Short ﬁlms and complex cases for education of primary health care professionals

Since 2009, the Federal University of Health Sciences of Porto Alegre (UFCSPA), participant of the Brazil's Open Health University (UNA-SUS), has oﬀered an e-learning Family Health Specialization (FHS) Course which has graduated 1902 students (physicians, dentists and nurses). The FHS is a Distance Learning Course (DLC) arranged in two areas. In the ﬁrst one, general content concerning public health is covered. The second is based on a problem-based-learning strategy in which professionals are exposed to complex clinical cases. The aim of this article is to share a methodological experience in teaching in a Family Health Specialization Distance Learning Course by using complex cases and their adaptation to short ﬁlms. Forty-two cases designed by the UNA-SUS/UFCSPA’s team were used in the FHS course. From these, six were adapted to short ﬁlms. They have scripted narratives in which literary elements were used to organize the stories and make scenes more similar to what is experienced at work, preserving the clinical aspects to represent the daily life of professionals, patients and their conditions. Topics covered in the ﬁlms include clinical, social, and family aspects, as well as community-related ones. The scenes depict a realistic portrait of health services provided by Brazil's Universal Health System, they help to develop observation and communication skills, critical analysis of the attitudes, besides clinical knowledge. Complex Cases represent an expressive way to learn and interact with diﬀerent knowledge and skills which are required of health professionals. Students are able to identify with real-life situations projected into the screen and their imagination to learn about them.


Introduction
UFCSPA has been part of the Open University of SUS -UNA-SUS since 2009. The UNA-SUS is a consortiun initiative of the Brazilian Ministry of Health whose role is to qualify the professionals working in primary health care units at the Brazilian Health System (SUS). Nowadays, UFCSPA is one of the 31 consortium universities and has offered since 2010, as one of the activities of the project, the Specialization Course in Family Health, which uses a distance learning methodology.
The course is divided into two areas: the Public Health and the Clinical Professional Performance cores. The methodological approach of the course is based on the contextualization of contents in fictional cities created in light of narrative theories, already presented in other AMEE 1 conferences. Such methodology involves the safeguarding of professional ethical issues and the ambience of contents of the reality experienced by professionals in believable situations (orders of simulacra 4 ).
For the second part of the course, of Clinical Cases, the faculty opted to develop forty-two complex cases to emphasize medical, nursing and dental clinical situations, also amplifying the context of social determinants, family relationships and other facts which influence health. These cases were presented to students in several ways, among them the short films. The objective of using these medias is to diversify the presentation of complex cases for teaching in health, one of them being through short films.

Methodology
The planning phase of the contents for the Specialization Course in Family Health involved the discussion between the pedagogical and technical team of Professors (Doctors, Nurses, Dentists) of which was the best educational approach to present the clinical content. According to our Political Pedagogical Project, The course adopts relational pedagogy and its epistemological assumptions in the development and conduction of teaching-learning processes, regarding the student as an active subject, protagonist of their own formation process, and the teaching-learning process as focus of the pedagogical action, based on the relationship established between student and object of knowledge, learner and educator, student and teacher (BECKER, 2001). It is assumed as a principle that human action makes learning possible, favoring reflection through interaction. In order for learning to be truly consolidated, communication among the actors in the process through dialogue and sensitive listening is paramount. through 3D reality -planned and developed in light of the fictional cities of literature, with credible elements and according to the three regions in which the students could be living when taking the course. Today, the course is comprised of three fictional cities: Santa Fé, located in the south of Brazil; Muiraquitã, in the Amazon region; and São Luiz Gonzaga, in the northeast of the country. The choice of location of the cities is related to the epidemiological data, once Brazil is of continental proportions and has a large variation in the prevalence of diseases in their different regions. Such cities and their development are described in other papers. The whole content of the course is developed based on the three cities also in the Public Health area of the Specialization.
The second part of the course deals with problem-based-learning strategies through the use of complex cases. The greatest challenge was to develop them in a way which the professional working in Primary Health Care would identify with format that the contents addressed, doing the learning processes really significant and applicable to the student's reality.
The course consists of forty-two Complex Cases. Originally, twenty of them were adapted from cases of the Brazilian Society of Family and Community Medicine and twenty-two were created from scratch 3 .
Based on the principles of narrativity and verisimilitude proposed by Aristotle and Ricoeur, the team took the information which is usually collected from a patient and turned it into narratives which represented stories of fictional lives. From the ambience, such as the physical structure of a Brazilian Primary Health Care Unit, to the characteristics of the patient and their way of acting, everything was planned, thought of and constructed by the faculty of the course using the theories of narrativity.
After this phase, there was a textual revision period in order to adapt the textual cohesion and coherence for the finalization of the texts and their contents so that the activities based on Complex Cases could be planned. To improve the distance learning experience, the cases are presented in different ways -comic books, texts, Photograph soap opera and also six of them have become short films.
The filming of the six cases comprised the following steps: narrative scripting; selection of settings (locations) similar to those described in the cases; setting ambience; actors and costumes selection; rehearsal; recording, editing, final product. Each stage involved different professionals, and many of the project collaborators, health professionals and scholarship students were so involved in the projected that they participated as actors. All the stages were accompanied by the professors of the medical, nursing, dentistry and literature courses, to guarantee the fictitious and technical reality which was needed, since they were not ordinary short films, but short films with didactic purposes.
There was about six months of work between the conception and the six final products, which today are used in the course by more than 2000 students and are available on ARES (Collection of Educational Resources in Health) -a v i r t u a l , f r e e p u b l i c r e p o s i t o r y m a i n t a i n e d b y t h e B r a z i l i a n M i n i s t r y o f H e a l t h -a n d o n YouTube (https://www.youtube.com/user/UnASUSUfcspa) for public domain, with English subtitles.
The complex cases were the denominated by name of the principal patient which are Darlene, Danrley Anderson, Samuel, Agenor, Dona Margarita (Part 1 and 2), Amélia (Part 1 and 2).

Discussion
The Political Pedagogical Project of the Specialization Course in Family Health is based on the theoretical and Moreover, Czeresnia (2003) also considers the theoretical basis of Health Promotion, in which the concept of health situation extends the concept of health promotion, considering the options of the social actors involved in the process. In this way, it seeks to identify needs through analyzes and objective procedures, in which the analysis of the problems demands more complex approaches, being configured through the choice of priorities which involve the individual and collective subjectivity of the actors in their daily spaces.
In Primary Health Care, through the interlocution with the Family Health Strategy in Brazil, professionals are challenged to always see the patient and their surroundings, so there is nothing more appropriate than to use the fictionalization and narrative representation of these experiences to produce the contents of the course through active learning processes in the production of complex cases. Working whit complex cases requires that the student developed articulated thinking connecting processes through intersectoral operations and actions of promotion, prevention and health assistance and Team work. This way experiencing the dynamics of the places and the fictitious and verisimilar 4 subjects (individual and collective), that revealsocial inequalities and health inequities, should simulate the reality that configure the actions of the Family Health Strategy. (FIGUEIREDO, 2012, page 3) (BRAZIL, 2011).
In addition, the use of fictitious complex cases, but which represent the reality experienced by the student in his daily work, safeguards ethical issues in dealing with the patient and the production of learning, since the student can identify the fictitious situation with their reality, but produces learning by the hypotheses brought about by the clinical exercise in the imagined situation.
Another important aspect to consider is the shape and the dynamics of the presentation of the complex cases in the form of short films. This presupposes to activate in the student other interpretative relations generated by the contact with the Seventh Art. Visualizing the concreteness of the narrative means transcending the interpretive aspects and immediately triggering the most significant memories of the professional performance, causing the student to reconfigure in the learning the temporality of his performance through the proposed reflections.This material also can be use as part of in class activities, usem the short films as introduction to the discussion about clinic, problems of health systems, primary health care as well as how to work as a team. This provides the possibility of developing several competences such as communication skills, clinical reasoning and ethical attitudes, among others.

Conclusion
From the work developed, one can perceive the merger of four areas of knowledge: health, pedagogy, literature and computer science, producing a course with interdisciplinary methodology for the area of Health.
It is concluded that there is an innovative methodological experience, which uses specific theoretical reference on learning, teaching in health, narrativity and imagination to foster the distance course, ensuring the safeguarding of the ethical issues involved, as well as active and participatory learning of the student through Identification, albeit fictitious, with working situations.
The use of narrative and its theories in the production of contents in Health proved to be a Simulated shaped film addressing the context of Health assistance, reality witnessed by the students of the course . Consideration should be given to the creation of a resource which offers other uses beyond the objectives of the course, since the clinical approaches of the cases bring themes and contents known worldwide and which are prevalent in the populations in the case of Primary Health Care, such as Diabetes Mellitus, Hypertension, Schizophrenia, Tuberculosis, Male Impotence, Postpartum, Depression, Dementia, Asthma, Vaginal Candidiasis, Heartfailure.
The videos can be used to illustrate the distance learning material but also as an auxiliary tool in blend learning, when the teacher can choose which aspects presented in the film should be used in that moment. 2. Translation by the authors.

Notes
3. First, the team surveyed the clinical contents to used by students in each specialty of the course -doctors, nurses and dentists. The starting point for the use of SBMFC cases, which had only the contents for Medicine, was to develop the clinical parts for the other public. After this step, there was the adaptation to the fictional reality of the cities and to the aspects of the narrativity. At the end of the process of the twenty cases, it was noticed that clinical contents were still missing, for which the team then created another twenty-two. All are set in the cities according to the clinical contents that they regard to.
4. Concepts taken from the Narrative Theory proposed by Luckács in the Analysis of Literature Novels; by Aristotle, in The Poetics; and by Paul Ricoeur, in Time and Narrative. Such concepts elucidate that the relations of man with the world and existence (consciousness of finitude) are temporal, and that it is through narrative discourse that time is organized through the elements of narrative (time, space, characters, action) in a verisimilar way, that is, resembling reality but not reality itself. In this sense, the transposition of such concepts in the use of teaching and learning in Health can surround the student of his reality through the imagination, which makes him understand, recreate and elaborate learning by distance from reality, which is represented in complex cases.

Take Home Messages
To use complex cases adapted to short films could be a promising tool in the education of health professionals. This method makes the learning process more attractive for multiples reasons; Effective teaching methodology from an educational and professional point of view; Problematized situations similar to the reality experienced in Primary Health Care; Interrelationship with other knowledge and skills necessary for the practice of professionals of health;

Alessandra Dahmer:
PhD in Computer Science; Professor of UFCSPA; Coordinator of the UNA-SUS / UFCSPA Project. Works as a researcher in the area of Computer Science in the following subjects: distance education, software engineering, information technology in education and artificial intelligence.

Márcia Rosa da Costa:
PhD in Education; Professor of UFCSPA; Pedagogical Coordinator of the Specialization Course in Family Health / UNA-SUS / UFCSPA. Co-coordinator of the Storytelling Program for Health Promotion; Works with the following themes: childhood, teacher training, teaching and curriculum methodologies, training of health professionals.

Maria Eugênia Bresolin Pinto:
PhD in Epidemiology. Adjunct Professor of UFCSPA. Coordinator of the UNA-SUS / UFCSPA Program. Works as a physician, with emphasis in Family Medicine and Community in the following subjects: medical education, physical activity, technology and education, primary care and sports medicine.