Medical education in Brazil

Understanding the USMLE journey of Brazilian medical students and graduates: a narrative review

Over the past decades, advances in medical technology and research have promoted the globalization of medicine, drawing medical students and physicians worldwide into seeking for better career and financial prospects, as well as enhanced clinical and research training abroad. The medical landscape in Brazil has been marked by significant challenges over the past years, particularly within the Unified Health System (SUS). Despite the expansion of medical schools and initiatives such as the Mais Médicos program arising as efforts to improve healthcare access and decrease regional inequalities in the country, such problems as under-resourced working environments, inadequate infrastructure, and unattractive financial compensation for both physician and research careers, have risen as persisting challenges. In the pursuit of improved conditions, the United States Medical Licensing Examination (USMLE) has emerged as an increasingly common pathway for those seeking to overcome these challenges. This review explores the motivations behind Brazilians pursuing the USMLE while examining structural and financial challenges within the country's medical education and SUS landscape.

For which entrustable professional activities must medical students be prepared if unsupervised patient care without further training is an expectation? An international Global South study

INTRODUCTION

Training medical students requires objectives that are often translated into frameworks of competencies. Since the introduction of entrustable professional activities (EPAs), these tasks or 'units of professional practice', originally conceived for postgraduate training, define what residents must be prepared to do unsupervised. Nowadays, EPAs are also applied to undergraduate training, with the prospect of entering residency. However, in many countries, especially in the Global South, a substantial number of medical graduates will be working in healthcare with little or no supervision and no further training soon or ever. EPAs for these conditions cannot be copied from undergraduate medical education EPA frameworks in Global North countries.

METHODS

We conducted a generative investigation to identify and elaborate EPAs for Global South countries who must train students for unsupervised general practice. We included 39 medical educators from 13 Global South countries and 17 specialties in either one of two online focus group sessions using a nominal group technique (NGT) or as Delphi panel member. Results from the two NGT sessions were merged and fed into the two-round Delphi investigation.

RESULTS

A framework of 11 EPAs resulted, each with an elaborate description (specification, setting and limitations).

CONCLUSION

This framework of undergraduate medical education Global South EPAs differs in its nature and specifications from existing Global North EPAs. The authors do not pretend universality for all Global South countries with graduates who face expectations of unsupervised practice but present it to support countries that consider introducing the model of entrustable professional activities.

Reliability across content areas in progress tests assessing medical knowledge: a Brazilian cross-sectional study with implications for medical education assessments

BACKGROUND

Brazilian medical schools equitably divide their medical education assessments into five content areas: internal medicine, surgery, pediatrics, obstetrics and gynecology, and public health. However, this division does not follow international patterns and may threaten the examinations' reliability and validity.

OBJECTIVE

To assess the reliability indices of the content areas of serial, cross-institutional progress test examinations.

DESIGN AND SETTINGS

This was an analytical, observational, and cross-sectional study conducted at nine public medical schools (mainly from the state of São Paulo) with progress test examinations conducted between 2017 and 2023.

METHODS

The examinations covered the areas of basic sciences, internal medicine, surgery, pediatrics, obstetrics and gynecology, and public health. We calculated reliability indices using Cronbach's α, which indicates the internal consistency of a test. We used simple linear regressions to analyze temporal trends.

RESULTS

The results showed that the Cronbach's α for basic sciences and internal medicine presented lower values, whereas gynecology, obstetrics, and public health presented higher values. After changes in the number of items and the exclusion of basic sciences as a separate content area, internal medicine ranked highest in 2023. Individually, all content areas except pediatrics remained stable over time.

CONCLUSIONS

Maintaining an equitable division in assessment content may lead to suboptimal results in terms of assessment reliability, especially for internal medicine. Therefore, content sampling of medical knowledge for general assessments should be reappraised.

Managing assessment during curriculum change: Ottawa Consensus Statement

Curriculum change is relatively frequent in health professional education. Formal, planned curriculum review must be conducted periodically to incorporate new knowledge and skills, changing teaching and learning methods or changing roles and expectations of graduates. Unplanned curriculum evolution arguably happens continually, usually taking the form of "minor" changes that in combination over time may produce a substantially different programme. However, reviewing assessment practices is less likely to be a major consideration during curriculum change, overlooking the potential for unintended consequences for learning. This includes potentially undermining or negating the impact of even well-designed and important curriculum changes. Changes to any component of the curriculum "ecosystem "- graduate outcomes, content, delivery or assessment of learning - should trigger an automatic review of the whole ecosystem to maintain constructive alignment. Consideration of potential impact on assessment is essential to support curriculum change. Powerful contextual drivers of a curriculum include national examinations and programme accreditation, so each assessment programme sits within its own external context. Internal drivers are also important, such as adoption of new learning technologies and learning preferences of students and faculty. Achieving optimal and sustainable outcomes from a curriculum review requires strong governance and support, stakeholder engagement, curriculum and assessment expertise and internal quality assurance processes. This consensus paper provides guidance on managing assessment during curriculum change, building on evidence and the contributions of previous consensus papers.

The impact and the challenges of implementing a faculty development program on health professions education in a Brazilian Medical School: a case study with mixed methods

PURPOSE

Faculty development in health professions education is still challenging in developing countries like Brazil. Work overload and the lack of financial support hinder faculty members' participation. Ribeirão Preto Medical School founded its Center for Faculty Development in 2016. Since then, an essential skills module (ESMo) on health professions education (HPE) has been offered regularly to faculty members and preceptors of seven undergraduate programs. This case study aims to evaluate the impact of this Essential Skills Module on the educational practices of participants two years after attending the module and the challenges faced during the process.

METHOD

The study used a mixed-method approach with a description of the demographic and professional profile data of the ESMo participants. Immediate post-ESMo perceptions (satisfaction and learning) of the participants were determined with structured instruments. Two years later, a semi-structured interview was conducted and recorded to determine the long-term effects (application of learning and behavior changing as an educator). NVIVO® software was used to store and systematize the thematic discourse analysis with a socio-constructivist theoretical framework interpretation.

RESULTS

One hundred forty-six participants were included: 86 (59%) tenured faculty members, 49 (33,5%) clinical preceptors, and 11 (7,5%) invited teachers. Most were female (66%), and 56% had teaching experience shorter than ten years. 52 (69%) out of 75 eligible participants were interviewed. The immediate reaction to participating in the module was quite positive and 80% have already implemented an educational intervention in their daily activities. Discourses thematic analysis showed five emerging themes appearing in different frequencies: Changes in teaching activities (98%); Lack of previous pedagogical training (92.3%); Commitment and enthusiasm towards teaching (46.15%); Overlapping functions inside the institution (34.6%) and Challenges for student assessment (23%).

CONCLUSION

This first in-depth evaluation of the long-term effects of a faculty development intervention in a Brazilian Health Profession Education school showed that participation positively changed participants' teaching & learning practices. These interventions consistently fostered a community of practice and valued faculty development processes in local and national scenarios.

Teaching and learning pharmacology in Brazil before COVID-19 pandemic: a case study in Rio de Janeiro

BACKGROUND

Knowledge of pharmacology is crucial for physicians to perform rational and safe medicine. Medical professionals are responsible for prescribing drugs and a weak performace of those can result in medication errors leading to disability, hospitalization, and death, among other situations. It occurs worldwide, including in Brazil, so that learning pharmacology impacts on public health service. We aim to investigate the current pharmacology educational practices in medical schools in the state of Rio de Janeiro, Brazil.

METHODS

We surveyed 14 of 22 medical schools in Rio de Janeiro. Pharmacology teachers (n=16) and medical students (n=89) answered a semi-structured questionnaire that included questions about the staff characteristics, pharmacology content, teacher's concepts, and common practices and resources that were used in pharmacology classes.

RESULTS

Our results revealed that the medical schools had similar overall curriculums. Pharmacology teachers work more than 30hs a week (75%) and conducted both research and teaching (62.5%). We also found that the multimedia projector was the most common resource (71.9%), and passive pedagogical methodologies (e.g., expository classes) remain a current strategy in pharmacology classes (89.9%). In general, medical students are poorly motivated (55%), which may be related to their performance in assessments. In addition, students believe that pharmacology is a complex (52%) or very complex subject (46%) since for its full understanding the student needs concepts from other disciplines, which can have an impact on the performance and motivation of students. As a result, these medical students do not fully understand the integration between pharmacology's basic concepts and their clinical applications.

CONCLUSION

These data seem to demonstrate that the adopted teaching and learning pharmacology strategies and methodologies can be improved in Rio de Janeiro.

Diagnostic radiology training for medical students - a Brazilian multicenter survey

OBJECTIVE

This study aimed to assess diagnostic radiology training and exposure during medical school, from the perspective of medical students in Brazil.

METHODS

In this multicenter study approved by the Institutional Review Board, medical students from multiple universities in Brazil filled out an online questionnaire regarding their perception about diagnostic radiology training during medical school, including knowledge and use of the American College of Radiology Appropriateness Criteria and their confidence level in interpreting common radiological findings. Medical students from different regions of Brazil were sent invitations to participate in the anonymous survey through radiology group emails initiated by radiology professors and a group of ambassadors representing different institutions. Informed consent was obtained electronically at the beginning of the survey.

RESULTS

The survey demonstrated diagnostic radiology is frequently included in preclinical exams; however, radiology training during medical school was considered inadequate from the medical students´ perspective. Overall, radiological imaging teaching was provided by radiologists for more than half of the survey respondents; however, radiological imaging is frequently shown to students by non-radiologist physicians during case discussion rounds. Moreover, few respondents had a mandatory radiology training rotation during medical school.

CONCLUSION

This Brazilian medical student survey demonstrated that from the medical students' perspective, diagnostic radiology is an important subject in clinical practice; however, their radiology training and exposure are overall heterogeneous.

Entrustable professional activities for Junior Brazilian Medical Students in community medicine

BACKGROUND

Entrustable professional activities (EPAs) have been defined to promote the workplace participation of undergraduate medical students, generally in the context of high-income countries with a focus on the secondary and tertiary health care sectors. These EPAs have limited applicability to training and health care contexts in low- to middle-income countries that have a focus on primary health care, for instance, the context of community medicine. The purpose of this article is to report the process and results of defining EPAs for undergraduate medical training in a community health care setting.

METHODS

A modified Delphi study was performed to develop EPAs for the training of medical students in community medicine during their first and second years of education at the Marília Medical School (FAMEMA), Brazil. The supervision level was operationalized in terms of a student's ability to perform the EPA autonomously in an effective and safe manner with supervision readily available on request. Panellists (9 physicians and 6 nurses) rated the completeness of the proposed list of EPAs and EPA categories on four-point Likert scales. The threshold for consensus among panellists was a mean content validity index of at least 80%.

RESULTS

Consensus was reached after two Delphi rounds, resulting in 11 EPAs for undergraduate medical education and training in community medicine. These EPAs were organized into three overarching EPA domains: integrality of care for individual health needs in all phases of the life cycle (5 EPAs), integrality of care for family health needs (3 EPAs), and integrality of care for community health needs (3 EPAs). For each EPA, descriptions of the following categories were created: title; specifications and limitations; conditions and implications of the entrustment decision; knowledge, skills, and attitudes; links to competencies; and assessment sources.

CONCLUSION

The resulting 11 EPAs for training medical students in community medicine expand the application of the EPA framework to both early undergraduate medical education and the context of primary health care. This report can support and guide other medical schools in their attempts to train students in primary health care contexts and to incorporate EPAs into their curricula.

Comparison Between Students Admitted Through Regular Path and Affirmative Action Systems in a Brazilian Public Medical School

PURPOSE

Affirmative action policies to provide access to higher education for socially vulnerable students have been implemented in several countries and have faced many questions nowadays. The aim of the study was to compare the socioeconomic background and performance during and after completing the undergraduate course of students admitted through the regular path and social quota systems in a public medical school in Brazil.

METHODS

A retrospective cohort study including students admitted to a medical school within the School of Health Sciences (ESCS), in Brazil, between 2005 and 2012, and followed until May 2020. In the first phase, data collection was performed by analyzing documents from the ESCS academic management system and Brazilian government agencies. In the second phase, a survey with 12 questions was sent to the medical school alumni. The social quota system criteria were the public school attendance in all primary and secondary education levels.

RESULTS

Among 707 students, 204 (28.9%) were from the social quota and 503 (78.5%) from the regular path system. The place of residence of social quota students had a lower Human Development Index (p < 0.001) and per capita income (p < 0.001) when compared to regular path students. Regular path students were associated with the highest dropout from medical school (OR: 50.552, 95% CI: 12.438-205.453, p < 0.001). There was no difference between regular path and social quota students attending medical residency programs (OR: 1.780, 95% CI: 0.957-3.309, p = 0.069). Out of the 308 alumni who completed the survey, regular path students had more family members who were health professionals than social quota students (p < 0.001). There were no significant differences regarding monthly income, job satisfaction, employment, or management activities.

CONCLUSION

Affirmative action targeted students with a disadvantaged socioeconomic background. Regular path students had a higher dropout rate than social quota students.

Global versus local: A regional core embryology syllabus for medical students

"Core syllabus" in this work refers to knowledge topics that an instructor should necessarily and indispensably address during a discipline. This study describes the process of developing a regional human embryology core syllabus for undergraduate medical courses in Brazil, using a two-round modified Delphi method as a tool for reaching consensus. A list of 679 human embryology topics was generated based on three textbooks. The Delphi panel consisted of specialists (n = 51) with at least 2 years' medical experience in activities related to the contents of embryology or health sciences professionals with at least 5 years' experience in undergraduate medical education of embryology and other cognate disciplines. The panel rated the relevance of each topic on a Likert scale. Following consensus analysis, a list of 69 "core" topics was obtained. Then, in a second Delphi round, the panel was asked to "accept," "accept with modifications," or "reject" the new list. The research team performed a final revision/screening process and generated a core human embryology syllabus comprised of 63 topics. Comparing this regional syllabus with two international core syllabuses also built Delphi panels, 60.3% of the topics overlap with both syllabuses, and 39.7% of its content is unique. This study can be a valuable tool for decision-making in the embryology curriculum for health courses and reinforces the importance of local evaluation of international curricula of human embryology before implementing them, since the incidences of congenital anomalies vary in different regions of the world.

Transition to clinical practice during the COVID-19 pandemic: a qualitative study of young doctors' experiences in Brazil and Ireland

OBJECTIVES

To explore and compare the perspectives of junior doctors in Brazil and Ireland regarding transition and professional socialisation during the COVID-19 pandemic, with the purpose of identifying better ways to support doctors as they assume their new professional role.

DESIGN

27 semistructured interviews. Transcripts were analysed using qualitative thematic analysis. Cruess' framework of professional socialisation in medicine supported the interpretation of these data.

SETTING

Public health hospitals across four Brazilian states (Santa Catarina, São Paulo, Ceará, Paraíba) and County Cork in the South of Ireland.

PARTICIPANTS

Twenty-seven male and female medical junior doctors who had graduated between November 2019 and April 2020.

RESULTS

Fourteen Brazilian and 13 Irish junior doctors were interviewed for this study. Entry to clinical practice during the pandemic had a significant impact on factors influencing the professional socialisation of junior doctors. This impact was reflected across the following six thematic areas: lack of preparedness; disrupted trajectory of role adaptation; fewer opportunities for experiential learning; solidarity and isolation; altered interactions with patients; challenges to health and well-being.

CONCLUSIONS

Transition to clinical practice is an important stage in junior doctors' professional socialisation and identity formation. The COVID-19 pandemic created the opportunity for medical graduates to enter the workforce earlier than usual. Entering the workforce during this period created a lack of confidence among junior doctors concerning the boundaries of their new role and responsibilities, while simultaneously disrupting their social integration. Priorities to mitigate the impact of COVID-19 and future pandemics on this transition are presented.

Exploring pooled analysis of pretested items to monitor the performance of medical students exposed to different curriculum designs

Several methods have been proposed for analyzing differences between test scores, such as using mean scores, cumulative deviation, and mixed-effect models. Here, we explore the pooled analysis of retested Progress Test items to monitor the performance of first-year medical students who were exposed to a new curriculum design. This was a cross-sectional study of students in their first year of a medical program who participated in the annual interinstitutional Progress Tests from 2013 to 2019. We analyzed the performance of first-year students in the 2019 test and compared it with that of first-year students taking the test from 2013 to 2018 and encountering the same items. For each item, we calculated odds ratios with 95% confidence intervals; we also performed meta-analyses with fixed effects for each content area in the pooled analysis and presented the odds ratio (OR) with a 95% confidence interval (CI). In all, we used 63 items, which were divided into basic sciences, internal medicine, pediatrics, surgery, obstetrics and gynecology, and public health. Significant differences were found between groups in basic sciences (OR = 1.172 [CI95% 1.005 CI 1.366], p = 0.043) and public health (OR = 1.54 [CI95% CI 1.25-1.897], p < 0.001), which may reflect the characteristics of the new curriculum. Thus, pooled analysis of pretested items may provide indicators of different performance. This method may complement analysis of score differences on benchmark assessments.

Virtual Microscopy as a Learning Tool in Brazilian Medical Education

Virtual microscopy (VM) is a widely used teaching method in Medical Education in many developed countries. In Brazil, however, this is not the case for most medical schools, considering Brazilian social inequality and uneven access to technology. Recently, the Covid-19 pandemic has also challenged Universities to seek and make a transition toward more effective methods of full-time online education. Thus, the main goal of this work was to verify student's perception and academic performance, assessed upon VM implementation in a Brazilian Medical School. Ribeirao Preto Medical School students answered a 26-question survey with regards to optical microscopy (OM) and VM. Academic performance was compared between participants that were (year of 2019) or were not (year of 2015) exposed to VM. Taken the results together, subjective impressions such as handling, suitability, learning effectiveness, and pleasure using the tools, have shown a higher score for virtual microscopy (median = 29), when compared to optical microscopy (median = 24) with a P-value < 0.001 by Wilcoxon rank test, upon measurement using an ordinal scale. Regarding academic performance, no statistically significant differences were found between groups (P-value = 0.38, Cohen's d = 0.19). Therefore, VM proved to be adequate to the Brazilian medical education in light of Brazilian social contexts and Covid-19 pandemic.

The current status of psychiatric education in Brazil

The aim of this review is to present a brief historical perspective, the current status of psychiatric education in Brazil, discuss its role in Latin America, and its challenges ahead. The history of psychiatry in Brazil is intertwined with the history of medical assistance in Brazil. Psychiatric education in Brazil started in the asylum-centric era during the second half of the 19th century and evolved to occupy university teaching-hospital in the 20th century. The medical residency in psychiatry has shown considerable growth since its implementation 70 years ago. Undoubtedly, it currently occupies a prominent place in Brazilian medicine. However, there is a need to create and expand it in the less developed regions of the country. Brazilian psychiatric journals also have a leading position in developing evidence-based psychiatry in Latin America.