INTRODUCTION

Medical semiology is the foundation of clinical practice and, despite all advances in technology, the tripod consisting of the doctor-patient relationship, history and clinical evaluation will remain the essence of Medicine¹. Therefore, its teaching is part of the first trainings of medical students towards their future practice^2),(3.

The word semiology derives from the Greek words semeîon, which means sign, and logos, which means word, discourse, treatise⁴. In the health area, “sign” refers to something objective, verifiable and explicit, while “symptom” has a more subjective characteristic and depends on the process of illness and the disease expression in the person, which influence how they feel and interpret their suffering⁵. Semiology, therefore, comprises the evaluation of diseases in the individuals, through their signs and symptoms⁴. The word semiogenesis is defined as the knowledge of the forms of presentation of the disease signs and symptoms, while the word semiotechniques (i.e., physical examination techniques) is defined as the evaluation of the patient’s physical condition, which, associated with the investigation of signs and symptoms, allows the establishment of a syndromic diagnosis¹. The word ‘propaedeutics’ derives from the Greek, propaideutikós, in which ‘pro’ means before and paidein means to teach, that is, preparatory study⁶.

According to Devine et al., the multiple denominations of semiology and its integration in the curricula make the assessment of its curricular workload challenging⁷. However, we found some comprehensive international studies on semiology in medical schools. A Cuban study compared the different components of the curriculum in the academic year 1985-1986 with those for the year 2010-2011⁸, after a change in Cuba’s “study schedule” in 2010. In Colombia, a study reviewed information on semiology in the curriculum of five of the six schools in the city of Cali⁹. In the United States, the Association of American Medical Colleges provides data on the medical course disciplines per academic year¹⁰ and there is a study on the teaching of physical examination before clerkship in 106 medical schools of 141 medical schools (75%) accredited by the Liaison Committee on Medical Education in the academic year 2015 - 2016¹¹. Two studies carried out in Europe analyzed the curricula of medical schools. One of them assessed 32 medical schools from 18 European countries from 2001 to May 2002¹² and another assessed 16 medical schools from six southeastern European countries from March to July of 2003¹³. Devine et al. conducted a study on teaching practices in 25 of 35 UK medical schools in the 2014-2015 academic year. However, the authors combined the contents of semiology and physical examination with internal medicine and general practice, not allowing the identification of specific data on semiology⁷.

In Brazil, we found one study on the teaching of semiology in 14 medical schools in Rio de Janeiro in 2006. At the time, Brazil had a total of 119 medical schools, with 57 of them located in the Southeast region, of which 15 were located in the state of Rio de Janeiro¹. We also found a study carried out in Universidade Federal de Minas Gerais, which described the two semiology modules they offered and analyzed the perception of 157 third-year undergraduate medical students who had completed their training about semiology³. The study found that 56.1% of the students considered the workload to be insufficient, 54.1% considered that they knew how to collect the patient’s history, and 65% thought that, despite being able to perform the patient’s physical examination, they did not master the necessary skills to perform a more extensive physical examination³.

The National Curriculum Guidelines (DCN, Diretrizes Curriculares Nacionais) for the undergraduate medical course in Brazil address semiology in the key action of “identification of health needs” of its subsection I (“of attention to individual health needs”) and establish that, when carrying out the clinical history, the student must have an ethical relationship, favor the construction of the bond with the patient, consider the biopsychosocial and cultural aspects related to the health-disease process and organize and guide the anamnesis using “clinical-epidemiological reasoning and semiological technique”; and that, when performing the physical examination, the student must look after “the safety, privacy and comfort” of the patient and maintain an “ethical posture and technical dexterity”, while considering the “clinical history, ethnic-racial singularity, gender, sexual orientation and linguistic-cultural and gender identity”¹⁴. All these aspects must be permeated by adequate communication and other components of professionalism, including humanistic ones such as empathy⁷. The DCN also define the minimum limit of the medical course workload at 7,200 hours and that 35% of this workload is destined for clerkship¹⁴. However, they do not define limits or percentages of the specific workload of the contents taught before the clerkship, nor do they suggest when each content should be included in the curriculum. If, on the one hand, the non-definition of limits provides greater autonomy in curriculum planning, on the other hand, as this is permeated by discussions between teachers and managers and is influenced by the power of each teaching area, there is a risk of a greater workload of non-essential contents and a lower workload of others that are essential¹⁵, including semiology.

Taking into account the importance of semiology for medical practice, the non-definition of workload limits and the time of inclusion of curricular contents of the medical course before the clerkship, as well as the non-identification of a study in Brazil with a national scope that addressed these aspects of adult semiology in medical school curricula, the aim of our study was to analyze the distribution of adult semiology in Brazilian medical schools.

METHOD

RESULTS

A total of 226 of the 335 medical schools active in Brazil in December 2020 (67.5%) were included in the present study, representing 103 of the 113 federal or state schools (91.1%) and 123 of the 222 municipal or private schools (55.4%).

The proportion of schools included in the study was similar by geographic region, chi²(4) = 4.30, p = 0.367. However, Brazil had more private schools in 2020 than federal and state schools, chi²(3) = 20.60, p < 0.01, and, consequently, non-free-tuition schools, chi²(1) = 14.13 , p < 0.01.

The time of existence of the medical course among the included schools was:

As for the curriculum design, 84 of the 226 schools had a traditional curriculum, which concentrated the basic sciences in the first two years of the course (37.2%) and 142 schools integrated the curricular contents (62.8%) by modules or axes and called their curricula as:

The distribution of the time of inclusion of semiology in the curriculum of the 226 schools is shown in Figure 1. As depicted, it is most frequently inserted only in the 4^th semester of the course. It can also be observed that while some schools teach semiology in just one or two semesters, others teach it throughout the first four years of the course.

Source: the authors.

Figure 1 Distribution of the time of inclusion of adult semiology in the curriculum of the 226 active Brazilian medical schools in December 2020 that made this information available on the internet, per semester in schools with semester admission or per year in schools with annual admission. 

Table 1 shows the distribution of semiology contents in the 226 analyzed schools. It can be observed that, in some schools, general semiology and clinical reasoning are offered in the 1^st semester. Therefore, we remind readers that reasoning was only included as content when the school incorporated it into the semiology discipline. In schools that offered it as a separate discipline, it was not included in the semiology discipline. Therefore, it appears both in semiology and in the contents integrated into the axes and modules.

It was only possible to identify the workload of 117 of the 226 medical schools (51.8%) and, among them, 44 were tuition-free (37.6) and 73 were not tuition-free (62.5%).

Table 2 shows the mean and median workload hours of the course, clerkship and semiology, showing that the workload of practical semiology classes was greater than the theoretical one. Table 3 shows the distribution of the semiology workload by region, type of administration, tuition-free/non-tuition free characteristic, and time of existence of the school. As shown, there was no statistical difference regarding any of these variables.

The percentage of the semiology workload in relation to the total course workload had a non-parametric distribution, with a median of 2.9% (P_25-75 = 2.0 - 4.0) and a mean of 3.2% (SD = 0 .2; 95%CI = 2.8 - 3.5).

Frame 1 shows the names of the disciplines, modules and axes that contain semiology and the contents integrated to it in 142 schools of the 226 analyzed ones, per semester or year of inclusion in the course, according to the type of semester or annual admission of the school. It also shows that several contents provide opportunities for the learning of semiology, such as anatomy, pre-hospital care and fractures integrated with osteoarticular semiology.

DISCUSSION

In our study, tuition-free medical schools made their curricula available on the internet more often than non-tuition-free medical schools. Perhaps, this fact is due to the more recent increase in the number of private schools, which had not yet included their curricula on their websites. Also, as some of these schools already existed and were incorporated into business groups, usually, their names had changed and, when we could not find the data related to a school belonging to a business group, this also happened with all their other schools.

We found eight names related to semiology, without considering the name of modules or axes that integrated it or their qualification and association with other terms. These were: semiotechniques, propaedeutics, semiology, semiology and propaedeutics, signs and symptoms, initiation to clinical examination, introduction to internal medicine and introduction to medical practice. The modules and axes that integrated it had specific logics in the integrated contents in each school and a certain creativity regarding the denominations.

In the Brazilian study in medical schools in Rio de Janeiro¹, it was observed that some of them differentiated semiology from propaedeutics, with the first being related to anamnesis and, often, to the physical examination, whereas the second was more specific to the physical examination. The term introduction to internal medicine was mentioned in a European study¹³ and the term propaedeutics was found in a Cuban study⁸, a European study¹² and a Colombian study⁹. In the latter, the terms ‘introduction to medical practice and human conduct’ were also found to designate the teaching of semiology.

In our study, we observed that semiology was more frequently included only in the 4^th semester of the course, unlike the study carried out in Rio de Janeiro¹, in which it was more frequently included in the 5^th and 6^th semesters; and the Colombian study⁹, in which it was more frequently included in two semesters or from the 4^th to the 7^th semesters; and the Cuban study, in which semiology was included in the third year of the course under the name “Clinical Propaedeutics and Pathophysiology” in the academic year of 1985-1986, and “Clinical Propaedeutics and Clinical/Imaging Laboratory” in the academic year of 2010-2011⁸.

Clinical reasoning was the only content included in all semesters of the course before the clerkship among some Brazilian medical schools in our study. In the North American research, its teaching started in the first two semesters of undergraduate medical school and was associated with physical examination in 84 of 116 analyzed schools (79%), although 60% of the time was dedicated to the physical examination¹¹.

Some schools included in our study integrated semiology with other areas of knowledge, such as anthropology and sociology, and with other contents, including biosecurity, ethics and bioethics, narrative-based medicine, concepts and principles of the Brazilian Unified Health System (SUS, Sistema Único de Saúde), communication, first aid, medication application, anatomy, physiology, histology, imaging, collection and analysis of laboratory tests, among others, in accordance with article 29 of the DCN¹⁴.

In the Colombian study, semiology was integrated with basic biomedical and clinical disciplines⁹ and in the North American study, 92 schools associated the teaching of physical examination with the patient’s clinical history (87%), 59 with clinical reasoning (56%), 64 with anatomy (60%) and 56 with physiology or pathophysiology (53%), with these contents being taught in an associated manner in 48 of these schools (45%)¹¹. Neither the study carried out in Colombia⁹, nor the study carried out in the United States¹¹ mentioned the integration of semiology or physical examination to contents of the Human and Social Sciences, in addition to communication and ethics.

We consider that the student should be seen as a professional in training since the first day of the course and, as semiology is the foundation of clinical practice, its teaching should start in the first semester of the course, integrated with clinical contents and contents of basic, social and human sciences, including communication, ethics and other components of professionalism. This inclusion should be continued throughout the course, showing increasing complexity, so that the future physician can establish a good doctor-patient relationship, perform an anamnesis considering the biopsychosocial, cultural and spiritual aspects related to the health-disease process, carry out a high-quality physical examination and demonstrate comprehensive clinical reasoning.

When comparing the values ​​of the total workload of the course that we found with that of other studies, we observed that it is lower than what appears in the Cuban study plan, which is over 9,000 hours throughout the six-year course⁸ and similar to the study carried out in Rio de Janeiro, which comprised 8,426.9 hours (SD = 272.1; 95%CI = 7,839.0 - 9,104.7)¹. However, it is much higher than the average load of 21 of the 32 European schools, which was 4,497.8 hours (SD = 270.2; 95%CI = 3,934.2 - 5,061.4)12, and of 16 medical schools in Southeast Europe, which was 4,990.8 hours (SD = 113.6; 95%CI = 4,748.2 - 5,233.4)¹³.

In relation to Europe, the duration of the medical course in many of its countries is of five years¹² and the shorter course load is probably a result of the reform movement in higher education that resulted in the Bologna Process¹⁸. In medical education, in 1998, this movement generated the declaration of the World Federation for Medical Education, which highlighted the need to change the structure and process of medical education to prepare physicians to meet the needs and expectations of society, deal with the increasing scientific knowledge and technological advances, develop the capacity for lifelong learning and adapt to changes in the context and in the health system. One of its recommendations was the development of a core curriculum with essential contents for medical training, aiming to avoid an overload of contents, which should be supplemented by optional subjects¹⁹. These aspects were also highlighted in the Bologna Declaration¹⁸.

As for the median workload of semiology among 117 Brazilian medical schools in our study, we observed that it tends to be lower than that of the 14 schools studied in the study performed in Rio de Janeiro, which was 368.7 hours (SD = 42.7; 95%CI = 276.4 - 461.0), equivalent to 4.6% (SD = 0.6; 95%CI = 3.1 - 6.0) of the course load¹. However, this trend may have occurred because the study carried out in Rio de Janeiro included only 11.8% of Brazilian schools existing in 2006.

Regarding the studies in Europe, the median of semiology workload hours found in our study is well above that found in medical schools in 18 European countries, which was 135.0 hours (P_{25 - 75} = 94.0 - 220.5 )¹² and in the 16 medical schools located in Southeast Europe, which was 105.0 hours (P_{25 - 75} = 22.5 - 135.0)¹³. However, the percentage of semiology workload in relation to the course in the study carried out with 18 European countries was 4.2% (SD = 3.5; 95% CI = 2.6 - 5.8)¹², similar to the present study, while that of the study carried out in Southeast Europe was 2.0% (SD = 1.3; 95%CI = 1.2 - 2.7)¹³, lower than that found in our study.

It was not possible to make comparisons with some studies. The Colombian study provided data that allowed calculating only the workload of semiology in one school, which was 240.0 hours, since in the other four schools, it was provided as credits, without clarifying how many hours these credits were equivalent to⁹. In the Cuban study, the workload of semiology was 495 hours in the academic year of 1985 - 1986 and 686 hours in the academic year of 2010 - 2011; however, it included other contents with which it was integrated, including pathophysiology, laboratory and imaging⁸. The study performed in the United States only analyzed the workload of the physical examination content, whose average was 82.0 hours (SD = 71.0), with a minimum value of 10 hours and a maximum of 360 hours. In addition to the fact that physical examination was just a part of the teaching of semiology, it was integrated with other contents in some of these schools¹¹. Moreover, on the website of the Association of American Medical Colleges (AAMC), among its data up to 2013-2014, it was stated that the teaching of “introduction to physical diagnosis” had an average of 30.8 weeks, without informing its contents or what the weekly workload was¹⁰.

We did not find any differences in the median of the total workload of semiology per region, tuition-free characteristic, type of administration and time of existence of the school in the 117 schools that specified it. This finding may perhaps indicate that, despite having included only 34.9% of the total of 335 Brazilian schools, the values ​​may represent the rest of the schools, but that cannot be stated with certainty.

The resent study showed that the workload of practical semiology was higher than the theoretical one. This finding was similar to that of the study performed in Rio de Janeiro, whose schools had a mean theoretical workload of 105.5 (SD = 15.9; 95%CI = 71.3 - 140.1) hours and an average of 241.7 practical workload hours (SD = 24.5; IC95% = 167.2 - 316.2)¹. However, even though the theoretical workload was similar to that of the present study, the practical workload tends to be higher. Nevertheless, we emphasize that it showed a low representativeness of Brazilian medical schools¹.

The limitations of our study included the collection of data available on the internet, which resulted in the inclusion of only 67.5% of Brazilian medical schools, with a predominance of tuition-free schools. The non-inclusion of many non-tuition-free schools was due to the fact that many private schools were incorporated into the same business groups that did not provide details of the curriculum of their schools on the internet. Some of these schools have even changed their names, making it more difficult to find them. Additionally, only 117 schools (51.8% of the 226 included and 34.9% of all existing schools) provide data on their semiology workload. These limitations pose a risk of bias and the results related to this workload should be interpreted with caution. However, as it was similar per region, type of administration and tuition-free characteristic, we believe that, perhaps, the results may have some validity. When searching for comprehensive national and international studies, which included the workload of semiology, we found only a few that allowed comparisons with our study and we could see the difficulty in obtaining a representative number of schools, especially when their number in the country is very large.

The strength of our study was allowing the identification of the time when semiology was introduced in the course and the contents that can be integrated into its teaching, as well as providing national and international comparison with the workload of 117 Brazilian medical schools.

For future studies, we suggest obtaining the pedagogical projects and learning programs directly from each school, so that, in addition to including more schools, the school viewpoint regarding its curriculum, pedagogical approach, including teaching and evaluation, and the practice scenarios used in teaching semiology can be assessed. Additionally, we suggest incorporating interviews with managers, teachers and students, for a better understanding of their perception of this teaching.

CONCLUSIONS

A total of 226 medical schools of the 335 active ones in December 2020 in Brazil were studied.

More than half integrates semiology into modules or axes and most of them offer semiology only in the 4^th semester. However, some schools offer it in the 1^st semester of the course, and, among them, there are those that offer it from the 1^st to the 8^th semesters of the course.

Of the 117 schools that make the semiology workload information available on the Internet, the total semiology workload is 240.0 hours (P_25-75 = 165.4 - 338.2), with no difference per geographic region, tuition-free characteristic, type of administration and time of existence of the school, and the median of its percentage in the course is 2.9% (P_25-75 = 2.0 - 4.0).