Adopting a pedagogy of connection for medical education

Abstract

In this article, we propose developing a “pedagogy of connection” based on the history and evolution of medical education in Brazil. This pedagogy emerged from the intersection of the healthcare and higher educational systems, both dedicated to the principles of social justice and universal access, in response to the country's efforts to address the enduring impacts of slavery and social inequality. Following the “Sanitary Reformation” movement—a foundational moment for Brazil's healthcare and medical education systems—Brazil established the Unified Public Healthcare System (Sistema Único de Saúde — SUS). SUS is founded on principles of universality, integrality, equity, community participation, political and administrative decentralisation, hierarchisation and regionalisation. Aligned with these core principles and inspired by critical pedagogy, Brazilian medical education has evolved with a profound commitment to social justice, critical consciousness, professional presence and compassion. This evolution has given rise to a “pedagogy of connection,” which imbues medical education with a sense of purpose and joy, preparing future medical professionals to address the challenges of our ever‐evolving society and healthcare systems. The connections fostered by this pedagogy occur in complementary dimensions: (a) healthcare system and society, (b) community, (c) profession, (d) patients, and (e) ourselves. This innovative pedagogy enhances medical education discourse and practice by emphasising the development of a professional identity grounded in social justice and patient‐centred care, which remain challenges for current medical education systems. As the global medical education community embraces decolonisation, this pedagogy offers a framework that can be adapted and enriched in various contexts worldwide, fostering opportunities for mutual learning from diverse educational systems in a dialogical and democratic manner.

Short abstract

Brazil’s “Pedagogy of Connection" is analyzed as a means to bridge healthcare, community, and social justice while offering a model for decolonizing and humanizing medical education.

1. INTRODUCTION

In this article, we introduce the “pedagogy of connection” (POC), a novel framework derived from the trajectory of medical education in Brazil. This pedagogy emerges from the deep integration of Brazil's healthcare and higher education systems, both rooted in the principles of social justice and universal access established during the country's “Sanitary Reformation” movement. ¹ These systems have evolved together within Brazil's unique social context, mutually influencing each other and reflecting the nation's ongoing struggle for social justice. By examining the evolution of medical education in Brazil, we highlight how its commitment to critical consciousness and community engagement can inform and enhance medical education practices globally. We explore how the insights gained from Brazil's experience can be adapted and applied in various international contexts to foster more equitable and inclusive healthcare landscapes. Specifically, we offer a focused reflection on how this POC could contribute to the US medical education system.

In crafting this article, we have adopted an oral tradition approach, which emphasises the use of narrative to convey the interconnectedness of healthcare and medical education systems. ² , ³ This method aligns with the principles of epistemic communalism, where knowledge is created, justified and transmitted through collective storytelling and shared experiences. By utilising narratives about the evolution of Brazil's healthcare and educational systems, we aim to generate insights that inform our proposed POC. We seek to engage readers in a dialogical process that showcases the communal and interconnected nature of medical education and healthcare. Our ultimate goal is to promote a comprehensive, inclusive and equitable educational framework. Before describing our POC, we will tell the story that made it possible.

2. CONNECTING MEDICAL EDUCATION TO SOCIAL JUSTICE: THE UNIFIED HEALTH CARE SYSTEM (SUS) IN BRAZIL

Being a good doctor in Brazil means mastering clinical skills and meaningfully connecting with patients, their families and communities. ⁴ This connectedness involves understanding and acting on societal needs and contributing to Brazil's public healthcare system. From the first week of medical training, students learn the core principles governing the Brazilian healthcare system: universality, integrality, equity, community participation, political and administrative decentralisation and hierarchy of care and regionalisation. These principles, rooted in Brazil's struggle for freedom and social justice, are embodied in the Sistema Único de Saúde (SUS). The creation of SUS happened during the re‐democratisation of the country in 1988, after more than 20 years of military dictatorship, and represented the coronation of years of fight for social justice.

Brazilian medical educators emphasise the importance of students critically reflecting on and acting upon SUS, viewing it as an evolving entity. ⁵ , ⁶ This perspective aligns with Paulo Freire's concept of “unfinishedness,” which suggests that reality is not fixed but continuously changing and therefore always open to improvement. ⁷ “Unfinishedness” instils hope by fostering the belief that a better future is possible and cultivates the grit needed to enact change. It encourages medical students to see themselves as active and responsible agents in the ongoing transformation of the healthcare system.

The understanding that medical students are co‐responsible in the evolution of SUS led to the creation of the Brazilian Directives for Undergraduate Medical Education, a set of principles to guide the development of medical curricula, which are mandatory for all medical schools. ⁴ These directives emerged from a democratic process initiated in 1991, just after the creation of SUS, by the National Interinstitutional Commission for the Evaluation of Medical Education (CINAEM). ⁸ , ⁹ CINAEM included representatives from medical schools, teachers, students, residents, doctors, medical professional organisations, higher education unions and the council of Brazilian universities. This democratic dialogue across diverse social actors was vital to create a shared understand of the relevance of using the needs of the healthcare system to guide the development of the medical curriculum. After a decade of debate, the first national directives were published in 2001 and updated in 2014, ensuring that medical education serves both the healthcare system and society, as stipulated by the Brazilian constitution. ¹⁰

These directives encompass three main dimensions of governance:

1. Attention to health. The first dimension emphasises the engagement of medical students with the social determinants of health. It requires students to focus on individual patients' needs, respect diverse cultural backgrounds and uphold patients' dignity. Simultaneously, students need to learn to address the healthcare needs of the communities they will serve as doctors. The directives mandate medical schools to adopt a holistic approach to medical care. This approach encompasses promotion, prevention, recovery and rehabilitation, integrating the biological, social and psychological dimensions of health, and reflecting the SUS main principle of integrality.

2. Healthcare management. The second dimension covers the understanding of how SUS must be an instrument of social justice. Students learn about SUS historical development, its legal and organisational structures and its ongoing challenges. Students should feel part of this historical and dynamic process and take active responsibility in addressing these challenges. Students must also engage in public health activities to understand how complex and interconnected the system is, and how gathering input from its users is vital for SUS continuous improvement. This commitment with community participation is also one of SUS's principles. This second dimension also covers the need to create the educational context for students to experience how interprofessional collaboration is vital to achieving better health outcomes.

3. Healthcare education. The third dimension focuses on the responsibility of medical schools and educators in fostering students' development into independent, reflective and critical lifelong learners. Students are taught to base their clinical interventions on the best scientific evidence, contextualised by patients' perspectives and cultural traditions. This dimension also demands for nurturing a professional culture where every doctor becomes an educator for patients, communities and peers, as well as a professional who engages with knowledge production focusing on the challenges of their clinical practice within SUS. ⁴

The three dimensions work together to conceptualise an approach to curricular development that is broader than listing (and teaching) the competencies of the individual medical doctor. In Brazilian medical schools, medical students begin to engage in practical activities in the context of public health and family medicine in the first week of the undergraduate medical training. This early engagement allows students to get in touch, learn from and care for patients and their communities while interacting with and getting feedback from diverse healthcare professionals. The connections with patients, communities and peers create a shared understanding that mastering the interaction with people in meaningful, responsible and gentle ways is as important as mastering the biomedical knowledge, mechanisms of diseases and therapeutic principles. This early contact with SUS also nurtures a sense of responsibility over its continuous improvement and expands students' understanding of medical professionalism — particularly at a system's level. This tightly woven and interdependent connection between the healthcare system and the medical curriculum create a sense of responsibility over the system, which inform the future professional development of medical students.

To understand why medical education in Brazil developed in this direction, we need to understand the history of its healthcare system and how SUS connects with Brazilian social landscape.

3. MEDICAL EDUCATION HAPPENS WITHIN A SOCIAL SYSTEM

Brazil is a young democracy. ¹¹ During the Portuguese invasion and occupation (1500–1822), the native population drastically decreased, with survivors either moving to remote areas or being enslaved. In addition to slaved natives, approximately 5.5 million enslaved Africans were forced into the country, making Brazil the largest single destination for enslaved Africans. ¹² , ¹³ These individuals had to change their names, forget their history and experienced a post‐slaved life expectancy of 8 years. ¹⁴ , ¹⁵ , ¹⁶ The Brazilian elite, educated in Europe, built their wealth on the slave trade and other exploitative economic activities. This legacy persists in Brazil's stratified social structure, with the rich mostly white and the poor mostly brown and black. The 350 years of slavery ingrained the belief that the rich have special privileges and can exploit the poor. ¹⁷

Brazilians achieved independence in 1822, but it was not until a military coup in 1889 that the republic was established. The nascent republic experienced periods of dictatorship and political fraud until the re‐democratisation in 1989, marked by the 1988 constitution, which defined health as a citizen's right and the state's duty. A critical aspect of re‐democratisation was the implementation of SUS to reform the inequitable healthcare system and promote social justice. Since 1990, SUS has improved health indicators such as life expectancy, child mortality, immunisation coverage and access to care. Strategies like the “Family Health Strategy” enhanced healthcare outcomes without raising costs. SUS also runs successful national programs for epidemic control, including human immunodeficiency virus and hepatitis C, and leads in organ transplantation worldwide. ¹⁸ , ¹⁹ , ²⁰ , ²¹ , ²² , ²³ , ²⁴ Medical students are introduced to this history of successes and stimulated to embrace equity as a core personal and professional value. They learn to feel responsible for the public welfare and are called to rescue the dignity of the people who were marginalised by the country's history of social and economic oppression.

Medical educators in Brazil realised they had to lead by example. Clinical teachers and public health specialists from various universities were active in conceptualising SUS. ²⁵ , ²⁶ Departments of Preventive Medicine and Public Health in different medical schools were incubators of the “Reforma Sanitária” (Sanitary Reformation), a movement that viewed health as a multi‐dimensional construct. ¹ In the 1970s, community clinics with active participation from medical students and residents tested the principles that govern SUS today. This led to the understanding that a new model of medical education was needed to create and sustain SUS, highlighting the interwoven nature of healthcare and medical education in Brazil. The same way that the Flexner report set the foundations of modern medical education in the United States, grounded on science within academic settings, the Sanitary Reformation in Brazil founded a medical education grounded on social justice and nested in a public and universal healthcare system. ¹ , ²⁷ , ²⁸

Medical educators in Brazil also believe that the diversity in higher education in general, and medical education in particular, should mirror the diversity of Brazilian society. Since 2012, all medical schools within public universities in Brazil must reserve 50% of their places for students from public high schools (in general with a low socio‐economic status when compared to students from private schools), with 25% of the total reserved for black students and specific places for Native‐Americans. ²⁹ , ³⁰ For the international reader, we need to explain that, in Brazil, race is self‐declared in a national census, and the data are used to inform these affirmative polices.

Over its 35‐year evolution, SUS has nurtured a close relationship between the educational and healthcare systems to achieve social justice and humanised care. For instance, within the regulatory structure of SUS, the healthcare system shares responsibility with the educational system to deliver the next generation of healthcare providers in service to the public. Every unit of SUS, from simple to complex care, is statutorily recognised as a place for undergraduate, postgraduate and continuous professional development in service to these ends. ³¹ National programs of the Ministry of Health provide funding to align educational processes with healthcare needs, such as creating extra residency places for family physicians and supporting emergency medicine training. ³² Additionally, and since recently graduated physicians in Brazil can work autonomously in primary and emergency care units, the national medical curriculum directives obligate that at least 35% of its clinical experiences should relate to these two specialties. ⁴ In sum, this emphasis in connecting the education and healthcare systems is to guarantee that medical education will serve patients, communities and society, and promote social justice and equity.

4. CRITICAL PEDAGOGY (CP)

In addition to the Brazilian medical education community's commitment to co‐construct SUS and to promote social justice, higher education in Brazil is deeply rooted in the concepts of CP. ⁷ , ³³ , ³⁴ Indeed, the atmosphere created by CP was fundamental for the educational realm to embrace SUS needs.

Developed by Paulo Freire during the military dictatorship in Brazil, CP is a mix of educational movement, philosophy and theory. ³⁵ , ³⁶ CP understands education as a situated process of developing a critical consciousness — a capacity to identify, reflect on and resist those oppressive forces internal and external to the individual, that prevent individuals to be or become a full citizen. ³³ , ³⁴ A full citizen, in this context, is someone capable of making autonomous choices and acting upon the reality to enact change. ³³

For Freire, education happens (is situated) in the world and, in Brazil, the world of medical education is the healthcare system. The forces acting upon medical students, healthcare professionals, patients and communities come from social processes that originate in both the medical culture and society‐at‐large. Thus, to become a full professional, medical students need to identify and reflect on these societal processes and position themselves to take action to improve the system and move toward social justice. This has been the goal of medical educators in Brazil: prepare the next generation of doctors to further improve SUS and dismantle the structural inequality that still prevents the Brazilian people to strive.

In CP, the teacher has the responsibility to ground the student‐teacher relationship within a democratic dialogue, based on curiosity and openness to the other, in a way that the educational encounter transforms not only the reality of the student but also the reality of the teacher. Teachers need to acknowledge students' context, personality, goals and motivations. They need to preserve students' dignity and embed their values within the educational process. In summary, the educational encounter needs to make sense for the student and for the teacher and for both to be affected by each other presence. ⁷

Guided by the ethic of CP, the student–teacher relationship in Brazil is seen as a model for the doctor‐patient relationship. Both relationships start in a context of a perceived power asymmetry, and both, in becoming democratic, depend on the person in position of power adopting an active listening attitude. Within this ethic, the powerful must constantly search for ways to share the power by activating the powerless to take control over their development. This democratic approach to both relationships depends on the powerful understanding, legitimising and celebrating different perspectives, previous knowledge and social capital. A medical professional educated through the lens of CP is fully committed to nurturing and preserving the dignity of patients when establishing meaningful doctor‐patient relationships.

This approach to the doctor–patient relationship complements the structural change envisioned by adopting CP. While alignments of the structural elements of Brazilian educational and healthcare systems are seen as critical in achieving social justice, so too are the personal relationships within these systems, particularly the doctor‐patient relationship. To become capable of building such democratic relationships with patients and communities, students need to learn how to be present in the clinical encounter.

5. PRESENCE

We define presence as a commitment to connect, an openness to the other, an alertness of body and mind, a focus on the here and now, and a conscious utilisation of time. When students are present in a clinical encounter, their attention is fully deployed on the patient. Students' emotions and reason work together to create a comfortable space for the patient — a space free of moral judgments. A healthcare system committed to presence must allow students to take the time to make sense of patients'` trajectories, connecting with their suffering, while actively searching for ways to heal or comfort. To fine‐tune the construction of the doctor‐patient relationship, students must gather real‐time feedback by paying attention to patients' reactions, making sure that the clinical encounter is growing as a therapeutic encounter. ³⁷

In SUS, physicians are seen as having an active role in modulating the care process to dictate how much time is needed for the clinical encounter to be therapeutic. Every medical encounter is seen as unique. Every doctor and every patient are seen as having different personalities and identities. As a result, clinical teachers in Brazil understand that learning how to communicate and establish therapeutic relationships with patients goes far beyond learning specific (prescribed) behaviours. ³⁸ , ³⁹ , ⁴⁰ , ⁴¹

To be present in therapeutic relationships, students must also learn how to bond emotionally with their patients. ³⁷ Evolution shaped emotions to improve our capacity to understand ourselves, the other and the context. ⁴² Emotions also qualify our decision‐making and help us to make sense of the world. ⁴³ Becoming sick is an emotional process and asking for help idem. Learning how to navigate this emotional realm is vital to master the art of medicine and offer individualised, meaningful, patient‐centred care.

The mandate to further educate students on how to connect with patients within healthcare systems is our drive to suggest a POC.

6. POC

Based on the Brazilian socio‐political experience, the history and evolution of SUS, and its underlying ethic of CP, we believe Brazilian medical education can contribute to the international conversation about medical education by inspiring the adoption of a POC: a connection of medical education with the healthcare system and society, with the community, with patients, with the profession and ultimately with ourselves.

6.1. Connection with the healthcare system and society

One of the challenges medical educators struggle with is the identity dissonance students experience during their transition to practice. ⁴⁴ , ⁴⁵ , ⁴⁶ Research shows that students construct an idealised view of themselves and the healthcare system and have difficulties accepting and dealing with the realities of practice. ⁴⁷ Part of this dissonance is related to a perceived sense of powerlessness, which culminates in feelings of isolation and emotional suffering. ⁴⁴ Students feel like consumers of a system that appears a fixed, unchangeable reality. Alternatively, connecting students with the healthcare system since the beginning of the medical course and teaching them about its structure, goals and principles will position medical students differently. By being early exposed, students may come to understand the system as an ever‐evolving social mechanism that is susceptible to the influence of its constituents, including themselves. By understanding the history of developments that took the system to the now, they will see how powerful healthcare providers are to enact change and create its future. Feeling empowered, students can experience a stronger sense of responsibility; a higher sense of agency to engage in conversations about change. Considering the societal challenges we have ahead of us, challenges that will stress healthcare systems worldwide, we can certainly take advantage of the creativity of our future medical professionals. ⁴⁸

6.2. Connection with the community

Medicine is a profession of solidarity. It is a service to the community that impacts on people's lives. Doctors wake up every morning with the goal of supporting someone who is suffering and needs help. Someone who loves and is loved. When medical students are connected with the communities they serve, they can realise this impact and understand and feel the relevance of their work. In under resourced seatings like Brazil, this sense of purpose feeds students' motivation and prepare them to engage with the sacrifices demanded by the medical profession. In countries where medical education does not allow this connection with the community, it becomes harder to create such a sense of purpose.

6.3. Connection with the profession

Engaging in social change is challenging because the time take to change social structures is slower than we want to accept. To deal with this challenge, it is important to be part of a group of people who share the same motivation to change. If medical schools manage to create a culture of solidarity inside and across the healthcare professional groups, the resilience of healthcare professionals and students increase, and engaging with change becomes easier. Feeling part of a professional group is not only about developing an identity. It is about finding support to keep going, even when things are not going well. It is a source of renewed energy and comradery.

6.4. Connection with patients

Patients are a continuous source of transformative learning. When students learn to be present in the clinical encounter, to engage with their minds and spirits, they experience intense emotional development that impacts their personal and professional lives. ³⁸ By opening themselves to learning from and alongside their patients, students gain a unique form of practical wisdom. Here is how it unfolds: patients enter the clinical setting, bringing with them stories that encompass the full spectrum of human experience. Observing patients as they bravely reinvent themselves and their lives amidst vulnerability, medical students are not mere spectators but active participants in these narratives. This joint journey of patient and student — a shared reflection and sometimes a mutual evolution — lays the groundwork for students to introspect and cultivate wisdom. Beyond gaining insights from patients, the doctor–patient relationship can offer therapeutic benefits to the doctors themselves. Research underscores that forming meaningful connections stands as the most significant contributor to our happiness. ⁴⁹ Thus, the field of medicine should intentionally cultivate spaces where such meaningful relationships can flourish daily.

6.5. Connection with ourselves

The journey to become a doctor is intense and involves personal sacrifices. ⁴⁶ Human beings make sacrifices in the name of something or someone they value or love. Learning about what we find important, right and good is critical for engaging with and making sense of the sacrifices demanded for becoming a doctor. Without joining this journey to know themselves, medical students struggle to integrate their personal and professional identities. And without feeling whole, students may find it harder to connect with patients in meaningful ways. Worse still, students may find themselves in a place of solitude, without finding purpose in their lives.

This POC can create the conditions for the medical educational systems worldwide to deliver to society doctors committed to social justice, equipped to enact change and capable of establishing loving relationships with patients, colleagues and communities. This POC is also a way to rescue the joy of being a doctor. Finally, this POC can also open a new venue for underrepresented voices in medical education to be heard.

7. DECOLONISING MEDICAL EDUCATION

Recently, there has been an increased attention to how the field of medical education might better include underrepresented voices. ⁵⁰ This awakening follows a similar movement in clinical medicine as researchers from leading academic centres in the so‐called Global North have begun to recognise the power of healthcare innovations from under resourced countries to increase healthcare quality and decrease healthcare expenditures even when adopted by wealthy countries. ⁵¹ At the same time, these same researchers fear that a new colonisation process fuelled by the imposition of quality standards based on criteria coming from the North may shut down the voice and creativity of researchers and innovators from historically underrepresented centres.

We salute the effort of medical educators from the North to create spaces, such this special issue in Medical Education, to make this democratic dialogue possible. Nonetheless, we want to further open the eyes of the international medical education community to the diverse ways of producing knowledge.

Knowledge production in medical education goes beyond the content that is published in academic papers. There is a lot of wisdom spread around the world on how to engage students, connect with the healthcare system, implement interprofessional education, teach doctor–patient relationship, conceptualise medical professionalism and include patients in the learning process. This is particularly true for cultures who have a strong oral tradition and disseminate this wisdom from one generation to the other through storytelling and role modeling, often taking advantage of strong community bonds and informal interactions.

However, when international accreditation systems and big educational conglomerates expand by selling their curricula and imposing standards disconnected from the local context and purposes, there is great risk of losing opportunities to learn from and with each other. We hope the medical education community will continue the movement to create a dialogue that is both North–South and South–North. In this dialogue, academics from the North need to open themselves to learn from academics and practices from the South. We trust the medical education community is ready to expand the conversation beyond the explicit academic knowledge to incorporate the tacit wise knowledge that comes from alternative educational, social and political practices.

We must reproduce the democratic dialogue we cultivate with this POC in the international medical education arena to prevent the tragedy that happened with the Native‐American cultures. When the Europeans arrived in Brazil, there were 1175 languages being spoken there. Currently, there are less than 180, and this number goes down every year. ⁵² These different ways of making sense of the world will never be recovered. For similar reasons, we should protect and learn from the different ways of making sense of medical education.

8. CHALLENGES GOING FORWARD

As documented across the various sections of this paper, the development of a POC is located within the historical intersections of Brazil's healthcare and educational systems. One pressing challenge to our analysis is whether the particular drivers of a Brazilian‐informed POC have relevance and applicability to other healthcare and educational systems — given the unique historically grounded circumstances of those countries/systems. If we seek to understand medical education as both embedded in and reflective of the healthcare and social systems in which it operates, we can expect some consistency between these systems and their outcomes (all under the Denning‐esque mantra that “every system is perfectly designed to get the results it gets”). With this in mind, how can we examine other countries' healthcare and educational systems to understand how closely they align with the POC model developed in Brazil?

Worldwide, healthcare systems are grouped across four main types: (1) the Beveridge model, (2) the Bismarck model, (3) the National Health Insurance model, and (4) the out‐of‐pocket model. ⁵³ , ⁵⁴ Brazil has a Beveridge system, ⁵⁵ similar to Great Britain, Spain, most of Scandinavia, New Zealand and Hong Kong, with Cuba being an extreme version of total government control. ⁵⁶ In contrast, the US is unique in that it incorporates elements of all four models rather than adhering to a single system. For example, the Veterans Health Administration (VA) System in the United States exemplifies the Beveridge model, some employer‐based healthcare plans reflect the Bismarck model, Medicare represents the National Health Insurance model, and the uninsured or underinsured population falls under the out‐of‐pocket model. ⁵³ , ⁵⁴

Given this framework, and the inevitable variations within each model, how might we anticipate either elements of a preexisting POC in other countries or the potential to establish such affinities in the future? All four models, including the United States's mixed system, reflect different strengths and weaknesses. Therefore, how might we begin to examine whether Brazil's particular alignment of its health and educational systems, along with its commitment to social justice, critical consciousness, professional presence and compassion represents something other than a one‐off?

One possibility is to begin at the ends of an imaginary continuum with Cuba representing an extreme example of the Beveridge model (which includes Brazil) at one end and with the United States representing a non‐system model at the other. Given at least a modicum of similarities between the Cuban and Brazilian systems, we might reasonably expect, in exploring similarities and differences between the two countries, additional understandings of POC.

Alternatively, the United States represents more of a Sisyphean challenge given its multiple models and therefore varying points of concordance and tensions. For example, The VA System with its Beveridgian leanings represents a possible pocket of receptivity. We know that while the vast majority of US medical schools offer some kind of VA experience for their trainees, with clinical supervisors originally trained (as residents and fellows) within the VA system, huge segments of the US medical students not only lack that exposure but also (and impactfully so) receive the bulk of their training and thus socialisation within a subspecialty and capitalistically‐oriented environment, where the “majority” patient population is covered by employer‐based healthcare plans (and thus the Bismarck model). It may well be that US medical education, within its contrasting models, offers an already POC inclined individual opportunities to pursue their social justice and public‐service passions, even as the overall system socialises the majority of their peers to internalise more of a Bismarckian, market‐focused and capitalistic understanding of health, healthcare and public service.

If we were to judge the underlying social justice ethic of the US medical education system by the overall specialty and geographic employment and deployment decisions of its graduates, then we should at least consider the possibility that we have in fact a system perfectly designed to get the results it gets — a system where social justice, equity, diversity and inclusion may be proclaimed but far from delivered. ⁵⁷ However, it is also possible that the US system has POC islands at certain medical school training sites such as the Uniform Services University School of Medicine (USUHS) which trains future Army, Navy, Air Force and US Public Health Service physicians, or at particular medical schools with strong religious and thus a religiously‐grounded public service ethic. In short, while the overall US medical education engine may seem relatively antithetical to a POC model, the presence of POC affinity pockets within this antisystem, and thus the potential for cultural and structural difference, may offer exceptional opportunities to explore additional or even alternative understandings of a POC‐informed medical education.

Points of inconsistency notwithstanding one may also consider US medicine and its educational “system” to be at some crossroad — even as such a framing has been used in the case of US medicine for well over 50 years. ⁵⁷ , ⁵⁸ , ⁵⁹ Nonetheless, recent calls in the United States for a more diversity‐equity‐and‐inclusion (DEI) informed and focused medical education have emerged front and centre. Concurrently, more traditional rallying cries, such as professionalism, are being called out as weaponised remnants of all too entrenched system of power and privilege. ⁶⁰ , ⁶¹ Further complicating this picture, the United States also is experiencing increasing consolidation of its delivery systems along with the carnivorous entry of private equity into its trillion‐dollar healthcare marketplace — all accompanied by increasing gaps between “the haves” and the “have nots.” Meanwhile, the nation's largest for‐profit health care system, HCA Healthcare, has launched its own medical school (Thomas F. Frist, Jr. College of Medicine at Belmont University). The College's mission calls for “diverse physician leaders,” a “community of service learning” all of which is “inspired by the love and grace of Christ’ represents an intriguing opportunity to explore POC connections. At the same time, this medical school also comes with an (official) estimated annual cost of $96 649 for its inaugural (2024–25) class of students. ⁶² It may well be that its mission of service may be available only to those able to assume what amounts to a $400 000 debt load. The intrigue continues.

If the US society, and its healthcare and medical education systems, want to commit to social justice, reflecting on how these systems are intertwined to produce inequality and adopting POC offer a way forward. From a POC perspective, achieving social justice depends on connecting educational and healthcare systems with societal movements committed with this goal. This interconnected approach ensures that medical education, healthcare delivery and societal values evolve together, creating a cohesive and comprehensive framework for addressing systemic issues. Engaging diverse social players—educators, healthcare providers, policymakers and community leaders—in a unified movement can amplify the impact of POC, driving meaningful change across all levels of society. In Brazil, this movement started 80 years ago, and is still ongoing.

If nothing else, a POC is a pedagogy of hope and where education and health care systems are aligned in service to the public. It is also a pedagogy based on a training system that prepares its graduates to carry that hope along with a commitment to service and social justice into the future. While both healthcare and education systems in Brazil face challenges, including pressures from Western and capitalistically oriented interests, ⁶³ , ⁶⁴ the potential insights and innovations from countries like Brazil (and Cuba) — whose medical education systems have been largely invisible to most US medical students and practitioners — are too tempting to ignore.

9. CONCLUSION

In this article, we elaborated a “POC;” a framework derived from the Brazilian experience that integrates healthcare and educational systems to promote social justice and universal access. The Brazilian approach, rooted in the principles of the Unified Public Healthcare System (SUS) and inspired by CP, emphasises the interconnected evolution of social systems, reflecting the nation's ongoing struggle for social equity. This approach aligns with the global challenge faced by medical education of preparing healthcare professionals who are not only technically proficient but also socially responsive and compassionate. This POC aims to address these needs by fostering critical consciousness, community engagement and professional presence in future healthcare providers, preparing them to face societal and healthcare challenges with a commitment to equity and patient‐centred care. This pedagogy ensures that medical education serves not only individual patients but also the broader community and society.

However, we acknowledge that this paper posits one alternative way of making sense of medical education, and there may be other alternatives (see other papers in this State of the Science, for example). By explicitly acknowledging that there are a variety of ways in which one might address the issues outlined, we hope to contribute to a broader and more inclusive dialogue.

Deciding to implement a POC requires a structural and cultural shift in medical education. Key strategies include embedding the core principles of social justice and universal access into the curriculum, fostering early and continuous engagement with the healthcare system, and promoting an educational environment that values critical reflection and community involvement. Specific policies, such as reserving spots for students from underrepresented backgrounds and mandating substantial clinical experiences in primary care and public health, are essential to this integration. A curriculum committed to this pedagogy places patient experiences in the centre of the learning activities.

We believe that diverse educational systems can adopt and adapt the principles of the POC by:

1. Fostering integration: Ensuring that healthcare and educational systems evolve together, reflecting the socio‐political context and addressing local needs.

2. Promoting equity: Implementing affirmative policies to ensure diversity in medical education, mirroring societal demographics.

3. Engaging communities: Encouraging medical students to engage with communities early and continuously, fostering a sense of responsibility and connectedness.

4. Incorporating CP: Co‐constructing safe educational environments that promote critical consciousness and social justice.

5. Global adaptation: Reflecting on how these principles can be tailored to different international contexts, fostering a global dialogue on medical education reform.

By embracing these recommendations, medical education systems worldwide can move towards a more equitable and socially responsive model, benefiting not only individual patients but entire communities. The POC offers a transformative pathway to reimagine and revolutionise medical education, ensuring that future healthcare professionals are well‐equipped to address the complex challenges of our evolving societies.

AUTHOR CONTRIBUTIONS

Marco Antonio de Carvalho Filho: Conceptualization; writing—original draft; writing—review and editing. Frederic William Hafferty: Writing—review and editing; conceptualization.

CONFLICT OF INTEREST STATEMENT

The authors declare no conflicts of interest.

ETHICAL REVIEW

Not applicable.

de Carvalho Filho MA, Hafferty FW. Adopting a pedagogy of connection for medical education. Med Educ. 2025;59(1):37‐45. doi: 10.1111/medu.15486

DATA AVAILABILITY STATEMENT

Data sharing is not applicable to this article as no new data were created or analyzed in this study.