El desarrollo de la función directiva de la Atención Médica Integral The development of the directive function of Comprehensive Medical CareFidel Creagh Bandera* José Alviño García**Zulema de la Caridad Matos Columbié** *Ciencias Médicas. Guantánamo. Cuba**Universidad de Guantánamo. CubaORCID: http://orcid.org/0000-0002-8829-6859 http://orcid.org/0000-0003-4296-488X http://orcid.org/0000-0002-6952-617XCorreo(s) electrónico(s):fcreagh@infomed.sld.cuesoj1963.garcia@gmail.comzulema@cug.co.cuRecibido: 15/04/2020Aceptado: 10/09/2020Resumen: Se realizó un estudio descriptivo transversal para exponer las problemáticas más importante para la dirección del proceso pedagógico que acontece en el 3er año de la carrera Medicina, sobre el desarrollo de la función directiva de la Atención Médica Integral (AMI) que rectora su accionar como Médico General (MG) cuya formación compromete la concepción médica cubana actual. Se afrontan las principales aristas de, qué hacer y cómo, se implican cada proceso sustantivo de la universidad referente desde la asignatura Medicina Interna, mediante un sistema de actividades curriculares, extensionistas y sociopolíticas que orienta el colectivo de añoPalabras clave: Proceso pedagógico; Atención Médica Integral; Médico General; Medicina Interna. Abstract: A descriptive cross-sectional study was carried out to expose the most important problems for the direction of the pedagogical process that occurs in the 3rd year of the Medicine career, on the development of the directive function of the Comprehensive Medical Care (AMI) that guides its actions as General Physician (MG) whose training compromises the current Cuban medical concept. The main aspects of, what to do and how are addressed, each substantive process of the referent university is involved from the Internal Medicine subject, through a system of curricular, extension and socio-political activities that guides the group of the year Keywords: Pedagogical process; Comprehensive Medical Care; General Physician; Internal Medicine.Introduction In the current scenario of the practice of Medicine, the pedagogical process in Higher Education has the mission to respond effectively to the continuous improvement of human capital formation, so that the professional who graduates expresses the appropriation of knowledge, skills and attitudes that enable him/her to manage processes of varying complexity and be able to influence independently in the organizational, in their professional work scenario.The above-mentioned social demand also reaches the general practitioner who, in medical practice, must direct medical care processes focused with integrality, guiding the provision of quality services in the context of the general and frequent problems expressed by the health/disease process of a specific population, the object of his or her care. The above requires that from the undergraduate level, the student appropriates the theoretical, procedural and attitudinal knowledge of the systematized medical culture and it is based on this that the student reasonably dominates the processes of health management in general and personalized medical care in particular.The above presupposes that the MG in initial training should strengthen its possibilities for IMS-oriented managerial science to the individual in his or her family and community context. This need orients the dialectic unity between the appropriation of medical knowledge required for the IMS, knowledge related to its direction, and the development of a favorable attitude toward this end. This is precisely a demand and a need of Cuban medical education, since the development of professional functions, in general, and the one directed to the IMS, in particular, contributes to the fact that its exit reveals a better formation to practice the profession and pays tribute to its future social transcendence, mainly, that it enhances the Professional Model of the career. The achievement of the above requires the design of a way for the MG -during his undergraduate formation- to master -knowledge, know-how and being- those actions that make possible to direct the processes contained in the IMS and to reveal a proactive attitude towards it. In coherence with this, the following objective is formulated to explain some considerations about the development of the directive function of the IMS from the pedagogical process of the Internal Medicine subject in the 3rd year of the Medicine career. DevelopmentThe directive function and its development in 3rd year medical students. The term direction has many meanings, but since the 50's of the 20th century it has gained strength, as the scientific-technical development advances direction as an independent scientific discipline and is assumed mostly to the fields of knowledge today. According to Bringas Linares, J. A. (2003, p. 48) "Management is a general science that reflects the fact that it is a process inherent to all social activity". In other words, there is no social activity -the health system is contemplated- that does not conceive, explicitly or not, a process of direction in some way, it is impossible not to attend to the main contributions and reveal them according to the object of work and the sphere of action of the professional who is dedicated to that activity. "Management is conceived as the conscious influence of the management bodies on human groups in order to ensure the achievement of objectives, organizing and guiding their activity accordingly”. (Omarov, A.M.1977.5) From this definition, the conscious influence stands out, since just as the Teaching and Learning Process, the medical act is a conscious process, directed to more or less precise purposes - professionals - objectives - although not always explicit in the process itself, for which it guides the action of the MG as a professional, and consequently models its functions.In management there is a term that is often used: function, - which is also used in the direction - understood as a "set of activities different from each other, but similar by the common purpose that seeks to direct their staff to enhance the different activities that are entrusted, but that are related by the common purpose that they all have, to achieve timely delivery of the service that has been requested (Flores Jimenez, M. 2015.21) From the above, a necessary definition for this thesis related to the function of the physician is derived, in the context of the subject Internal Medicine is admitted as "The competence exercised by the physician to carry out his professional work whose objective is the interpretation and correct approach to the objective of the profession: event(s) that occur in the process of health/disease of a given person, and that otherwise involves the family and the community and, demands the fulfillment of their professional role and the responsibility specified in cognitive, procedural and attitudinal knowledge that make up their mode of action" ( Creagh Bandera F. , 2016) The two previous definitions are directly related to another one of great value, the directive function of the general practitioner - in the context of the Internal Medicine subject - is understood as ("The activity that is oriented to the design, execution, evaluation and control of a transformation oriented to the health/disease process of a person in his family and social context supported by the cognitive, procedural and attitudinal knowledge for the performance of his professional role") ( Creagh Bandera F., 2016) The directive function of the IMS is conceived -in the context of the Internal Medicine subject- as "The professional activities oriented to the design, execution, evaluation and control of the IMS to an adult with some disturbance or clinical event in his PSE which implies his family and social context supported by the cognitive, procedural and attitudinal knowledge that the general practitioner possesses" (Creagh Bandera F., 2016) Having determined these conceptualizations, and considering that in this thesis the directive function is conceived as a professional function of the general practitioner that is integrative because: it coheres, it integrates within it the other professional functions. Internal direction also has functions, logical elements or phases of direction activity (Borrego, O., 1989), management cycle, actions of the directive function, among others. For the interests of this research, we assume those of the directive cycle that contemplates: design, execution, evaluation and control that form a complex and dynamic system due to the level of relations that they establish among them.II-. Comprehensive Medical Care as a professional function of the general practitioner "Comprehensive medical care is the system of actions that, in an integrated and sequential manner, the physician must execute aimed at diagnosis and medical intervention to transform the health-disease condition of the patient, in the family and community context" (Elías Sierra R., 2015: 29)The ability of integral medical care as the expression of the domain by the general practitioner of the cognitive, procedural, evaluative and attitudinal knowledge that allows him to execute the system of actions and operations necessary for an IMS, specified in his way of acting to solve the patient's health problems in his family and social context. On this basis and in light of the theoretical systematization carried out, the author of this thesis, with 33 years of experience as a medical specialist in Internal Medicine and professor of the same subject, assumes that: Comprehensive Medical Care is the professional activity of comprehensive medical-organizational management offered by the general practitioner in his service, according to his cognitive, procedural and attitudinal knowledge to direct, accompany, provide stability and transform the health/disease process of individuals, family, community, which conceives man as a dynamic biopsychosocial system living in specific environmental conditions"( Creagh Bandera F., 2016)The accompaniment in the IMS -beyond the subject of Internal Medicine- consists of offering cooperation, help, stability (during the attention that it provides to the person -sick or not, family, community) to the subject to whom the actions are applied, according to its framework of medical dispensing that orients to the levels of intervention that admits health and must reveal that each stratum of its knowledge is applied, be it cognitive, procedural and attitudinal and, must reveal the modes of action that characterize GM. The ADP of the subject Internal Medicine for the development of the managerial function of the IMSIn the case of the medical career, the category of pedagogical process is conceived as a criterion to be worked on, which the group of authors, under the direction of Blanco Pérez. A (2001) define it as: "It is the unity of the teaching and educational processes, organized as a whole and directed to the formation of the personality. Consequently, it exists as a management process. A type of specific activity, organized and socially regulated with the objective of channeling education towards the achievement of the goals and objectives socially established with respect to the formation of the individual. The pedagogical process is a particular form of the social relationship called education, which takes place at a specific time and place and with the help of specialized methods and means".From this perspective, the training process is general with respect to the pedagogical process and the teaching-learning process (TLP). The pedagogical process is assumed because it includes the TLP as a process of organized and directed towards the integral formation of the student's personality and the achievement of social goals (formation of the general practitioner).Between teaching and learning there is a dialectic unit that forms another, where these are chained as a teaching-learning process. "The school pedagogical process has the essential characteristics of the former, and it is distinguished for being much more systemic, planned, directed and specific, since the teacher-student interrelationship becomes a much more direct didactic action, whose only purpose is the integral development of the students' personality. The above determines the Process of teaching learning development "that which constitutes a system where both teaching and learning as subsystems, are based on a developmental education, which implies an intentional communication and activity, whose didactic action generates learning strategies for the development of an integral and self-determined personality of the student, within the framework of the school as a social institution transmitting culture. (González Soca, A. M; et al, 2005., 53)IV- Structure of the management function of the IMSIt is valued that the development of the managerial function of the AMI goes through different stages, in which they are revealed in three important dimensions (theoretical, procedural and attitudinal) as they are represented in the graph of the Theoretical Model of the conceptual elements and the dimensions of the development process in the students of the managerial function of the IMS.Source: Self-elaboration1-. Appropriation of the cognitive, procedural and attitudinal knowledge characteristic of Internal Medicine as a curricular unit3-. It represents, in the educational field, diverse activities that contain coordinated actions on the IMS to the clinical patient integrated to the directive function2-. Appropriation of specific cognitive, proce-dimental and attitudinal knowledge of scientific direction as a general scienceDevelopment of the IMS leadership roleDesign of what will be implemented in the teaching practice solution to clinical patient health situations and guide and achieve this end with the EBS4 Reveals strength in solving diverse teaching situations that demand roles on clinical patient problems, individual - collective (EBS), and approach from IMS integrated to the Directive Function5-. Expresses evaluations (individual - collective) and behaviours compatible with the ethical-humanistic requirements of the professional exercise of the IMS integrated to the management functionDimension Theoreticalin exercising the leadership function of the IMSProce-dimental Dimension when exercising management function of the IMSDimensionAttitudinal when performing directive functionsof the IMSFigure 1: Structure of the management function of the IMSI-. Knowledge system. (Know)It is integrated by a system of basic, preclinical and clinical knowledge that begins in the 1st and 2nd years and is completed in the 3rd year, with systematicity in the remaining years (4th, 5th, 6th). For this reason, it acquires a general, particular and singular character, with formative value in the subject of Internal Medicine (table 1). Consequently, three knowledge nuclei have been determined that are integrated into the TLP to contribute to the development of the directive function of the IMS, they are:Table 1: Knowledge system (Know)General basic knowledge .Medical knowledge of clinical profileSpecific knowledge of scientific managementIt takes advantage of the biosocio-medical bases that precede the subject of Internal Medicine, which supports the formation of the three profiles (clinical, epidemiological and general), so it is the integrator, which should be used to develop the management function of the IMS in the 3rd year provides the knowledge base that allows the formation of the clinical profile of the career. The year group must plan both the supervision and the method-logical work and the work plan of the brigade that integrates in the academic, labor, research, extensionist and socio-political.Start of clinical cycle (5th and 6th semesters). It presents the clinical profile of medicine as invariant to the general profile of the physician, thus revealing as a reality a gradual derivation of the general mode of action of the professional model and therefore, it has inserted the IMS as a professional function with its constitutive elements that values the man as a biopsycho-social being in an environment de-terminated to; beginning of clinical cycle (5th and 6th semesters). It promotes the clinical-epidemiological methodRelated to the application of scientific direction to the health/disease process and very particularly to the management function of the IMS. The important thing is that the student learns how to direct processes and fulfillment of the directive cycle. This specific knowledge of management should contribute to the general practitioner's concrete action as a professional medical-assistential activity of management that contains the object of the profession, which is why the ADP of the Internal Medicine course in 3rd year is focused on the clinical profile, which is complemented with the epidemiological profile and integrated monolithically to configure the general profile of the general practitioner.Source: Self elaborationII-. System of procedural actions. (Know-How)It refers to the mastery of the actions to execute the management function of the IMS, therefore, the functions of the management cycle must be revealed in each activity: planning, organization, execution, evaluation and control. It must facilitate the student to master and apply the knowledge of the procedures of the management function of the IMS and use them in situations (hypothetical or concrete) at different levels of intervention. The general objectives-skills expressed in the Professional Model are assumed and derived to the disciplines and subjects in correspondence with the cycle and the academic year. III-. System of actions with attitudinal content (Being: Attitudes, Values).It is necessary to reveal in his ways of acting as a general practitioner the knowledge, the know-how in the different scenarios and levels of intervention. The Model of the Professional has very well defined what are the shared values in the formation of the general practitioner, for example: spirit of abnegation and sacrifice; sensitivity, responsibility, modesty, simplicity, disinterest, altruism; honesty and austerity; patriotism, among others, above all, values that allow him/her to demonstrate a clear conception of his/her role as a professional at the service of the people, away from elitist positions, devoid of mercantilist feelings regarding the performance of the profession, he/she will act according to the principles of medical ethics and will temper his/her actions, as a physician and as a citizen, to the demands of the historical moment and the place where he/she provides his/her services. Therefore, the following is proposed: System of actions and operations of each of the functions of the management cycle:Table 2: System of procedural actions. (Know-how)FunctionActionsOperationsPlanningCarrying out the input diagnosisDetermine methods and techniques to be applied depending on the dimensions and indicators to be evaluated.Process and interpret the information obtained from the instruments applied.Elaborate summaries of the main difficulties, threats, strengths, opportunities and potentialities found in the diagnosis.Determine the basic learning needs in the different knowledge areas that are needed.Definition of the objectivesPrevious definition of the objectives to be achieved, Selection of alternatives or variants, tasks to be executed, time, means and methods for their execution and levels of responsibilityTo satisfy the defined needs, the human, material, financial and time resources necessary to achieve the proposed goals, the possible current decision making, and for the future.Determine procedures-Determine what to do, how, when, where and who will do it, To project oneself into the future, to bridge the gap between the current state of the organization and the necessary state.Make the potential of the organization and its inherent elements a reality. It must be given both in the tactical-operational level and in the strategic level, which must be taught to manage the process in each professional context where it is performed.Guide the action of all elements involved in achieving the objectiveIt covers all activities and has the general objective of guiding the action of all the elements involved in the achievement of the AMI that are very necessary to direct it, and are related to:-. Building the model of operation and can be adopted through a plan that is developed by different deadlines and organized to achieve a well-defined final purpose.-. Anticipating during the process of building the model and not during the operation of it to the greatest extent possible contradictions, deficiencies, mismatches, negative factors, and changing conditions that may arise in the future to resolve.-. Orientar el proceso se dirige a personas, familia y comunidad, ello significa no hacer un trabajo improvisado, sino, uno orientado hacia objetivos concretos que solucionen el problema de salud/enfermedad-. Integration in itself is a process that integrates various elements - people, conditions, demands, scenarios -, so the general practitioner must learn to fulfil individual tasks, and therefore must organise this process, and in his strategic plan he must not forget that he has a general objective supported by other specific objectives.-. To serve: the designed plan allows the measurement and evaluation of the results that are reached in the process, to know if what was planned had the expected or needed result and that it did what it should have done, that is why they take up again the alternatives and the decision making before a situation that requires it. Without plans, you cannot organize your human, material and financial resources, nor can you manage with confidence or expect others to follow you, much less achieve your goals and know the way forward.Develop the action planTake into account the results of the initial diagnosisIt will cover the needs of the institution and its elements, as well as the ways and means of meeting them.To stand out in the plans, as material instruments for its practice and its quality depends to a great extent on the management. The plan constitutes an anticipated model of the future reality that is needed. Its structure depends on the author's creativity or on the institution's requirements.Apply the principles of management.OrganizationOrganize the resources availableOrganize the human, material and financial resources required in order to meet the objectives set with maximum efficiencyThey emphasize the organic correlation of its components and the convenient relations of coordination and subordination among them.Determine the people and the method to be usedDefine with whom, with what and how the planned will be executed, Determination of the relationships that will be established between the performers of the activity and how they will communicate with each other. Combination of the human, material and functional means available, depending on the achievement of the proposed objectives.DetermineCommunication and its styleMethod and style of communication that will prevail: participatory, horizontal, assertive, dialogical.Relations established, hierarchization, coordination and subordination among the participants.The role that each one assumes depending on the tasks assignedExistence of a command, of a boss.Make the previous elements more dynamic in the decision making outlined in the planning where the relevant objective has been set.To ensure that the objectives are reached with an efficient organization. It must be given both in the tactical-operational and in the strategic, and it must be taught to manage the process in each professional context of its performanceExecutionDetermines manner of completion of the designed planIt should be noted that this operation also means command, implementation, regulation, development.To ensure the normal functioning and development of the management system, according to the programmed objectives and concrete tasks.To maintain the established organization and the required coordination between the different elements involved in the process.Application of methods, techniques and conditions required for implementationDetermine where, with whom, when the actions determined in the plan will be applied.Apply the exercise of authority, its methods, techniques and the conditions that a subject must have to command (boss) and be obeyed by others (collaborators or subordinates) in the process.To guide and orient the group work, the art of motivating, helping and developing the subordinates must be highlighted.To conceive the way in which the supervision of the work will be done. Start the system, ensure its operation and normal development in accordance with the objectives set out in the plan.To preserve, maintain and improve the state of order and organization of the planned system.To develop what is planned and organized, which implies the directive management to ensure that the system maintains its dynamic stability, is perfected and developed.Interlink several key elements of management: communication, decision-making, delegation of tasks, line of command, leadership, teamwork, management styles and leadership training, among others.Evaluationand controlCheck the actual result of the workTo highlight the difficulties that arise in daily practice.Determine if the activity or task performed or in execution was carried out, if the state of the system at a given time corresponds to the desired or normal state.Apply scientific methods and techniques that allow to identify if the result was introduced and what the current situation is.Analysis of the information obtainedTo detect deviations and the causes of difficulties.Take steps to rectify the relevant aspects in timeAvoid working on irreversible facts. To permanently guarantee the self-regulation of the system.Decisión making.Make decisions depending on the specific situation.Take timely corrective and regulatory measures to improve decisions. Prevent possible non-compliance. Start of a new management cycle.Correcting or avoiding deviations that hinder your final objective means discovering negative deviations and deficiencies.Reveal creative acts and potentialities to support the new and develop it. Multiplying your disclosure of results.Facilitate the introduction of the desired process into practice once it has been optimized.Source: Self- elaborationThe curricular activities will have the following structure. For example.Internal Medicine ClassType of class: Education on the Job (labor component). Modality. Visitor's passTopic 4. Respiratory System Problems. Content: Klepsiella Pneumonia.Objective: to assess how to manage the IMS from the analysis of the health situation of a hospitalized patient. Previous knowledge: acute infectious disease, the steps of the clinical method, basic skills: interrogation, observation, palpation, percussion, auscultation, indication and interpretation of diagnostic means, the specificity of pneumococcal pneumonia, filling out the clinical history, patient-family communication in the APS, medical ethics, comprehensive community work. Skills to be developed: to apply the clinical method for the elaboration of the diagnosis and the intervention in its integration to the levels of intervention (education, promotion, prevention, diagnosis, treatment and rehabilitation of health), to execute the directive function of the IMS. Values to be formed: responsibility, professionalism, and solidarity, humanism, respect for personality, humility, sensitivity. Teaching method: joint elaboration, partial heuristic search, problematic, clinical method. Procedures: For presumptive diagnosis. Concord and Discord Technique.Methodological guidelinesOnce you have finished the sighting pass, meet in your respective team (no more than 3 colleagues) and read carefully the problematic situation and analyze the activities contained in the work sheet, which also explains the questions that each team must answer from the Technique: agree and disagree. The aim is to answer the questions adequately, following the logic of the presentation and revealing the application of the content referring to scientific direction with output in the clinical-epidemiological method, which would assign to the first one a character of quasi-own content. In the answer, the adjustment to the topic, the synthesis of the information, the integration of medical knowledge and procedures and the argumentation will be measured based on making explicit the literature used.We will work in the workshop mode, in the initial 30 minutes we will reconcile the answer to each question and then take it to the plenary where the team (questions 1, 2, 3 and 4), Team 2 (questions 5, 6, 7 and 8), Team 3 (questions 8, 9, 10, 11 and 12), while one team exposes, the other listens and makes notes, because it is permissible: to ask, to complete, to argue and, to exemplify, always respecting the criteria of others and without using words that hurt them. The technique of agreeing and disagreeing will be for the debate, in a conclusive way what has been done in the questions. Each team proposes its self-evaluation and the others propose an evaluation. Then, through the proposal of the evaluation considered by the teacher, a final evaluation is proposed by consensus.The teachers have to assume the objectives and nuclei of previous contents to be dominated by the student to exercise the levels of medical intervention provided by the AMI for the purposes of this conception defends that from this subject - in interdisciplinary integration with the others of the academic year that focus the visit pass - are directly interconnected, with those essential to the management of the AMI (management cycle), and that for a better methodological organization must know their actions and general operations, contained in each level of intervention, both diagnostic and transformative profile that underlie each of them to know:Diagnostic profile actions of the health problemFor medical interventionDefinition of the diseasePsychosocial determinants of the disease Physiopathology of the diseaseDiagnostic means (Pathological Anatomy, Microbiology, Imaging, Clinical Laboratory, etc.)Diagnosis of the disease: positive, differential, etiological and others.Evolutionary course Natural history of the disease: evolution, complications, prognosis, etc.Design of the management cycle for the diagnosis: planning, organization, execution, evaluation and controlHealth education.Health promotion.Health prevention Treatment: medical and surgical Rehabilitation of the patient.Design of the directive cycle for the diagnosis: planning, organization, execution, evaluation and controlThe student-oriented literature will be: Roca Goderich, Reynaldo. "Internal Medicine Issues". Before. A. "Subjects of General Integral Medicine". Updated bibliography on the subject of Heart Failure that can be consulted on the Internet. Class notes.The extensionist and socio-political activities fulfill educational and instructional objectives and support the curricula. The most important thing is that the integral community work and the direct contact with the community, its general characterization and the health situation are promoted so that the student has a vision of his future scenario of professional performance in the PHC.Conclusiones The theoretical systematization about the development of the directive function of the AMI is a topic of much need and socio-professional importance in the pedagogical process of the Medicine career for the undergraduate, as it is directed to prepare the student to fulfill the professional functions that the Professional Model and the society designate to the MG, on that base this thesis contributes a way that from the science marks the route of, what and how to do it in the different levels of intervention: education, promotion, prevention, diagnosis, treatment and rehabilitation.The directive function of the AMI is conceived as a process that is structured in five stages that are inserted in three fundamental dimensions: theoretical, procedural and attitudinal, which in synthesis specify the system of knowledge that assumes the knowledge, know-how and being by means of the outline of activities where the directive cycle is revealed in the work of the general practitioner.The integral work of the pedagogical process in the 3rd year strengthens the preparation of the students for the development of the activities of curricular content {academic, labor (includes Education at Work) and research}, extensionist and socio-political guided from the teaching-learning process of the Internal Medicine subject, but framed in a scenario of important formation for it: the year group.Bibliographic ReferencesBlanco Pérez, A. (2001). Introducción a la Sociología de la Educación. La Habana: Pueblo y Educación.Bringas, J. A. (1999). Propuesta de modelo de planificación universitaria. Tesis presentada en opción del grado científico de Doctor en Ciencias Pedagógica. Instituto Superior Pedagógico "Enrique José Varona". La Habana. Creagh Bandera, Fidel (2015). Una concepción pedagógica para el desarrollo de la función directiva hacia la Atención Médica Integral. II Simposium Internacional Universidad y Sociedad. Universidad de Guantánamo.Creagh Bandera, Fidel (2016). El colectivo de año en el desarrollo de la función directiva de la Atención Médica Integral. IV Simposium de Ciencias Pedagógicas. Universidad de Guantánamo.Elías Sierra, Reinaldo (2015): La formación de la habilidad Atención Medica Integral en la asignatura Medicina Interna en el 3er año de la carrera. Tesis en opción al grado científico de Doctor en Ciencias Pedagógicas. ICCP. La Habana.Flores Jiménez, M., Ruth, A. (2011). Curso de Administración Estratégica. Licenciatura en Administración Universidad Autónoma del Estado de Hidalgo. Escuela Superior de Tlahuelilpan. Omarov AM. Elementos básicos de la dirección científica de la sociedad. La Habana: ORBE, 1977.F. Creagh Bandera; J. Alviño García; Z. de la C. Matos Columbié: El desarrollo de la función directiva de la Atención…PAGE \* MERGEFORMAT130EduSol Vol.21 Núm.74 Andrés Ferrer Castillo; Raúl Hernández Heredia; Pedro Planes Cumbá: La cultura organizacional en el … PAGE \* MERGEFORMAT124EduSolVol. 21. Núm.74.ISSN: 1729-8091Publicada en línea: enero de 2021 (http://edusol.cug.co.cu)iVBORw0KGgoAAAANSUhEUgAAAboAAACOCAYAAABHa82KAAAAAXNSR0IArs4c6QAAAARnQU1BAACx jwv8YQUAAAAgY0hSTQAAeiYAAICEAAD6AAAAgOgAAHUwAADqYAAAOpgAABdwnLpRPAAAAAlwSFlz AAAh1QAAIdUBBJy0nQAAQr9JREFUeF7tfQmYXEXVdieZnpksoIBASHqSsGg0CuqHy4eKfKgooiDw IyibIPALIhi2DwRlEdmVRWRHUDYBk8lkAREEBGRHCWHf9zUQErbsk+99q6t7qm/Xvbfq9r29zZnn 6ad7uuvW8tby1jl1zqnc9Hz+6OtyuVVz8heKwFW53PBp+fwxN+dyowQmQUAQEAQEgRZDoC+ffwKL +Mt9nZ3brMjlhrRY9TOv7syOjo2Bz8PAZ/G1udzKmRcoBQgCgoAgIAikiwCJDov4Crz6saBPndLd PT7dElozN5Da6sDkQryWaXyE6FqzK6XWgoAgMNgRMIiOZLdiWmfnO72dnb+gum4wYnNfLpfv7ej4 GXCYqwlO4SIS3WAcDdJmQUAQaAsEgkRXWtwh3T2N1w6DRZ3JdqLtW2k1ZYnczHeR6NpixEsjBAFB YNAhEEZ0hjRzz/Surs3blfDYrmldXV9He28PSHBBshOiG3SzQxosCAgCbYGAA9GVFnwSwXeuzuWG tUPD2Q6oJ7fA67YYghPVZTt0uLRBEBAEBi8CHkRXOsN7AM/sPiOXG9GKqP09lxsJ9eSeILgHHAlO iK4VO1rqLAgIAoJACQFfojPO8N7As6fAcOUTrYAmyG393nz+NLwHjUxs53FyRtcKnSp1FAQEAUHA 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