SciELO - Scientific Electronic Library Online

 
vol.139 número1Linfomas asociados a infección por Virus de Inmunodeficiencia Humana: Experiencia de un centro hospitalario de la V región, ChileDesarrollo y validación de encuesta de percepción del portafolio en estudiantes de medicina de pregrado índice de autoresíndice de materiabúsqueda de artículos
Home Pagelista alfabética de revistas  

Servicios Personalizados

Revista

Articulo

Indicadores

Links relacionados

Compartir


Revista médica de Chile

versión impresa ISSN 0034-9887

Rev. méd. Chile v.139 n.1 Santiago ene. 2011

http://dx.doi.org/10.4067/S0034-98872011000100005 

Rev Med Chile 2011; 139: 36-44

ARTÍCULO DE INVESTIGACIÓN

 

Teaching of Medical Ethics: Students' perception in different periods of the course

Percepciones de los estudiantes acerca de la enseñanza de ética médica

 

DÉBORAH PIMENTEL1, CARLA BARBOSA DE OLIVEIRA1, MARÍA JÉSIA VIEIRA2a

1Departamento de Medicina da Universidade Federal de Sergipe.
2Núcleo de Pos Graduacáo em Medicina da Universida de Federal de Sergipe.
a
Nurse, PhD.

Dirección para correspondencia


ABSTRACT

Background: Medical Ethics is structured to guide doctors towards a better professional practice. However, its teaching in medical schools seems to be neglected. Aim: To evalúate the perception of Federal University of Sergipe medical students about ethical conflicts duringtheir academic practice, in two different periods of a medical course. Material ana Methods: A cross-sectional, analytic and observatio-nal study. Using a qualitative approach, analytic categories were identified using an open questionnaire answered by two groups of students, before and after attending the medical ethics course. Results: In everyday practice, the participants referred embarrassment in front of patients. When considering the relationship with the professional/professor, they identified negligence and conflicts of interests in their practice. The students also detected bad infrastructure and professional relationship in public services, when compared to prívate ones. The conflicts experienced by the students in their own practice were insecurity, inability to cope with patients' problems and inadequate perception of medical confidentiality limits. According to the respondents, contribution of ethics teaching varied from adequate, when itwas effective to orient their practice and provide confidence, to inadequate or absent be-cause of an overall superficial approach. Conclusions: Major deficiencies related to the teaching of medical ethics were identified, pointing to the need to change current medical education model.

Key words: Education, medical, undergraduate; Ethics, medical; Students, medical.


Antecedentes: La ética médica debería guiar a los médicos hacia una mejor práctica profesional. Sin embargo, se enseña deficientemente en las escuelas de medicina. Objetivo: Identificar las percepciones de un grupo de estudiantes de medicina acerca de los conflictos éticos durante su práctica profesional en dos períodos distintos de un curso de medicina. Material y Métodos: Se efectuó un estudio transversal con un grupo de estudiantes de medicina que habían recibido el curso de bioética y otro grupo que no había recibido el curso. Ambos grupos respondieron un cuestionario abierto acerca de los conflictos que vivieron al enfrentar pacientes. Resultados: En la práctica diaria, los alumnos relataron sentir vergüenza al enfrentar pacientes.

Acerca de su relación con los profesores, notaron negligencia y conflictos de intereses en su práctica. Los alumnos también detectaron una mala infraestructura y relación entre profesionales en servicios públicos, al ser comparados con clínicas privadas. Los conflictos que relataron los alumnos fueron inseguridad, incapacidad de enfrentar con los problemas de los pacientes y una percepción inadecuada de la confidencialidad médica. Los alumnos consideraron que la contribución de enseñar ética fluctuó desde ser adecuada cuando orientó su práctica profesional y les dio confianza hasta inadecuada o ausente, debido a ser enseñada en forma superficial. Conclusiones: Se identificaron las principales deficiencias en la enseñanza de ética médica, señalando la necesidad de cambiar el modelo educacional utilizado actualmente.


 

The problem

Human behavior is a complex entity, and regulations and laws have always been conceived to guide men's behavior in accordance to what is expected for one specific society. Since Hippocrates, medicine practice has expressed formal concern about moral procedures and respect for life. These were the beginnings of Medical Ethics.

The medical professional is subjected to pre-established ethical standards that guide his/her conduct in the different activities he/she may be exposed, and ethical discussions have been included as a specific discipline in the medical course curriculum in some, but not all universities1,2.

Ethics and moral are complementary terms. Ethics, from the Greek ethos, means "way of being", "character" and moral, from the Latin mor or morís, means "usual", i.e., a set of standards or rules acquired by man by ordinary use3,4.

Professional Ethics or Deontology includes the guiding principies for professionals when interacting with patients, other professionals and the institutions where they work. These principies are limited to professional environment and have specific standards, such as the Brazilian Medical Ethics Code, established from discussions between doctors and society and approved by the Federal Council of Medicine2,5,6.

For some authors1, the concept of Medical Ethics should prioritize medical practice. They understand that the Medical Ethics Code is no longer enough to guide the physician behavior. In an increasingly complex society, medical decisions go beyond purely cognitive aspects, so overrated in academia. It seems crucial to focus on medical education for ethics topics inclusión, inserting most of the problems students will potentially face during professional life7. Technical skills must be accompanied by ethical valúes early in medical education.

It is known that in many universities in Brazil, in their traditional medical course curriculum, Bioethics is notyet included as a discipline to guide the acquisition of abilities that allow the student to identify and analyze ethical problems yet. Only some of these themes are included in the subject of Forensic Medicine and Deontology, which prioritizes the Medical Ethics Code and the legal aspects of medical practice. Perhaps these contents are not sufficient to fulfill the needs of students relating to the ethical conflicts in their academic practice.

Therefore, a research was made to identify how medical students deal with ethical conflicts befo re and after the formal teaching about Medical Ethics at the discipline of Forensic Medicine and Deontology; to identify situations of ethical conflicts during the academic practice and to verify the contribution of Ethics formal courses to dealing with these conflicts.

As well, this paper, as a clipping of this research, aims only to identify the perception of Federal University of Sergipe medical students about ethical conflicts during their academic practice, in two different periods of the course.

The method

This is a cross-sectional study in regard to the Medical Ethics teaching at the Medical School of Federal University of Sergipe (UFS), in Aracaju, Brazil. An open questionnaire was used, with 19 questions regarding subjects of students' studies, motivations, methodology, disciplines that contributed to the practice experience, and ethical dilemmas they could have experienced during the course.

The study was performed with two groups of students, corresponding to two different context units: the first one, attending the 5th and 6thsemes-ters, with students who had not studied the Forensic Medicine and Deontology, and the second one, attending the 9th and lOth semesters with students who had just finished that course. The same questionnaire was applied to both groups.

The discipline Forensic Medicine and Deontology was used as a landmark for the división of the groups, since it is the only one that formally approaches ethical contents.

The students participated in the classroom, where they received the questionnair, and those who agreed to particípate in the research returned it to a predetermined local.

The present article used data from a single question that asked the students to write a brief story about the most important ethical conflicts perceived in their academic practice.

This study was approved by the Research Ethics Committee of the Federal University of Sergipe and all respondents were informed about the purposes of the research and about their rights, in accordance to the regulations for research in human beings8.

The total number of questionnaires returned was 110 (71.4%): 56 from the first group and 54 from the second.

The first group of students was formed by 24 women and 32 men, with an age range of 19 to 27 years and mean age of 22.3 years. The second group was formed by 22 women, 31 men and one respondent who did not declare the gender, with an age range of 20 to 41 years and mean age of 24.47 years.

Data was analyzed using a technique of categorical approach of content analysis9. Individual analysis was blinded by using a strategy in which each questionnaire was coded as A or B for the first and second groups respectively and a sequential number for the students in each group. Content analysis was performed9, and each sense nucleus was identified at the registry units (words, clips of speeches),leading to the analytical precategories. The resulting categories were grouped by similarity and registered with their sense nucleus, regarding to those categories presence in different contexts and not to their frequency of occurrence.

Results

In view of the ethical conflicts identified by the student of both groups, the results were organized into four analysis sub-categories:

1. Conflicts involving the patient (Table 1);


2. Conflicts involving the professional / professor (Table 2);


3. Conflicts involving the structure of services (Table 3);



4. Conflicts involving their condition as students (Table 4).


Discussion

Frequently the relationship student-patient has been considered merely technical, depersonalized and sometimes troubled, bringing negative stress to the student. It was observed (Table 1) a similaritybetween the two groups regarding these conflicts, either with the student's acts invading the patient's privacy or when they are victims of patient's violence or harassment.

The results of the present research are, most of the time, coincident with the ones of other authors cited in literature.

In these two context units, the contact with patients resulted in conflicts at some point during medical training. Students demonstrated a variety of fears while relating to the patient, probably due to lack of experience and insecurity in medical practice10,12.

For students in the 5th and 6th semesters, it seems to be more significant, for collecting the first medical history and performing the first physical examination usually awake emotional reactions in students and make them anxious12,13:

Feeling of bothering the patient, insecurity and difficulty to examine the patient when it is necessary to undress him (All, 5).

The feeling of using the patient as an object for study is also named as a nuisance to the students, creating feelings of being invasive or abusive to their fellow-being11-14:

Patients were also a source of conflict for having hostile attitudes when facing different situations. It seems to reflect changes in society, where patients are not as "patient" as before15. Real life shows that the patient out of the books is a human being who suffers, complains, does not always cooperate and requires a quick and effective solution for his/her problems16:

I was threatened by a patient for delaying to attend him. I was almost beaten (A8, 6).

The results show that the interaction with various professionals allows having experiences in many types of conflicts, particularly as mutual respect, which is missing in medical education. In the two contexts units we found an inadequate attitude of professional/ professor, regarding to the relationship with patients. In second unit, however, students made it clearer, perhaps because they have already been exposed to specific discussions about that topic (Table 2).

Overcoming these difficulties relies on the professor's aid,because it is during academicback-ground that the students must obtain the resources they need to deal with human dimensión of the-rapeutic relationship. A professor's example seems to be essential in building up professional identity, which enhances the patient-doctor relationship(10).

However, important conflicts involving pro-fessors were observed. There are unethical and inhuman attitudes by health professionals in general and by professors, and these models are incorporated into the student's practices as a standard for their professional behavior7,15.

Some professors do not consider patient au-tonomy17,18 and do not act within recommended ethical and humanistic approaches:

In the investigation of certain conditions, it is not questioned whether the patient wants to be submitted to thatprocedure (All, 9).

... professors seem to forget that they arefacing thepatients and talk about the disease (...) without caring about the human being in front of them (A22,10).

In regard to that situation, some authors1820 report patient perceptions about the treatment received at the University Hospitals and reveal that the visits at the bedside are the only negative aspect, once they feel themselves like subjects under study. There must be ways to teach new doctors without embarrassing the patient. On the other hand, there are researches in which the patients relate they accept the student's presence in anamnesis as well as in the physical examination, as long as they do not particípate in the decisions at diagnosis and treatment11.

Situations of abuse, defined as "negative actions or words, unnecessary and avoidable, inflicted by one person to another or others"(21) were indirectly referred, but such circumstances are very common, and literature21,22 refers that many students reported abuse at some time point at the course.

... the occurrence of maltreatment of patients and students from professors (Al, 5).

Teachers" lack of compromise is also referred by students. They identify professors without up-dated teaching material, showing uncommitment to teaching process and frustrating student expec-tations about school contribution to their medical career with interesting and motivating teaching situations10,23:

Some (professors) were arrogant,pretendingthey were almighty, without compromise with education (A3, 9).

... arrived late or missed the clinic (A 21.9).

The relationship within the workplace was perceived as unethical and marked by a spirit of competition(24):

Authoritarian personality towards other professionals (A18, 5 ).

Professors do not miss any opportunity to lower a workfellow's image (A7, 9).

Interest conflict was identified by second unit students, referring to the influence of non-technical factors in medical prescriptions (25-27) and mercantilist attitude of some professionals (28):

Doctors prescribe only one type of medicine and receive privileges from laboratories, like free travel to medical conventions, help injob dispute between professionals, patient referral to their prívate offices ... (A19, 9).

In this context, learning motivation can be influenced by the professor and the existence of conflicts in this relationship may cause depression and discouragement to studying and having a good relationship with patients13:

My doctor ideal, as a person who is concerned about others' suffering, does not exist here. Doctors are insensitive. Patients are treated in an inhuman way. Isee ethics as respecting the patient as a human being, and not as legal principies. Medicine has be-come aprofession like any other (A32, 6).

The authors21 remind us that when the professor gives some freedom, security and confidence to the students, they feel more stimulated, while the aggressive response from him would be an obstacle to learning.

The students point out the lack of physical and organizational structure observed in public services and their anxieties about the quality of learning, considering the usual shortage of conditions for implementing knowledge. Also here, students of second unit relate problems more clearly, even identifying the care provided by unsupervised students (Table 3).

Medical schools should provide an infrastruc-ture with adequate materials and professors com-mitted to guide, encourage and foster students' learning based on humanism and ethics23. The overail situation is, inversely, the lack of commitment of professors and of hospital infrastructure to face student needs and aspirations29:

In addition, the respondents have conflicts with their role as a student. As medical students, they may fear specific responsibilities that they are not prepared to deal with. This may be a matter of lack of experience or technical skills, or it may happen because of shyness (Table 4).

The expectation to be a good doctor stumbles on the frightening prospect of increasing respon-sibility associated with the fear of making mistakes or not knowing what to do in the face of several situations12,23:

The relationship with patients' relatives is sometimes interpreted as an obstacle to a good relationship with the patient:

When the accompanist does not allow thepatient to express by him/herself or when he/she inquires us about what the patient tola us (A12, 9).

Facing death brings suffering, the students become aware or discover that it cannot always be avoided. The contact with chronic or terminal patients awakens in students a sense of impotence, and they realize that they do not really know how to deal with these situations12,13,30:

... to learn how to deal with children suffering from cáncer andpoor prognosis (A21,10).

Doubts about the confidentialitybody of cha-racter substantive in the doctor-patient relation(24), created discomfort for some students:

Patient who refuses medical recommendations and I did not know whether to inform the doctor, as the patient only told me secretly. (Al, 6). Patient with AIDS accompanied by the husband, whom doesnt know about it (A5, 9).

The current individualistic visión discourages a listening attitude in daily relationships and makes doctors less prepared to work with sub-jectivity, and to develop a healthy doctor-patient relationship31.

... knowing to what extent we may/must get involved with patients' problems (A26, 9).

There are also difficulties in understanding the patient, and it is important for the doctor to try to transíate their language, sometimes full of primitive signs31,32.

Finally, the results also show how some sub-jects, according to the students, clarified some ethical points, and were able to solve problems during the course33.

In general, for the first group important relief could be felt in knowing that they are not the only ones with conflicts, that some conflicts are expected, indeed.

For the other group the guidelines are more detailed according to each situation, with some theoretical deepening missing, and some practical skills also.

There were students who did not feel assisted, in any way, by the institution with the conflicts they had to deal with, describing the school's contributions as insufficient or nonexistent.

It was observed that the teaching of ethics, as from the point of view purely deontological or understood as a guideline for dealing with moral conflicts of medical practice, constitutes a little explored field within the university, despite its great importance.

Meanwhile, society requires more and more that doctors should have ethical attitudes and a holistic view of the patient, beyond the technical training so stimulated during their course.

The failing in the ethics formation within the university brings conflicts of the magnitude pre-viously reported. The relationships in all fields, are worn, and students, most of the time, feel helpless.

The results show major deficiencies in many respects, although a more sharp ethical conscience was evident in students from the second group, who studied Forensic Medicine and Deontology. They more often felt that they were more skilled to manage conflicts after having studied this discipline, also considering that different levéis, age, and other variables must give different perceptions and experiences.

It is important to consider that the drawing of the study with different groups does not follow the maturation of the pupils throughout the course. As well, despite it is known that the students of the first group were younger and less mature than the ones of the second group, and that these factors can influence their perception and administration of conflicts, what is argued in this paper is that there is no preparation of the pupils of the first group about ethical considerations to face academic practice and patients contact, and this contact happens before they are prepared for this.

As for the second group, neither the subject Forensic Medicine and Deontology fulfils the students needs, because it is not a Bioethics specific matter, pointing to the need of Medicines courses, which have that matter as the only possibility of study of ethical subjects, to try to adjust its courses of study to contribute to the formation of the pupils and their future practice.

It is in progress another stage of the same re-search to identify, with the medical professionals, the conflicts in their practice and the contribution that the university education had to dealing with these conflicts.

Ahead of the results presented in this research, it is strengthened that there is an urgent need for greater commitment with education focused on the humanization of medical practice, with more prepared professors, better infrastructure and a curriculum reform that will prioritize the teaching of ethics.

References

1. Athanazio RA, Lemos KM, Fonseca DC, Cunha MS, Braghiroli MIFM, Almeida AM, et al. Academética: um novo método de estudo continuado sobre Ética Médica e Bioética. Rev Bras Educ Med 2004; 28: 73-8.        [ Links ]

2. Miller S. What use are ethical codes?. An analysis of three possible rationales for the use of ethical codes in medical schools and a review of the evidence relating to them. Med Educ 2000; 34: 428-9. Avaliable at:http://www3.interscience.wiley.com/cgi-bin/fulltext/119010634/PDFSTART. Accessed March 05, 2009.        [ Links ]

3. Grisard N. Manual de Orientacao ética e Disciplinar. Florianópolis: CREMESC; 2006.        [ Links ]

4. Castilho EA, Kalil J. Ética e pesquisa médica: principios, diretrizes e regulamentacóes. Rev Soc Bras Med Trop 2005; 38: 344-7.        [ Links ]

5. Cohén C, Segre M. Breve discurso sobre valores, moral, eticidade e ética. Rev Bioética 1994; 2: 19-24.        [ Links ]

6. Figueira EJG, Cazzo E, Turna P, Filho CRS, Conterno LO. Apreensáo de tópicos em Ética Médica no ensino-aprendizagem de pequeños grupos, comparando a aprendizagem baseada em problemas com o modelo tradicional. Rev Assoc Med Bras 2004; 50: 133-41.        [ Links ]

7. Cordingley L, Hyde C, Peters S, Vernon B, Bundy C. Undergraduate medical students exposure to clinical ethics: a challenge to the development of professional behaviours?. Med Educ 2007; 41: 1202-9.        [ Links ]

8. Conselho Nacional de Saúde. Resolucáo 196 de 10 de Outubro de 1996. Disponible en: http://conselho.saude.gov.br/docs/Resolucoes/Resol96.doc. Consultado el 07 de enero de 2008.        [ Links ]

9. Bardin L. Análise de conteúdo. Lisboa: Edicóes Setenta; 2006.        [ Links ]

10. Moreira SNT, Silva CAN, Tertulino FF, Tertulino FMF, Vilar MJP, Azevedo JD. Processo de significacáo de estudantes do curso de Medicina diante da escolha profissional e das experiencias vividas no cotidiano académico. Rev Bras Educ Med 2006; 30: 14-9.        [ Links ]

11. Beca I JP, Browne L F, Repetto L P, Ortiz P A, Salas A C. Relación estudiante-enfermo: Visión del paciente. Rev. Med. Chile 2006; 134: 955-9. Avaliable at: https://scielo.conicyt.cl/pdf/rmc/vl35nl2/art01.pdf [Acessed feb. 02, 2010].        [ Links ]

12. Beca I JP, Browne L F, Repetto L P, Ortiz P A, Salas A C . Relación estudiante de medicina-enfermo: visión de los estudiantes. Rev. Med. Chile 2007,135: 1503-9. Avaliable at: https://scielo.conicyt.cl/pdf/rmc/vl35nl2/art01.pdf. [Acessed feb. 02, 2010].        [ Links ]

13. Araújo D, Peixinho AL. Avaliacao qualitativa em Medicina: experiencia em propedéutica médica na UFBA 2003. Rev Bras Educ Med 2006; 30: 20-30.        [ Links ]

14. Mukohara K, Ban N, Sobue G, Otani T, Ymada S. Follow .The patient: process and outcome evaluation of medical students' educational experiences accompanying outpatients. Med Educ 2006; 40:158-65. Avaliable at: http://www3.interscience.wiley.com/cgi-bin/full-text/118729356/PDFSTART [Accessed March 05,2009].        [ Links ]

15. Taquette SR, Regó S, Schramm FR, Soares LL, Carvalho SV. Situacóes éticamente conflituosas vivenciadas por estudantes de Medicina. Rev Assoc Med Bras 2005; 51: 23-8.        [ Links ]

16. Bellodi PL, Martinho T, Massaroppe B, Martins MA, Santos MAS. Temas para um Programa de Tutoría em Medicina: urna investigacao das necessidades dos alunos da FMUSP. Rev Bras Educ Med 2004; 28: 119-27.        [ Links ]

17. Almeida HO, Alves NM, Costa MP, Trindade EMV, Muza GM. Desenvolvendo competencias em comunicacao: urna experiencia com a Medicina Narrativa. Rev Bras Educ Med 2005; 29: 208-16.        [ Links ]

18. León RT, Bedregal P, Shand BB. Prevalencia de problemas éticos en Servicios de Medicina, desde la perspectiva del paciente. Rev Med Chile 2009; 137: 759-65. Avaliable at: www.scielo.cl [Accessed July 12,2009].        [ Links ]

19. Cortopassi AC, Lima MCP, Goncalves IJ. Percepcao de pacientes sobre a internacáo em um Hospital Universitario: implicacóes para o ensino médico. Rev Bras Educ Med 2006; 30: 42-8.        [ Links ]

20. Wiggins MN, Coker K, Hicks EK. Patient perceptions of professionalism: implications for residency education. Med Educ 2009; 43: 28-33. Avaliable at: http://www3.interscience.wiley.comcgi-bin/fulltext/121575141/ PDFSTART [Accessed March 05, 2009].        [ Links ]

21. Costa LSM, Pereira CAÁ. O abuso como causa evitável de estresse entre estudantes de Medicina. Rev Bras Educ Med 2005; 29: 185-90.        [ Links ]

22. Berk R. Derogatory and cynical humour in clinical teaching and the workplace: the need for professionalism. Med Educ 2009; 43: 7-9. Avaliable at: http://www3.interscience.wiley.com/cgi-bin/fulltext/121575140/PDFSTART [Accessed March 05, 2009].        [ Links ]

23. Dini OS, Batista NA. Graduado e prática médica: expectativas e conceptees de estudantes de Medicina do Io ao 6° ano. Rev Bras Educ Med 2004; 28: 198-203.        [ Links ]

24. Monte FQ. A ética na prática médica. Rev Bioética 2002; 10: 31-46.        [ Links ]

25. Luiz NW, Neto FJRO, Thomaz JB. O Ato Médico. Aspectos éticos e legáis. Rio de Janeiro: Rubio; 2002.        [ Links ]

26. Molinari GJDP, Moreira PCS, Conterno LO. A influencia das estrategias promocionais das industrias farmacéuticas sobre o receituário médico na Faculdade de Medicina de Marília: urna visáo ética. Rev Bras Educ Med 2005; 29: 110-8.        [ Links ]

27. Salas SP, Osorio FM, Vial CP, Rehbein VAM, Salas AC, Beca I JR. Conflicto de intereses en la práctica clínica: Análisis ético de algunas relaciones con la industria. Rev Med Chile 2006; 134: 1576-82. Avaliableat: www.scielo.cl [Accessed January 12,2008].        [ Links ]

28. Gomes AMA, Moura ERF, Amorim RF. O lugar da Ética e Bioética nos currículos de formacáo médica. Rev Bras Educ Med 2006; 30: 56-65.        [ Links ]

29. Castro FC. Os temores na formacáo e prática da Medicina: aspectos psicológicos. Rev Bras Educ Med 2004; 28: 38-45.        [ Links ]

30. Colares MFA, Troncón LEA, Figueiredo JFC, Cianflone ARL, Rodrigues MLV, Piccinato CE, et al. Construcáo de um instrumento para avaliacáo das atitudes de estudantes de Medicina frente a aspectos relevantes da prática médica. Rev Bras Educ Med 2002; 26: 194-203.        [ Links ]

31. Grosseman S, Patricio ZM. A relacáo médico-paciente e o cuidado humano: subsidios para promocáo da edu-cacáo médica. Rev Bras Educ Med 2004; 28: 99-105.        [ Links ]

32. Mirza DM. The language of instruction. Med Educ 2009; 43: 99. Avaliable at:http://www3.interscience.wiley.com/cgi-bin/fuHtext/121575140/PDFSTART [Accessed March 05,2009].        [ Links ]

33. Goldie J, Schwartz L, Morrison J. A process evaluation of medical ethics education in the first year of a new medical curriculum. Med Educ 2000; 34: 468-73. Avaliable at: http://www3.interscience.wiley.com/cgi-bin/fulltext/119010624/PDFSTART [Accessed March 05, 2009].        [ Links ]

Recibido el 23 de Noviembre de 2009, aceptado el 29 de Noviembre de 2010.

Correspondencia a: Dra. Déborah Pimentel. Praca Tobías Barreto 510-1208, Bairro Sao José, Aracaju-Sergipe-Brazil. CEP 49015-130. Phone: 55 79 3214 1948. Fax: 55 79 32318372 E-mail: deborah@infonet.com.br

Creative Commons License Todo el contenido de esta revista, excepto dónde está identificado, está bajo una Licencia Creative Commons