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Background Primary care practice-based research is valuable for advancing scientific knowledge in real-world settings and promoting evidence-based practice. It has external validity to other primary health care settings, making translation of research findings easier. However, conducting such research can be challenging, especially in low- and middle-income countries with limited resources and infrastructure. Systematizing the challenges and recommendations is necessary to support researchers in producing high-quality research in primary care.Objective To identify challenges and recommendations for conducting practice-based research in primary health care services.Method An integrative literature review was performed on PubMed, Embase, Scopus, Web of Science and Lilacs databases.Results 440 articles were identified and 25 were included in the analysis. There was a prevalence of descriptive studies, conducted in developed countries, and the majority with the participation of physicians. The challenges and recommendations for conducting practice-based research in primary health care services were grouped into six topics: research planning; infrastructure; engagement of health professionals in research; knowledge translation; relation between universities and practice; international partnerships and collaboration.Conclusion The challenges to implementing research in primary health care settings are similar in several analyzed contexts and the recommendations found point to the necessity for lasting and systemic action that engages managers, decision makers, academics, health professionals of different categories and users, aiming towards the sustainability and transformation of the practice.

BACKGROUNDLack of skilled human resources in primary care remains a major concern for policymakers in low- and middle-income countries. There is little evidence supporting the impact of residency training in family medicine in the quality of care, and it perpetuates misconceptions among policymakers that the provision of primary care can be easily done by any physician without special training.METHODSThis article compares the risk of patients being hospitalized due to Ambulatory care sensitive conditions and the odds of having follow-up visits in primary care after hospital discharge, according to the type of their medical provider: (1) Generalists (reference), (2) Family physicians; and, (3) patients with no consultations prior to the event. Multilevel multivariate binomial regression models estimated the relative risks of a patient being hospitalized in a given month and the relative risks for the occurrence of a follow-up visit in primary care in a retrospective cohort of 636.640 patients between January 2013 and July 2018 in Rio de Janeiro.FINDINGSFor all 14 conditions, there was a higher risk of hospitalization when patients had no consultation in primary care prior to the event. Except for Ear, Nose and Throat infections, patients seen by family physicians had a lower risk of being hospitalized, compared to patients seen by Generalists. Follow-up visits were more likely to happen among patients treated by family physicians for almost every condition analyzed.CONCLUSIONWith two years of training in family medicine, Family physicians can reduce the risk of their patients being hospitalized and increase the likelihood of those patients having a follow-up consultation in primary care. Investments in residency training in family medicine should be made to fix the shortage of skilled physicians in primary care, reduce hospitalizations and improve quality and continuity of care.

Since 2012, the Besrour Centre for Global Family Medicine at the College of Family Physician of Canada has brought together its partners from the Americas annually, to reflect on the evolution of Family Medicine on the continent since Alma-Ata, and to look forward to future challenges. Family doctors are but one element of a strong health system. Family Medicine provides key ingredients to respond to population health needs especially as countries move through the epidemiological transition to face larger burdens of chronic disease and multimorbidity. In this paper, we provide a high-level overview of the state of Family Medicine on the continent. We then analyze trends in the education of family physicians to face this changing landscape, including the emphasis on the leader role of future family physicians. Postgraduate programs in Family Medicine in the Americas are placing increasing emphasis on teaching collaborative care in view of creating truly interdisciplinary health teams for the benefit of patients. Resumo Desde 2012, o Centro Besrour de Medicina Global de Família, na Faculdade de Medicina de Família do Canadá, reúne seus parceiros das Américas anualmente para refletir sobre a evolução da Medicina de Família no continente desde Alma-Ata e para os desafios futuros. Os médicos de família são apenas um elemento de um forte sistema de saúde. A Medicina de Família fornece ingredientes-chave para responder às necessidades de saúde da população, especialmente à medida em que os países passam pela transição epidemiológica para enfrentar um fardo maior de doenças crônicas e de multimorbidade. Neste artigo, fornecemos uma visão geral de alto nível do estado da Medicina de Família no continente. Em seguida, analisamos as tendências na educação dos médicos de família para enfrentar esse cenário em mudança, incluindo a ênfase no papel de líder dos futuros médicos de família. Os programas de pós-graduação em Medicina de Família nas Américas estão enfatizando cada vez mais o ensino do cuidado colaborativo, a fim de criar equipes de saúde verdadeiramente interdisciplinares para o benefício dos pacientes.

Resumo Treinamento especializado, provimento e fixação de profissionais na Atenção Primária à Saúde são desafios prementes no Brasil. A recente expansão dos Programas de Residência em Medicina de Família e Comunidade coexiste com lacunas na literatura sobre o efeito deste processo. O objetivo do trabalho é explorar a perspectiva do gestor municipal de saúde acerca das estratégias para o fortalecimento das residências e do papel destas na formação profissional e na qualificação da atenção. Trata-se de um estudo de análise quantitativa e qualitativa, com aplicação de questionário a gestores de municípios cenários destes programas. As respostas de 48 sujeitos foram submetidas a estatística descritiva e análise de conteúdo. Os resultados revelam um esforço em incorporar o Médico de Família e Comunidade na rede de atenção à saúde, uma percepção do potencial das residências no incremento da qualidade da atenção e da formação profissional e fragilidades nas ações para melhoria da estrutura e organização dos serviços com residentes. Vislumbra-se assim o potencial das residências para a superação de problemas históricos da Atenção Primária à Saúde brasileira, se atrelada a ações de fortalecimento do serviço, dos recursos humanos e do próprio programa. Abstract The training, recruitment and retention of primary care professionals is a constant challenge in Brazil. The recent expansion of family and community medicine residency programs in the country coexists with gaps in the literature on the effects of this process. This article explores municipal health managers’ understanding of these programs and the role they play in professional training and improving the quality of health care. We conducted a quantitative and qualitative analysis of the responses to questionnaires answered by 48 health managers working in municipal health services affiliated to residency programs. A descriptive statistical analysis of the quantitative data was performed and the qualitative data were analyzed using thematic analysis. The findings show that efforts were made to incorporate family and community doctors into the health care network and that managers recognized the potential residency program have to improve the quality of care and enhance professional training. Weaknesses were found in actions to improve infrastructure and facilities and the organization of the services affiliated to the programs. This study highlights the potential of residency programs for addressing longstanding problems in primary health care in Brazil when combined with actions to strengthen services, human resources and the programs.

Abstract Background There is a need for evidence that residency training in family medicine can benefit the care of patients in primary care in low- and middle-income countries. We tested the hypothesis that two years of residency training in family medicine enables doctors to better detect chronic health conditions while requesting fewer laboratory tests and providing more follow-up visits. Methods We performed a retrospective longitudinal observational analysis of medical consultations from 2013 to 2018 in primary care in Rio de Janeiro, comparing doctors without residency training in family medicine (Generalists) versus family physicians (FPs). Multivariate multilevel binomial regression models estimated the risks of patients being diagnosed for a list of 31 chronic health conditions, having a follow-up visit for these conditions, and having laboratory tests ordered from a list of 30 exams. Results 569.289 patients had 2.908.864 medical consultations performed by 734 generalists and 231 FPs. Patients seen by FPs were at a higher risk of being detected for most of the chronic health conditions, at a lower risk of having any of the 30 laboratory tests requested, and at a higher risk of having a follow-up visit in primary care. Conclusions Residency training in family medicine can make physicians more skilled to work in primary care. Policymakers must prioritize investments in capacity building of healthcare workforce to make primary care truly comprehensive.

Formar novos médicos de família é um desafio em qualquer cenário e muitas variáveis podem influenciar o sucesso ou o fracasso de um programa de residência. Este artigo é o resultado final de um trabalho colaborativo iniciado em junho de 2019, na Conferência Regional WONCA África em Kampala, Uganda, durante um workshop liderado pelo Centro Besrour do Colégio Canadense de Medicina de Família. Apresentamos aqui a perspectiva de um pequeno grupo de jovens médicos de família africanos sobre a experiência de ser residente em medicina de família na África em 2019, esperando que a imagem que representamos aqui ajude a promover as melhorias necessárias nos programas de residência na África em um futuro próximo.

BACKGROUND: Information about multimorbidity is scarce in developing countries. This study aimed to estimate the association of educational attainment with occurrences of multimorbidity in a population of public employees on university campuses in Rio de Janeiro. DESIGN AND SETTING: We conducted cross-sectional analyses on baseline data (1999-2001) from 3,253 participants in the Pró-Saúde study, conducted in Brazil. METHODS: The prevalence of multimorbidity, defined as a self-reported history of medical diagnoses of two or more chronic conditions, was estimated according to sex, age, smoking, obesity and educational level. The association between education and multimorbidity was estimated using odds ratios (OR) and the relative and slope indices of inequality, in order to quantify the degree of educational inequality among individuals with multimorbidity in this population. RESULTS: Greater age, female sex, smoking and obesity had direct associations with multimorbidity; and tobacco exposure and obesity also showed direct relationships with poorer educational level. There was a monotonic inverse linear trend between educational level and the presence of multimorbidity among women, with twice the odds (OR 2.47; 95% confidence interval, CI: 1.42-4.40) between extremities of schooling categories. There was excess multimorbidity of 22% at the lowest extremity of schooling, thus showing that women with worse educational status were more affected by the outcome. No trend and no excess multimorbidity was seen among men. CONCLUSIONS: Educational inequality is an important determinant for development of multimorbidity. Men and women experience its effect differently. Researchers need to consider that sex may be an effect modifier in multimorbidity studies.

Strengthening Primary Health Care (PHC) relies directly on training medical specialists in primary care. This text aims to report the Family Medicine training experiences in Rio de Janeiro between 2008 and 2016. It brings to reflection the development of preceptors in medical specialization through an experience report on three Family Medicine medical residency programs, namely, the Municipal Health Secretariat program, the Federal University of Rio de Janeiro program and the National School of Public Health program. The PHC reform in Rio de Janeiro created a demand for medical specialists working in networks, leading to the expansion of already established medical residency programs and the establishment of a new program sponsored by the Municipal Health Secretariat, providing new teaching positions in several health facilities within the municipal network. These three residency programs progressed through different paths to provide training to their preceptors, offering permanent courses and local actions seeking higher professional qualification and better balance between care and education responsibilities. Permanent investments to strengthen medical residency programs and preceptors training are essential to consolidate the PHC reform nationwide.

Resumo O fortalecimento da Atenção Primária à Saúde (APS) depende diretamente da formação de médicos especialistas em cuidados primários. Este texto tem como objetivo relatar as experiências de formação em Medicina de Família e Comunidade (MFC) no município do Rio de Janeiro entre os anos 2008 e 2016, tendo como objeto de reflexão o desenvolvimento de preceptores no âmbito da especialização médica, por meio do relato de experiência de três programas de Residência Médica em MFC (PRMFC): da Secretaria Municipal de Saúde (SMS), da Universidade Federal do Rio de Janeiro e da Escola Nacional de Saúde Pública. Dentro do cenário de reforma da APS no Rio de Janeiro criou-se a demanda por médicos especialistas para atuação na rede levando à ampliação dos PRM já estabelecidos e à criação do PRMFC-SMS, propiciando novos espaços de ensino em muitas unidades de saúde da rede municipal. Por caminhos distintos esses PRM avançaram na capacitação de seus preceptores, ofertando cursos e ações locais permanentes, na busca por maior qualificação profissional e melhor equilíbrio entre as responsabilidades de cuidado e de ensino. Investimentos permanentes no fortalecimento dos PRM e na capacitação de preceptores são essenciais para consolidar a reforma na APS em todo o Brasil. Abstract Strengthening Primary Health Care (PHC) relies directly on training medical specialists in primary care. This text aims to report the Family Medicine training experiences in Rio de Janeiro between 2008 and 2016. It brings to reflection the development of preceptors in medical specialization through an experience report on three Family Medicine medical residency programs, namely, the Municipal Health Secretariat program, the Federal University of Rio de Janeiro program and the National School of Public Health program. The PHC reform in Rio de Janeiro created a demand for medical specialists working in networks, leading to the expansion of already established medical residency programs and the establishment of a new program sponsored by the Municipal Health Secretariat, providing new teaching positions in several health facilities within the municipal network. These three residency programs progressed through different paths to provide training to their preceptors, offering permanent courses and local actions seeking higher professional qualification and better balance between care and education responsibilities. Permanent investments to strengthen medical residency programs and preceptors training are essential to consolidate the PHC reform nationwide.

Despite the great expansion of our specialty in the last 30 years, we are still far from meeting the Brazilian demand for family doctors. We currently represent only 1.4% of the total number of medical specialists in Brazil and less than 5% of the total number of residency vacancies in the country are allocated to family medicine (FM). With 70% of our population covered by the Family Health Strategy, only a small proportion has a family doctor trained in a FM residency program. Unfortunately, we have little scientific evidence to demonstrate the impact of FM training on the quality of care delivered to our patients and to support our ongoing discourse about the unique competencies within FM. This perpetuates a common notion among policymakers and managers that the provision of primary health care (PHC) is simplistic, unchallenging, and easily performed by any physician without specialized training. If FM intends to establish itself as the medical specialty responsible for PHC in Brazil and in developing countries, it needs to be able to study the universe of FM and PHC with the depth and rigor that these complex disciplines demand. As such, building capacity in research represents an important step towards the development of comprehensive PHC with a strong FM foundation. By questioning our practice and trying to see how much of a difference we really make in the care of our patients, we can expand the evidentiary basis of our discipline and demonstrate how much PHC becomes more qualified and comprehensive by having a doctor trained in FM. This essay addresses the difficulties of FM in showing its value and its importance for health systems and presents the vital role that scientific research must play in facing these challenges. A pesar del gran crecimiento de nuestra especialidad en los últimos 30 años, todavía estamos lejos de satisfacer la demanda brasileña de médicos de familia. Actualmente representamos solo el 1.4% del número total de médicos especialistas en Brasil y menos del 5% del número total de plazas de residencia en el país se asignan a medicina familiar y comunitaria (MFC). Con el 70% de nuestra población cubierta por la Estrategia de Salud Familiar, solo una pequeña parte tiene un médico de familia capacitado por un programa de residencia de MFC. Desgraciadamente, tenemos poca evidencia que muestre el impacto de la capacitación en MFC en el cuidado de las personas, y gran parte de lo que sustentamos como diferencial de nuestra práctica, carece de evidencia científica. Esto perpetúa una noción común entre los formuladores de políticas y los gerentes de que la atención primaria a la salud (APS) es una área de acción carente de desafíos, sin complejidades y que puede ser realizada por cualquier médico sin capacitación especializada. Si la MFC tiene la intención de establecerse como la especialidad médica responsable por la APS en Brasil, necesita avanzar en el desarrollo de habilidades de investigación para estudiar el universo de la MFC y de la APS con la profundidad y rigor que la complejidad de estos disciplinas demandan. El desarrollo de potencial para la investigación representa un paso importante en el proyecto profesional de nuestra especialidad y en la maduración de la APS. Al cuestionar nuestra práctica y preguntarnos si hacemos realmente la diferencia en el cuidado de nuestros pacientes, ampliaremos la base de evidencias de nuestra especialidad y demostraremos cuánto la APS adquire mayor calidad y competencia por tener un médico especialista en MFC. Este ensayo aborda las dificultades de la MFC para mostrar su valor y su importancia para los sistemas de salud y presenta el papel vital que debe desempeñar la investigación científica para enfrentar estos desafíos. Apesar do grande crescimento da nossa especialidade nos últimos 30 anos, ainda estamos muito aquém de atender à demanda brasileira por médicos de família. Atualmente representamos apenas 1,4% do total de médicos especialistas no Brasil e menos de 5% do total de vagas de residência no país são destinados à medicina de família e comunidade (MFC). Com 70% da nossa população coberta pela Estratégia de Saúde da Família, apenas uma parcela pequena conta com um médico de família treinado por um programa de residência em MFC. Infelizmente temos poucas evidências mostrando o impacto do treinamento em MFC no cuidado das pessoas e muito do que sustentamos no nosso discurso como diferenciais da nossa prática carece de provas científicas. Isso perpetua uma noção comum entre formuladores de políticas e gestores de que a atenção primária à saúde (APS) é uma área de atuação desprovida de desafios, sem complexidades e possível de ser realizada por qualquer médico sem treinamento especializado. Se a MFC pretende se firmar como a especialidade médica responsável pela APS no Brasil e no mundo, precisa avançar no desenvolvimento de habilidades para a pesquisa, para poder estudar o universo da MFC e da APS com a profundidade e o rigor que a complexidade destas disciplinas demanda. Desenvolver o potencial para a pesquisa representa um passo importante do projeto profissionalizante da nossa especialidade e do amadurecimento da APS. Ao questionarmos nossa prática e ao perguntarmos o quanto realmente fazemos a diferença no cuidado dos nossos pacientes estaremos ampliando a base de evidências da nossa especialidade e demonstrando o quanto a APS se torna mais abrangente ao ter um médico treinado em MFC. Este ensaio aborda as dificuldades da MFC em mostrar seu valor e a sua importância para os sistemas de saúde; e apresenta o papel vital que a pesquisa científica deve ter no enfrentamento destes desafios.