Brazilian Medical Schools Research Articles

International student exchange and the medical curriculum: evaluation of a medical sciences translational physiology course in Brazil

The objective of the present study was to conduct a short-term international course on translational physiology for medical students from Wright State University and the University of Iowa. The goals were to 1) provide students with an exposure to the academic, cultural, and medical environments in Brazil; 2) promote awareness of the global medical community; and 3) provide an academic course focused on translational physiology. An evaluation of the students was conducted to determine whether such a short-term course might be useful in the medical curriculum. The 2-wk course was held in the summer of 2005 at the University of São Paulo School of Medicine in Ribeirão Preto, Brazil, for 23 American students. The program included presentations of basic and clinical topics, meetings with medical students, and clinical presentations. The program finished with student attendance at a scientific meeting sponsored by the Brazilian Society of Hypertension. Student surveys evaluated issues related to perceived treatment, Brazilian medical school environment, culture and personal attributes, and career aspirations. The international Medical Sciences Translational Physiology course for medical students provided a brief, but intense, experience. It gave students a picture of the medical environment in Brazil and an appreciation for the differences and similarities in cultures. Most students reported that it was a positive experience that would be beneficial to their careers. In conclusion, a short-term international course provides an efficient means for medical students to experience aspects of global medical science.

RESPONSE LETTER TO DR. ROSSET ET AL. AND TO DR. RORIZ‐CRUZ ET AL.

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.

Research publications in the field of health: omission of hypotheses and presentation of common-sense conclusions

Medical literature should consist of knowledge applicable to professional education; nevertheless, the profusion of articles in databases provokes disquiet among students. The authors considered the premise that scientific production in the field of health follows a mechanical description of phenomena without the clarity of motivating questions. The aim was to interpret material from expert reports, applied by medical students to analyze articles from renowned journals. This research project was exploratory, searching for latent meanings regarding methodological problems in a sample of papers. It was performed in a Brazilian medical school. The sample was intentionally built, consisting of articles related to original research in the field of health, published over the previous five years. The results came from text content analysis, performed by a professor and his medical students. (1) Failure to state a hypothesis is an equivocal practice: articles did not show clarity of hypothesis to demonstrate that their authors had epistemological knowledge of the methods chosen. (2) There is a certain belief that in normal scientific practice, hypotheses are unnecessary: studies without explicit hypotheses led to suppositions that they merely repeat dominant models. (3) Presentation of common sense as scientific conclusions: research brings together what would have mobilized the researchers initially. Absence of formal hypotheses leaves scientific production vulnerable when put under epistemological discussion. Conclusions from scientific articles are often confounded with common-sense statements. Quantitative research is suggested, for studying the frequency of occurrence of these dubious methodological points.

Intensive care medicine teaching in a Brazilian medical school: the student's perspective

Several medical schools do not have a specific discipline for the teaching of intensive care medicine (ICM) topics in their curriculum. As a result, students often seek exposure to ICM in extracurricular activities.

Comitês de Ética em Pesquisa: adequação à Resolução 196/96

This article intends to evaluate the structure, functioning and performance of 17 Institutional Review Boards (IRB), from the viewpoint of their presidents, in relation to the instructions of Resolution 196/96 of the National Council of Health, Ministry of Health, Brazil. Presidents of 33 IRBs, that evaluated proposals for research on fertility control, were indicated by the professionals responsible for the area of gynecology in 46 Brazilian medical schools and by the directors of four research centers on human reproduction . A letter with a questionnaire were sent to the presidents, asking them to volunteer for the study. Seventeen presidents completed the questionnaire. Results disclosed a series of violations of Resolution 196/96. Three IRBs did not include representatives of the community among their members; four took over a month to release the Board's decision on proposals and 13 did not follow-up the studies. Composition and filing of the research proposals were in agreement with the Resolution. However, in eight IRBs time of mandate differed from that set forth in the Resolution. Almost all presidents (about 14 of the 17) thought that the composition and activities of their IRBs were adequate. Eleven considered the Resolution appropriate but difficult to comply with. These results suggest that an extensive debate on the operational viability of the Resolution would be timely. This endeavor could bring forth valuable suggestions for the improvement and applicability of the Resolution contributing to the improvement of the scientific and ethical quality of research.

Achados clínicopatológicos na tromboembolia pulmonar: estudo de 24 anos de autópsias

INTRODUÇÃO: Tromboembolia pulmonar (TEP) é ainda uma afecção enigmática em diversos aspectos clínicos e epidemiológicos e frequentemente erroneamente diagnosticada. OBJETIVO: Descrever a prevalência e os achados anatomopatológicos de TEP em uma série de 5261 autópsias realizadas em um hospital universitário de nível terciário, correlacionar estes achados com as doenças de base e verificar a freqüência de suspeita clínica antemortem de TEP. MÉTODO: Revisão dos registros das autópsias consecutivas realizadas de 1979 a 2002 para um estudo retrospectivo. Dos prontuários e dos relatórios de autópsias dos pacientes que tiveram TEP documentada, macro e/ou microscopicamente, foram extraídos dados demográficos, doenças de base, suspeita antemortem de TEP, localização dos trombos nos pulmões e provável local de origem da TEP. RESULTADOS: A freqüência de autópsias foi de 42,0% e TEP foi encontrada em 544 pacientes, sendo a principal causa da morte (TEP fatal) em 225 casos. Doenças infecciosas (p=0,0003) foram associadas com TEP não fatal e trauma (p=0,007) com TEP fatal. A taxa de não suspeita antemortem de TEP foi 84,6% e 40,0% destes pacientes apresentaram TEP fatal. Doenças do sistema circulatório (p=0,0001), infecções (p<0,0001), doenças do sistema digestivo (p=0,0001) neoplasias (p=0,024) e trauma (p=0,005), foram associadas com TEP não suspeitada clinicamente. A provável origem da TEP mais freqüente foram os membros inferiores (48,9%). CONCLUSÃO: A taxa de não suspeita clínica antemortem de TEP foi elevada. Atenção especial deve ser dada para a possibilidade de TEP em pacientes com doenças do sistema circulatório, infecções, doenças do sistema digestivo, neoplasias e trauma.

Clinical skills assessment: limitations to the introduction of an "OSCE" (Objective Structured Clinical Examination) in a traditional Brazilian medical school.

Assessment of clinical skills has a central role in medical education and the selection of suitable methods is highly relevant. The OSCE (Objective Structured Clinical Examination) is now established as one of the most valid, reliable and effective tests for the assessment of clinical skills. To describe student and faculty perceptions of an OSCE introduced in a traditional Brazilian medical school. Descriptive, semi-quantitative study. Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo. 258 junior medical students finishing an introductory course on basic clinical skills and six faculty members deeply involved with the OSCE administration. Over a period of three consecutive years, student perceptions on the examination were evaluated using a structured questionnaire containing several five-point scales; faculty members' opinions were collected using a structured questionnaire plus a personal interview. Student satisfaction or dissatisfaction with aspects of OSCE administration and positive or negative opinions from faculty members. Students were comfortable with cases and tasks, but nearly half (48%) of them criticized organizational aspects of the OSCE. Substantial proportions of students reported difficulties with both time management (70%) and stress control (70%). Improvement of several aspects of exams reduced criticism of organization to a minority (5%) of students, but the proportions of students reporting difficulties with time management (40%) and stress control (75%) during the exam remained virtually unchanged. Faculty members acknowledged the accuracy of the OSCE, but criticized its limitations for assessing the integrated approach to patients and complained that the examination was remarkably time and effort-consuming. The educational impact of the OSCE was felt to be limited, since other faculty members did not respond to the communication of exam results. In addition to shortage of resources and organizational difficulties, local cultural aspects and the absence of a more favorable educational climate may hinder lasting improvements in assessment methods in traditional medical schools.

Logistic Regression Analysis of Potential Prognostic Factors for Pulmonary Thromboembolism

To identify potential prognostic factors for pulmonary thromboembolism (PTE), establishing a mathematical model to predict the risk for fatal PTE and nonfatal PTE. The reports on 4,813 consecutive autopsies performed from 1979 to 1998 in a Brazilian tertiary referral medical school were reviewed for a retrospective study. From the medical records and autopsy reports of the 512 patients found with macroscopically and/or microscopically documented PTE, data on demographics, underlying diseases, and probable PTE site of origin were gathered and studied by multiple logistic regression. Thereafter, the "jackknife" method, a statistical cross-validation technique that uses the original study patients to validate a clinical prediction rule, was performed. The autopsy rate was 50.2%, and PTE prevalence was 10.6%. In 212 cases, PTE was the main cause of death (fatal PTE). The independent variables selected by the regression significance criteria that were more likely to be associated with fatal PTE were age (odds ratio [OR], 1.02; 95% confidence interval [CI], 1.00 to 1.03), trauma (OR, 8.5; 95% CI, 2.20 to 32.81), right-sided cardiac thrombi (OR, 1.96; 95% CI, 1.02 to 3.77), pelvic vein thrombi (OR, 3.46; 95% CI, 1.19 to 10.05); those most likely to be associated with nonfatal PTE were systemic arterial hypertension (OR, 0.51; 95% CI, 0.33 to 0.80), pneumonia (OR, 0.46; 95% CI, 0.30 to 0.71), and sepsis (OR, 0.16; 95% CI, 0.06 to 0.40). The results obtained from the application of the equation in the 512 cases studied using logistic regression analysis suggest the range in which logit p > 0.336 favors the occurrence of fatal PTE, logit p < - 1.142 favors nonfatal PTE, and logit P with intermediate values is not conclusive. The cross-validation prediction misclassification rate was 25.6%, meaning that the prediction equation correctly classified the majority of the cases (74.4%). Although the usefulness of this method in everyday medical practice needs to be confirmed by a prospective study, for the time being our results suggest that concerning prevention, diagnosis, and treatment of PTE, strict attention should be given to those patients presenting the variables that are significant in the logistic regression model.

Students' and tutors' perceptions of problems in PBL tutorial groups at a Brazilian medical school.

There are few published studies that address the problem of dysfunctional tutorial groups. Most studies are restricted to student or faculty opinions separately and to specific aspects affecting the tutorial group function. This study examined teacher and student perceptions of frequency and importance of problems observed in tutorial groups in a new PBL program. Tutors (n=30) and students in the second (n=75) and third (n=53) year completed a questionnaire at the beginning of the 1999 academic year. The questionnaire had 33 items grouped as seven "factors" related to tutor performance, feedback, assessment, educational resources, student performance, educational problems and external factors The most important problems identified were related to tutors (mainly in training aspects) and students (mainly in problem discussion). Students and feedback (quality) were the most frequent. There were statistically significant differences between tutors' and students' (higher) and between second and third year (higher) students' perceptions of different factors. (1) Marilia Medical School (FAMEMA) has problems in the tutorial group function mainly related to contributions of students and tutors. (2) Students' and tutors' opinions, as well as those of second and third year students, differ and therefore all need to be consulted to solve tutorial group problems. (3) It is necessary to develop a better student training program and also to improve the tutors training program. (4) There is a need for continued evaluation of problem-based learning at FAMEMA. We must look at perceptions of students from all years.

Adolescent medicine for medical students. A study of knowledge and performance among medical students in Brazil.

The objective of the study was to elaborate and apply an evaluation instrument designed to evaluate acquisition of knowledge and performance of medical students in the field of adolescent medicine. Study carried out during one year, with a total of 103 fifth-year medical students of a Brazilian medical school, divided into four groups. Questionnaire, pre and post-test, record of individual evaluation, exam marks and average of teachers' concepts. Each group was submitted to a test with a differentiated number of questions, though proportionality in the distribution of themes was maintained. Statistical analysis used the chi-square test or verisimilitude ratio test; means, standard deviations and analysis of variance; Turkey's test of multiple comparisons; and multivariate technique for repeated measurements. Values of p < 0.05 were considered statistically significant. The distribution of themes in tests and comparative analysis of tudents' mean score in the Pre-test did not reveal any statistically significant difference (p = 1.0; p = 0.08). A positive correlation was observed between performance evaluated by the research instrument and that measured by formal instruments of the course (r = 0.45; r = 0.68). There was an increase in acquisition of knowledge, with a positive correlation between scores of the Pre and Post-Test and between Post-Test-Pre-Test difference/Exam (r = 0.43; r = 0.27). The instrument was shown to be appropriate for evaluating the teaching of adolescent medicine at pregraduate level. There was increase in acquisition of knowledge. The methodology used can be a reference point for works with similar objectives.

Selective training and cross-year clinical tutoring as educational influences on generalist career choice.

This study was undertaken with all 299 graduates of 12 consecutive classes (in 6 years) of a Brazilian medical school. To appraise the relationships of gender, early preference for a career, the experience of selective training (a form of elective clerkship) and student preceptorship (cross-year clinical tutoring by peers), with the career choices of graduates. Data were obtained at three points: at the beginning of medical studies, on career preference; at the end of medical studies, on selective traineeship and student preceptorship; and after graduation, on medical residency selected. Chi-square tests and logistic regression analysis were done on the data of the graduates, grouped in terms of choice, or not, of frontline care specialties (internal medicine, pediatrics or obstetrics-gynecology). Findings are presented on 299 graduates, of whom 48.5% were female, and 53.8% preferred frontline care (FC) specialties at the beginning of the program. After graduation, 50.2% of the subjects chose FC specialties, among which two-thirds had kept their early preference for a specific specialty. Logistic regression analysis predicted 86.7% of the graduates' choices of FC specialties. Female gender, early preference, student preceptorship and, mostly, selective traineeship in the same broad area were significant factors. In this study a strong association was found between selective traineeship and career choice of FC specialties in relation to three additional predictive factors. It also revealed student preceptorship as a factor of potential educational significance in the career decision process and as a matter of institutional concern.

Transformation and trends in preventive and social medicine education at the undergraduate level in a Brazilian medical school

In the present study we discuss some transformations in undergraduate training in Preventive and Social Medicine in the Department of Social Medicine of the Faculty of Medicine of Ribeiro Preto, University of So Paulo, from 1993 to 1999. Aspects of the relationship between medical training and the reorganization of local services of the Brazilian national health system, and between graduate teaching in Preventive and Social Medicine and medical education as a whole are discussed. The crisis in Preventive and Social Medicine and its influence of medical training are evaluated. Trends for the application of a body of knowledge of the specialty and for the relationship between the department and the medical school are discussed.

Documenting Outcomes of a Faculty Training Workshop on Problem-Based Learning

Abstract: A faculty training workshop on problem-based learning (PBL) methods was provided to educators at a public medical school in Brazil. Wprkshop activities were designed to address specific knowledge, skill and attitudinal objectives that had been defined beforehand. Participants completed a structured questionnaire before and after the workshop to document attainment of the objectives. Twelve participants completed the 20-hour workshop, and questionnaire results. Though there were certain limitations on interpretation of the pre/post questionnaire, it does provide some assurance to program organizers and sponsors that objectives are attained. Participants' responses also help organizers improve their delivery techniques.

A First Step Incorporating Smoking Education into a Brazilian Medical School Curriculum

Smoking-related illnesses are the leading causes of morbidity and mortality in Brazil. Despite a smoking prevalence of approximately 40%, there is limited national effort to reduce tobacco use in Brazil by means of public education and training of health care professionals to promote smoking education. In particular, the need for information about tobacco warrants increased emphasis in undergraduate medical education. An educational program on nicotine addiction during medical school could facilitate the incorporation of smoking cessation interventions into routine medical practice. As a preliminary step toward implementing a tobacco education and intervention program, this study was designed to assess knowledge and attitudes about smoking among Brazilian medical students. Five hundred thirteen (N = 513) medical students from the Federal University of Rio Grande do Sul, the southernmost state of Brazil, completed a self-reported questionnaire during the 1995-1996 academic school year. Most students recognize the adverse health effects of smoking and the importance of their professional role in promoting smoking cessation. In contradiction, however, few medical students currently provide their patients who smoke with even minimal intervention. This discrepancy supports the idea that training in nicotine addiction and smoking cessation techniques will help medical students to develop the skills and confidence needed to successfully intervene with their current and future patients.

Health care systems in transition: Brazil Part II: The current status of AIDS in Brazil.

There were a total 71111 AIDS cases reported to the Ministry of Health through the National Control Program of STDs and AIDS (PNC DST-AIDS) by September 1995. 87% of these cases were in the southeastern and southern regions 55% were from Sao Paulo state and 82% of cases were men. HIV/AIDS risk factors were known for 82% of the 58567 men reported with AIDS; 56% were men who had sex with other men 26% were IV drug users 12% were heterosexuals and 5% were transfusion recipients. Half of the female AIDS cases with known risk factors were heterosexuals 30% were IV drug users and 11% were transfusion recipients. Since the beginning of the HIV/AIDS epidemic in Brazil the male/female ratio has come down from 43:1 in 1985 to 5:1 in 1995. Young children comprise 3.2% of all AIDS cases. The proportion of AIDS cases reported among men due to homosexual and bisexual activity has declined steadily since 1988 with an offsetting increase in the proportion of AIDS cases due to heterosexual relations and to a lesser degree IV drug use. HIV and sexually transmitted disease control policies are controlled at the central level by the Ministry of Health through the PNC DST-AIDS. Such policies are controlled at the state level by the state health secretariat while at the local level disease notifications are monitored medications are provided to individuals and public hospitals and bulletins are regularly published with statistics describing the progress of the epidemic. The authors note that despite the clear need in Brazil for trained health care providers to meet the challenges of HIV/AIDS the curricula of medical schools in Brazil fail to train undergraduates how to manage individuals seeking HIV testing newly HIV-infected persons or people with AIDS.