, such as those referring to the role of the student-doctor performer in relation to his patient and classmates in the T2DM clinic, originate from the power of the TL strategy used. It promotes reflection and insights in students about the level of their clinical competences, through tutored group discussion about the performance of the simulant in the clinical case (Beigzadeh et al. 2015; Bradley 2006; Hoang and Lau 2018).
The symbolized subjective phenomena that we infer from listening to students in this process and that are condensed in the categories are: the anguish that the T2DM condition causes them; the ideas about negative aspects of the treatment that distance the positive appreciation of what is healthy; the difficulties of taking on a task, caused by environmental issues such as the pressure of observation; the insecurity in failing to develop therapeutic solutions with the consequent possibility of harming someone. Such phenomena cannot be driven only by cognitive contents or objective TL strategies. They need attention and development through reflection, and support in the formative process (Hoang and Lau 2018). They are in the nature of a subjective psychology.
We found in Balint's research (Balint 1955, 2002) a contribution that clarifies the nature of reflective group work, developing subjective content, and the deepening of the DPR. This is the key point of the PBL used here as a TL intervention, and its intention is in line with the trends present in the T2DM medical education literature. In Balint's language, the physician focusing on DPR means prescribing himself to his patient, according to the current goals of Medical Education (Gorrindo et al. 2014; Lee et al. 2016; Remus et al. 2016).
We have already pointed out the central importance of establishing DPR in the T2DM clinic in which the physician prescribes him/herself as a TP facilitator. This bond will be made possible when the clinician is skilled and sensitive to the complex context that involves cultural, emotional and socioeconomic factors that are part of this clinic. For these reasons, the skills of how to consider such factors in management are educational targets addressed in the literature by Medical Education (Frommhold and Wolf 2017; Lee et al. 2016; Tsao and Yu 2016).
Balint called the physician's “apostolic function” the set of subjective difficulties that the general practitioner faces when dealing with the psychocultural complicating factors of a clinical case. It is a consequence of the physicians’ responses, full of therapeutic rage, to offers for healing opportunities that patients direct them to in a cyclical way, which becomes increasingly complex, but always postponing the real possibilities for this (Balint 1955). Our findings showed this type of response from the subjects from the simulation scenarios to which they were submitted. The answers reflect the effort with which the subjects sought to theatrically sustain a doctor's semblance to someone newly diagnosed with T2DM, or to someone who, due to the evolution of the T2DM condition, required complementary insulinization. Based on the theatrical performance contemplated and discussed in a group, reflections emerge that deepen the real conditions of the students' clinical skills levels and raise insights that show how they subjectively involved themselves in the clinical role.
What was reflected in the theatrical semblance played by our subjects intertwines with the other categories described by Balint: the patient and the illness. As for the illness, the figure that imposes itself is the anguish caused by the unpleasant restrictive measures with which the subjects identified. The patient, on the other hand, is revealed as condemned to follow a therapy constructed by a doctor-student that is still technically insufficient. We can infer how much this loaded semblance corroborates the demands of the Apostolic Function's fury and can harm the DPR (Balint 1955, 2002).
Balint warned that the ideal of therapeutic frenzy comes at the cost of discomfort with the consequent limitation of personal delivery to the clinic. He attributed part of this limitation to the training process, when it does not promote conditions for physicians to assess the “set of established beliefs about how illnessses are acceptable or not; how much pain, suffering, fear and deprivation a patient must endure, and when he has the right to ask for help or relief; how much discomfort to you is allowed to the patient” (Balint 1955). It was with the intention of filling this gap that Balint promoted research seminars with groups of physicians aimed at reflecting on their cases (Balint 2002).
Currently, medical schools adopt active teaching strategies, such as PBL and simulation activity, which brings together TL elements that allow experience and reflection on a wide range of issues involving student performance (Bradley 2006; de Carvalho Filho et al. 2020; Hoang and Lau 2018; Lavorato-Neto et al. 2019). Balint's proposals regarding the group reflection on the clinic show the potential of these strategies to develop the subjective field of students, with consequences for their abilities to establish DPR.
Our results strengthen the evidence on the TL activities of a humanistic and reflective nature to develop the skills and attitudes to the complexity of the T2DM clinic. The subjective reflection that it produces in the subjects highlights the nuclei of what, if not mitigated, can become a non-collaborative factor in the installation of DPR, which will suffer from some doctor's ideas.
The reflection deriving from the contemplation of colleagues and tutors allows the subjective change in these students' ideas, promoting training through collective feedback, which results in awareness. This uncomfortable feeling of being contemplated by someone becomes a self-contemplation, “as if I were being watched, evaluated all the time”, so “I need to do my best because people are watching me” (Leia). Therefore, this core of subjective exchange works like the device that Balint used in his research groups and continuing education for generalists in PHC: a device of insights resulting from the freedom to express and discuss. These performance-based reflection strategies address this creative and sensitizing exercise, also arising from elements of the arts (de Carvalho Filho et al. 2020; Hoang and Lau 2018). The artistic and creative nature of these strategies is dynamically capable of developing competences – in this work we demonstrate their usefulness in helping students to understand how to place themselves in the T2DM clinic.
Final Considerations
When we listen to the fourth-year medical students, in a performance reflection activity, in the simulation group of care of two scenarios of the T2DM clinic, we find the subjective and symbolic view they have about this health condition and its treatment. The students represented T2DM as a distressing affliction and its treatment as an impacting sentence, conceived from restrictive aspects that distance them from a positive appreciation in the acquisition of healthy habits of life in clinical management.
It was difficult to understand the simulated role of clinicians. Peer observation caused inhibition and pressure. Added to this was the insecurity in failing to develop therapeutic and caring solutions and the fear of harming someone, even if they were sure about the need to act in the control of the glycemic level and the evolution of complications. These subjective aspects about the condition, its treatment, and how they were placed in the clinic can make it difficult to install DRP as a means of building and favoring TP engagement with those affected.
The TL intervention by simulation allowed the students to gain insights into these subjective aspects, providing a unique opportunity and speculating to understand how they saw themselves in the T2DM clinic and on the level of their abilities. The subjects learned their limitations, emotions, fears, doubts and hesitations from the shared experience. The awareness of these elements is important to be free from the broad and sensitive understanding of the psychocultural conditions that involve those affected by T2DM, so that they can manage the barriers to treatment. This awareness that PBL reflection strategies promote is in line with the proposals of Balint's MPSY (which was continuing education to raise awareness of removing barriers with which physicians were involved in clinical cases).
Without due reflection on all these elements, our subjects would be different from the clinic recommended for T2DM by the best recommendations. We believe that this TL strategy was adequate to cooperate with the subjects and that it is also useful when added to the framework of those that can meet the present formative challenges of the medical role to the T2DM clinic in PHC, bringing together the development of technical and humanistic aspects.