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Introduction Medical schools worldwide are creating inclusion policies to increase the admission of students from vulnerable social groups. This study explores how medical students from vulnerable social groups experience belongingness as they join the medical community. Methods This qualitative study applied thematic analysis to 10 interviews with medical students admitted to one medical school through an affirmative policy. The interviews followed the drawing of a rich picture, in which the students represented a challenging situation experienced in their training, considering their socio-economic and racial background. The analysis was guided by the modes of belonging (engagement, imagination, and alignment) described by the Communities of Practice framework. Results Participants struggled to imagine themselves as future doctors because they lack identification with the medical environment, suffer from low self-esteem, aside from experiencing racial and social discrimination. Participants also find it troublesome to engage in social and professional activities because of financial disadvantages and insufficient support from the university. However, participants strongly align with the values of the public health system and show deep empathy for the patients. Discussion Including students with different socio-economic and racial backgrounds offers an opportunity to reform the medical culture. Medical educators need to devise strategies to support students’ socialization through activities that increase their self-esteem and make explicit the contributions they bring to the medical community.

Orientador: Marco Antonio de Carvaho Filho Dissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciências Médicas Resumo: Introdução: Tornar-se médico é um processo complexo e moralmente desafiador. Durante a formação profissional, o aluno de medicina precisa nutrir o compromisso social, tornar-se tecnicamente competente e internalizar um conjunto princípios éticos - autonomia, justiça, não-maleficência e beneficência - e valores morais como solidariedade, compaixão e integridade. Internalizar esses princípios e valores é fundamental na trajetória dos estudantes para tornarem-se médico, porém não é o suficiente para eles serem bem sucedidos nesse processo. No início da prática clínica os estudantes de medicina também devem identificar e ponderar valores morais pessoais e profissionais conflitantes para conseguir decidir qual o melhor curso de ação em casos clínicos complexos. Decidir qual o melhor curso de ação muitas vezes implica nos alunos reconhecerem, entenderem e lidarem com diferentes dilemas morais. Lidar com dilemas morais pode desencadear reações emocionais intensas e afetar o desenvolvimento profissional do estudante. Entretanto, as experiências morais dos estudantes de medicina e suas reações emocionais são explorados apenas superficialmente na literatura da educação médica e frequentemente no contexto da educação em ética médica ou do profissionalismo médico. Objetivos: Esse estudo aprofunda a compreensão dos dilemas morais dos estudantes de medicina ao (1) investigar a natureza dos dilemas morais vivenciados no início da prática clínica, (2) explorar a resposta emocional dos alunos a esses dilemas e (3) examinar como os alunos percebem a influência desses dilemas em seu desenvolvimento profissional. Métodos: Trata-se de um estudo transversal qualitativo realizado em 2017 com alunos do último ano da graduação em medicina que aplicou a análise de modelos temáticos a entrevistas individuais. As entrevistas foram associadas a desenhos realizados pelos alunos onde eles representaram os dilemas morais vivenciados no início da prática clínica. Resultados: Os dilemas morais têm quatro dimensões interligadas. A primeira está relacionada ao desafio dos alunos em priorizar, equilibrar e aplicar valores morais conflitantes; a segunda compreende o choque entre a motivação interna dos alunos e as constrições externas que limitam a ação moral; a terceira refere-se ao conflito entre as atitudes atuais dos alunos com as atitudes desejadas / idealizadas do médico que pretendem ser; a quarta corresponde a ponderar princípios éticos conflitantes durante a decisão moral. As respostas emocionais dos alunos são intensas, duradouras e com um notável efeito residual, principalmente quando a decisão moral não se alinha com suas crenças morais. Os dilemas morais são experiências impactantes que afetam o desenvolvimento profissional dos estudantes de medicina e podem culminar tanto no distanciamento afetivo quanto no crescimento da coragem moral. Conclusão: os dilemas morais são experiências complexas e emocionalmente intensas que impactam o desenvolvimento profissional dos estudantes de medicina. A compreensão dos dilemas morais dos alunos pode ajudar os educadores a conceber atividades pedagógicas para antecipar e refletir sobre essas experiências. Essas atividades devem acontecer sob a orientação de um facilitador sem julgamentos, capaz de ouvir e legitimar os pensamentos e sentimentos dos alunos, ao mesmo tempo que fornece compreensões para nutrir seu desenvolvimento profissional Abstract: Introduction: Becoming a doctor is a complex and morally challenging process. During professional training, medical students must nurture social commitment, become technically competent, and internalize a set of ethical principles - autonomy, justice, non-maleficence, and beneficence - and moral values such as solidarity, compassion, and integrity. Internalizing these principles and values is paramount in the students' trajectory to become doctors, but it is not enough for them to succeed in this process. At the beginning of clinical practice, medical students must also recognize and articulate conflicting personal and professional moral values to decide the best course of action in complex clinical cases. Deciding on the best course of action means that students need to recognize, understand and deal with different moral dilemmas. Dealing with moral dilemmas can trigger intense emotional reactions and affect a student's professional development. In medical education literature, medical students' emotional reactions to moral experiences are tangentially explored often in the context of ethical education or professionalism. Objectives: This study deepens the understanding of medical students' moral dilemmas by (1) investigating the nature of moral dilemmas experienced in early clinical practice, (2) exploring students' emotional response to these dilemmas, and (3) examining how the students realize the influence of these dilemmas on their professional development. Methods: This is a qualitative cross-sectional study carried out in 2017 with students in the last year of medical graduation, which applied the template thematic analysis to individual interviews. The interviews were associated with drawings made by the students where they represented the moral dilemmas experienced at the beginning of clinical practice. Results: Moral dilemmas have four interconnected dimensions. The first is related to the students' challenge to prioritize and balance conflicting moral values; the second comprises the clash between the students' internal motivation and the external constraints that limit moral action; the third refers to the conflict between the students' current attitudes and the desired/idealized attitudes of the doctor they intend to be; the fourth corresponds to considering conflicting ethical principles during the moral decision. Students' emotional responses are intense, long-lasting, and have a noticeable aftereffect, especially when the moral decision does not align with their moral beliefs. Moral dilemmas are impactful experiences that affect the professional development of medical students and can culminate in both emotional detachment and the growth of moral courage. Conclusion: moral dilemmas are complex and emotionally intense experiences that impact the professional development of medical students. Understanding students' moral dilemmas can help educators to design pedagogical activities to anticipate and reflect on these experiences. These activities should take place under the guidance of a non-judgmental facilitator, able to listen to and legitimize students' thoughts and feelings while providing insights to nurture their professional development Mestrado Ensino em Saúde Mestre em Ciências