MEDICAL EDUCATION IN MOTION: A NATIONAL OVERVIEW

Abstract: Introduction: The palliative care (PC) approach is a care modality recommended by the World Health Organization. Suffering and the process of dying are present in everyday clinical practice, affecting people with life-threatening diseases. However, the predominant model of teaching in Brazilian medical schools does not include palliative care. Objectives: The aim of the study was to get to know the Brazilian medical schools that include PC in their curriculum, and how it has been taught. Methods: Descriptive and exploratory study, carried out by searching for medical schools with disciplines in PC, through the analysis of the course syllabi available in the curricular matrices on the official websites of higher education institutions from August to December 2018. They were analyzed considering the offered period of the PC content, workload, scenario, and type of discipline (elective or mandatory). Results: 315 schools registered with the Ministry of Education were found, and only 44 of them (14%) offer courses in PC. These schools are distributed throughout 11 Brazilian states, of which 52% are located in the Southeast region, 25% in the Northeast, 18% in the South, 5% in the Midwest, and none in the North region. The predominant modality of the type of discipline in PC was mandatory in 61% of schools. Most Brazilian medical schools are private entities (57%), a similar percentage to the total number of medical schools identified with the teaching of PC. This course takes place in the 3rd and 4th years of the course; in most schools, the workload was 46,9 hours. The predominant scenario is the classroom, while some institutions provide integration between teaching community service and medical practice. The program contents are diverse, including thanatology, geriatrics and finitude, humanization, bioethics, pain, oncology and chronic diseases. Conclusion: PC education in Brazil is insufficient, which represents a barrier to the training of doctors in line with the recommendations of international entities, the National Curriculum Guidelines and legal frameworks within the scope of SUS. Investments by medical entities and government agencies are necessary to increase teaching in PC and the consequent qualification of medical training.

Since the 19th century formaldehyde has been used as a fixative for biological tissue. Although other forms of preservation were described before and after formaldehyde was identified as a universal chemical fixative, its has been widely used for corpses preservation since its description in 1867. This fixative is however harmful to human beings and to environment. Moreover, its use has been reduced since the end of the XX century. In this project we investigated the methods used by Biomedical and Medical Schools in Brazil for corpses preservation. Preservation of animal bodies were not taken into account at this survey. According to statistics from the Ministry of Education, Brazil has 298 Schools of Medicine heterogeneously distributed throughout its territory. Other Biomedical schools (nursing, biomedicine, nutrition, pharmacy etc) also have facilities for gross human anatomy practical teaching and corps preservation. A high percentage of institutions that offer medical education also offer other biomedical courses. The survey was elaborated as a google form and distributed through email messages. The link was sent to all members (n= 2778, including professors, students, technicians and inactive members) of the Brazilian Society of Anatomists (SBA). In this first attempt we received 187 answers. In a second attempt, we sent the link to the secretariat of the Brazilian Association of Medical Education (ABEM), to have it spread to all of its members. Finally, in a third attempt, we directly contacted professors of Anatomy of Medical Schools. A total of 224 answers were received until December 6th2017, but the questionnaire is still accepting responses. Forms filled out by Schools of Veterinary (9.8%) were disregarded in this survey. Size of medical and biomedical schools range from up to 200 students per year (15.6%) to more than 2000 students/year (12%), and their anatomy facility is able to store from 5 (13.8%) to more than 50 cadavers (10.3%). We observed that 86.6% (n=194) of our sample indicated the use of formaldehyde for embalming the cadavers, whereas 8.9% use a mixture of formaldehyde and phenol and the remaining Schools reported alternative solutions. The cadavers ‘preservation’ or ‘conservation’ methods include submersion in 10% formaldehyde solution in 71.9% of the cases, in a mixture of formaldehyde and phenol solution in 5.4% of the cases, in saline solution in 7.1%, preservation in glycerin in 40.2%, plastination in 5.4%, and other alternative methods in less than 0.5% of our sample. Based on this preliminary data we conclude that although formaldehyde is still in use by most of the Medical and Biomedical Schools in Brazil, there is a strong effort reported by many schools to minimize its use and to treat its waste before disposal. Plastination of specimens is highly stimulated by the International Society for Plastination which supports specialized training in this technique to brazilian universities.Support or Funding InformationInstitutional Fellowship for Undergraduate Students (Federal University of Rio de Janeiro ‐ UFRJ)This abstract is from the Experimental Biology 2018 Meeting. There is no full text article associated with this abstract published in The FASEB Journal.

Abstract: Introduction: The consolidation of rural internship programs is not a simple phenomenon, although its importance is currently recognized by students and teachers as a differentiated activity in their training itineraries. Medical schools still face considerable challenges in carrying out this type of activity. The existence of evidence that recruiting students to rural internships, offering meaningful experiences during undergraduate school and implementing a specific training program for rural areas after graduation, are the most effective interventions for recruitment and retention. Objective: Identify the rural internship programs in operation in Brazil, through the evaluation of Curricular Pedagogical Projects (PPCs,) of medical courses, fostering the debate on medical training for rural and remote areas, as well as emphasizing the importance of this type of training. Method: Cross-sectional, descriptive and documentary analysis study, with a quantitative characteristic, with a sampling of the access to the Curricular Pedagogical Projects (PPCs) of medical schools in Brazil with rural internships in the curriculum. Result: Of the 357 Medical Schools in Brazil, the authors found 18 programs with rural internships, corresponding to 5% of the institutions. The Southeast Region, when compared to the North region, concentrates the largest number of medical schools in Brazil (148), but the largest number of PPCs with rural internship is in the North Region of Brazil, totaling 6 (16%) in relation to medical schools in the region. Furthermore, of the 47 medical schools in the Southeast Region, in Minas Gerais, 2 rural internship programs were identified by the authors, in relation to other states in the same region. Conclusion: There are few rural internship programs identified in the PPCs in Brazilian medical schools. Changes are needed in the PPCs, with the inclusion of rural internships, with the inclusion of well-defined competencies and based on people’s health needs; construction of knowledge and development of skills and attitudes to solve problems, consistent with the reality of Brazil.

BackgroundAccording to recent surveys, 59% of British medical schools and 90% of US medical schools have courses or content on spirituality and health (S/H). There is little research, however, on the teaching of S/H in medical schools in other countries, such as those in Latin America, Asia, Australia and Africa. The present study seeks to investigate the current status of teaching on S/H in Brazilian medical schools.MethodsAll medical schools in Brazil (private and public) were selected for evaluation, were contacted by email and phone, and were administered a questionnaire. The questionnaire, sent by e-mail, asked medical school directors/deans about any S/H courses that were taught, details about those courses, S/H lectures or seminars, importance of teaching this subject for medical school directors, and medical schools characteristics.ResultsA total of 86 out of 180 (47.7%) medical schools responded. Results indicated that 10.4% of Brazilian Medical Schools have a dedicated S/H courses and 40.5% have courses or content on spirituality and health. Only two medical schools have S/H courses that involve hands-on training and three schools have S/H courses that teach how to conduct a spiritual history. The majority of medical directors (54%) believe that S/H is important to teach in their schools.ConclusionFew Brazilian medical schools have courses dealing specifically with S/H and less than half provide some form of teaching on the subject. Unfortunately, there is no standard curriculum on S/H. Nevertheless, the majority of medical directors believe this issue is an important subject that should be taught.

Pathology remains as one of the most important medical specialties, playing a pivotal role in diagnosis as well as in elucidating the pathogenesis of several diseases. Pathologists usually build a bridge between basic sciences and clinical practice, and are important players in translational biomedical research. Considering the foregoing information, it is clear that pathology is an important piece in medical education, since it provides a unique learning platform that unites molecular, cellular, mechanistic and structural alterations of human diseases. However, despite the multiple possibilities offered by the practice of pathology, Brazil is getting short of pathologists, mostly those interested in academic and investigative pathology. This situation has a trend to worsen, since the number of medical schools in Brazil increased significantly in the last few years. In such a context, it is almost mandatory to devise strategies to increase the efficiency of diagnostic pathology and to attract medical students to the specialty. The causes of the process that made pathology not so attractive to medical students have not been hitherto clarified. Potential agents are the monetary revenue of pathology practice, the emergence of new diagnostic areas, such as molecular biology and radiology, and, possibly, the context in which pathology is taught in medical courses. Indeed, it is quite possible that the courses of pathology are not clearly depicting the possibilities of professional and scientific achievements that pathology offers. At Faculdade de Medicina da Universidade de Sao Paulo (FMUSP), we decide to face the challenge, by including pathology throughout the six years of medical course. In the first two years, we used autopsies as the basis for education. The idea is to take advantage of a large autopsy service that performs about 15,000 autopsies of non-violent deaths per year. In this service, we installed a state-of-the-art imaging system that includes a 16-channel CT scanner, an ultrasound scanner, a 7-tesla magnetic resonance imaging (7T MRI) machine, 3-D printers, as well as a digital slide scanner. With such a platform, designed for research and teaching, we developed procedures capable of performing post-mortem angiography and spectroscopic metabolomics. In those activities, young medical students are exposed to a clinical discussion, the in-vivo and post-mortem images, followed by the autopsy, which is transmitted in real time from an autopsy room equipped with image facilities. The activity occupies an entire four-hour period and has the presence of basic scientists, clinical and anatomic pathologists, general clinicians and radiologists. More recently, we added professors of medical humanities, since the autopsy table is one of the settings where inequalities of access to medical treatment, driven by social and economic factors, are clearly observed. These activities are conducted on a weekly basis during the first two years of medical school and are highly appreciated by students. In the following week, they are exposed to histological preparations of tissue samples collected during the autopsy procedure. Since there are not many pathology services with the conditions to develop such a type of instruction, we explored the possibility of expanding our classes to other institutions. Indeed, once a month, we have the pleasure of sharing our classes with other medical schools by telepathology, and we have received a lot of inputs from students, clinicians and pathologists from the other schools, reducing our cultural inbreeding and expanding our experience. The autopsy-based learning began in 2002 and evolved until reaching the present form. Although the experience has not been so long, it is possible to identify two important impacts. First, the number of medical students from our institution applying to residence in pathology increased. Second, the autopsy course was ranked among the three disciplines that contributed most to medical education, as expressed by students at the end of the course. Apparently, expressing clearly the potential of pathology during the medical course is one of the strategies that may augment the number of pathologists in our country, and contribute to improve medical education. Thus, it is time to interact and use telepathology to build a network of medical schools, in order to face the challenge of teaching pathology in a scenario where the number of medical schools is increasing. By doing this, medical students will appreciate the beauty of our specialty and more and better pathologists will be graduated in our country.

This paper aims to describe and analyze medical education in Brazil, a history of over 200 years. As in most European countries and influenced by the Flexner Report, an undergraduate medical course in Brazil takes 6 years. Recently, medical education research has been advocating a shift from a teacher-centered and hospital-based approach to student-centered and community-based education. Nevertheless, a huge variation exists among Brazilian medical schools. The physicians’ supply program known as “More Physicians” has strongly impacted the number of medical schools in Brazil, which is growing rapidly. Professors of medicine from several institutions and other stakeholders have alerted authorities to the risks of operating so many schools without adequate time to prepare teachers, clinician-educators, curricula, and sufficient pedagogical structure to ensure quality medical education. The possibility of an imminent catastrophe in medical education has united stakeholders in pursuit of a guarantee of quality maintenance. This effort has resulted in the creation of an independent accreditation system approved by the World Federation of Medical Education. The study of the unbalanced relationship between stakeholders in medical education in Brazil until now has provided valuable information concerning the importance of having their roles and limits clear. It is possible that these findings might be replicable around the world.

Introduction According to the International Labour Organization, about 2.8 million people die from causes related to work annually, and the costs amount to almost the entire GDP of the 130 poorest countries in the world, which justifies investing in the teaching of occupational medicine in medical training. Objectives To study the teaching of occupational medicine in medical schools in Brazil and around the world. Methods Data was obtained from medical school websites. For the analysis of the information, descriptive statistics were used and compared with previous studies in Brazil and in the world. Results Of the 286 medical schools in Brazil, 241 (84.3%) make the curriculum available on their websites, and of these, only 29% offered the subject during graduation in 2023. In world studies, the subject was taught in 100% of medical schools in Australia and New Zealand (1998), 95% in Europe (2011), 68% in the USA (1994), 65% in Turkey (2010) and 52% in Mexico (2006). Compared to the supply of medical residency programs in Brazil in 2022, only 0.13% were for Occupational Medicine and of these, 56.5% were filled. Discussion Occupational Medicine is still in its infancy in most medical schools around the world. Although the number of medical schools has increased by 65% since the last study in Brazil, Occupational Medicine has grown by 4.5%. Conclusion The lack of importance given to subjects related to Occupational Medicine during undergraduate studies may have negative repercussions on the demand for specialized training, as well as on the demand for more specialized training.

ABSTRACTBACKGROUND:Common mental disorders (CMDs) have been correlated with consequences in different domains of life.OBJECTIVE:To summarize the prevalence rates of CMDs and factors associated with them among students at Brazilian medical schools.DESIGN AND SETTING:Systematic review and meta-analysis of studies developed in Brazilian medical schools.METHODS:In October 2021, searches were carried out in seven electronic databases, in Google Scholar and in reference lists. Observational studies reporting prevalence rates of CMDs among students at Brazilian medical schools were sought. Variables associated with CMDs arising from multivariate regression models were included in the synthesis. A meta-analysis was developed using a random-effects model and the risk of bias was assessed using an instrument developed from previous references.RESULTS:Fourteen original studies were included. The pooled prevalence rate of CMDs among undergraduate students at Brazilian medical schools was 43.3% (95% confidence interval = 38.9% to 47.6%; I2 = 87%; n = 3,927). Among the nine studies in which multivariate analyses were conducted, five showed risk associations between CMDs and medical school-related dissatisfactions, among which the desire to abandon the medical course can be highlighted (n = 3). In three studies, CMDs were associated with sleep indicators.CONCLUSION:Considering that the prevalence of CMDs among medical students is higher than in the general population, we recommend that Brazilian medical schools should give greater attention to this topic, and should enable expansion of care offerings relating to mental health.SYSTEMATIC REVIEW REGISTRATION:Prospective Register of Systematic Reviews (PROSPERO) database (CRD42020142184).

Few studies have investigated potential differences between the opinions of educators and undergraduates regarding spirituality in patient care. Understanding these differences, could lead to better strategies for educational proposes. To compare the opinions of medical teachers (MTs) and medical students (MSs) regarding spirituality training in a Brazilian medical school. A cross-sectional study was conducted. MTs and MSs filled out a questionnaire containing the Duke Religion Index, and questions regarding spirituality in clinical practice and at medical school. A comparison between early-curriculum MSs, late curriculum MSs and MTs was carried out. Chi-square (categorical) and Mann-Whitney (continuous/ordinal) tests were used. A total of 475 MSs and 44 MTs were evaluated. Results showed that MSs did not address spirituality as frequently as MTs (p<0.001), and that most participants did not feel prepared to address this issue, and believe that Brazilian medical schools are not giving all the required information in this field. Nevertheless, they believe MSs should be prepared to discuss these issues. Late-curriculum MSs believed that spirituality plays a more positive role in patient health (p=0.027), and were more prone to address this issue than early-curriculum MSs (p=0.023). These findings revealed some of the challenges faced by spirituality medical training in Brazil, and differences between MTs and MSs regarding this issue. Further studies are needed to replicate these findings in other countries.

Communication skills teaching in Brazilian medical schools: What lessons can be learned?

This is a secondary data-based study conducted to investigate whether gender is related to acceptance. Two Brazilian Medical Schools, Universities A and B, were studied. Their entrance exams (EE) were analysed and the number of candidates who took the EE was compared to the number of students admitted to the MS according to gender, in the period between 1995 and 2009. The same data from MS in the United States in 2011 was also evaluated. There was an increase in the percentage of female applicants but it did not correspond to the percentage of admitted students of the same gender. There was a trend of selecting men. At A, 39.3% of the applicants and 47% of the admitted students were men (OR = 1.37; CI95% = 1.24 – 1.51). In B, men represented 39.3% of the applicants and 65.4% of the admitted students (OR = 2.93; CI 95% = 2.76 – 3.11). This was not seen in US MS. The analysis of the EE suggests that the greater selection of men could be a product of EE format.

Transfusion medicine in medical education: an analysis of curricular grids in Brazil and a review of the current literature

To the Editor: We would like to thank Dr. Rosset et al. and Dr. Roriz-Cruz et al., from the Instituto de Geriatria, Universidade Católica do Rio Grande do Sul, Brazil, for the interesting, provoking comments in their letters. The elaboration of a necessarily limited text about a theme as vast as Brazilian aging reality1 leads one to make choices from among many interesting aspects. Although it is a fact that Brazil is a multiethnic society, as shown by its mitochondrial deoxyribonucleic acid, it is also true that the genetic pattern varies from region to region of this country, to reveal marks of successive waves of European migration during the 19th century, besides the Portuguese, blacks, and Brazilian Indians,2 as well as the more recent migrations from the Middle and Far East. It is worth noticing that the contribution to culture of Brazilian Indians greatly exceeds their actual proportions in the population. Different ethnic groups form the Brazilian people, each one of them bringing its individual contribution to Brazilian culture, which has motivated us to adopt the official data of the 2000 Brazilian Census. In addition to the regional heterogeneity of genotypic profiles, it seems to us (and apparently to the Brazilian Institute of Geography and Statistics) that, in a highly miscegenated society like ours, the openly stated race can express better the cultural options of each individual, regardless of his or her genetic profile. Concerning the Veranópolis Project, in 1996, this interesting study included 193 elderly persons, restricted to one Italian-Brazilian community3 that was not representative of the general elderly Brazilian population. Our group maintained a special cohort of 130 elderly male athletes4 in São Paulo since 2001 not referred to in the article, because they also were not representative of the general elderly Brazilian population. Other interesting elderly cohort studies were developed in Brazil, such as the EPIDOSO, in 1991, with 1,667 persons;5 the Catanduva Cohort, in 1998, with 1,656 persons;6 and the Botucatu Cohort, in 1992, with 640 persons.7 It is also important to refer to the Brazilian branch of the Saúde, Bem Estar e Envelhecimento—Health, Welfare and Aging (SABE) Study,8 a Pan-American Health Organization project for Latin America and the Caribbean, which was an important study of the condition of aged people in São Paulo city, with a sample of 2,143 people aged 60 and older. The Bambuí Cohort Project, in 1996, was a follow-up study with 1,742 individuals aged 60 and older. Developed by the Oswaldo Cruz Foundation's Nucleus for Public Health and Aging Studies and the Federal University of Minas Gerais (MG, Brazil), it has more than 50 publications.9 Because this project seemed to be more representative, it was incorporated into our study. Concerning the Roriz-Cruz letter, the authors make interesting and appropriate comments about the differences between geriatric training and geriatric medicine valuation in Brazil, the United States, and the United Kingdom. In spite of our agreement with the Roriz-Cruz arguments, the scope of our article was to describe geriatric characteristics in Brazil and not to make comparisons between geriatrics training in these three countries. That was the reason why we did not analyze the phenomenon of geriatric residence competition. Alternatively, we were afraid to oversimplify, in a few lines, the complex reality of geriatric education in these three countries with not completely comparable educational and social realities. Suffice it to say that the World Health Organization's international study “Global Survey on Geriatrics in the Medical Curriculum”10 could not have been conducted in the United States or in Brazil because of the complexity and diversity of medical education in those two countries. Of the 140 existing medical schools in Brazil,11 few have geriatrics as a discipline or an independent unit or ward, and only 15 medical residence programs in geriatrics12 were found throughout the country. This situation, combined with the reduced number of qualified geriatricians, could explain the high proportion of candidates to slots with no other variable. In spite of that, the question about differences and similarities in geriatrics training and valuation in Brazil, the United States, and the United Kingdom remains an interesting query and deserves specific research in the future. What seems clear, both in the above-mentioned paper1 and in the Rosset and Roriz-Cruz letters, is the not yet fully described reality of Brazilian gerontological wealth. This is definitely a great country with great opportunities. Financial Disclosures: Luiz Eugênio Garcez Leme is a professor at the University of São Paulo and received no financial support from companies. Author Contributions: Luiz Eugênio Garcez Leme is the single author of this letter. The concept, design, data, and analysis, as well as the preparation of the manuscript, were done by the author. Sponsor's Role: This letter was not sponsored.

The D&amp;T report

INTRODUÇÃO: Há importância na análise do ensino-aprendizagem na graduação médica que permita identificar oportunidades de melhoria no ensino dos cuidados no final da vida. OBJETIVO: Descrever atitudes e práticas do ensino dos cuidados no fim da vida no Brasil conforme relatado pelos coordenadores de curso. MÉTODO: Questionário sobre o ensino dos cuidados no fim da vida foi aplicado em 179 coordenadores de escolas de medicina brasileiras. RESULTADOS: Cinqüenta e oito coordenadores participaram (32,4%). A maioria (96,6%) considerou muito importante o ensino dos cuidados no fim da vida. Setenta e três por cento acredita que o tempo para ensinar sobre os cuidados paliativos em seus currículos é insuficiente, sendo sua prioridade insuficiente ou inexistente em 50,9% das opiniões. O pequeno número de docentes especializados foi considerado como uma das barreiras para incorporar esse ensino no currículo da graduação. CONCLUSÃO: As atitudes e práticas quanto ao ensino dos cuidados no fim da vida nas escolas médicas sugerem limitações. Embora os atuais coordenadores acreditem em sua importância, ainda é dada pouca prioridade ao ensino deste tema no Brasil.