Reasons for change: the “whys”

The course has a long tradition of permanent evaluation: it was the first to join CINAEM and participated in the first national Progress Test, in the 1990s. From 2003 onwards, this tradition was institutionalized in the Integrated System for Evaluation of the Course of Medicine (SIAMed, Sistema Integrado de Avaliação do Curso de Medicina), using as a reference the 2001² DCN and the National Higher Education Evaluation System (SINAES, Sistema Nacional de Avaliação da Educação Superior), proposed at the time by National Institute of Educational Studies and Research Anísio Teixeira (INEP) and Ministry of Education (MEC) - INEP/MEC³.

In 2018, in the ongoing evaluation effort, students from the 1^st to 4^th years performed written evaluations at the end of all modules and were invited to point out the main problems of the course and suggestions for improvement. Questionnaires, meetings and workshops were organized in 2018-2019 to collect the opinions of the entire academic community on the course.

All these data were carefully reviewed by the Structuring Faculty Nucleus (NDE, Núcleo Docente Estruturante). Based on this analysis, the most commonly mentioned problems were grouped into five broad categories:

In addition to the abovementioned issues, other justifications for change were accumulating. The course score in the National Student Performance Examination (ENADE, Exame Nacional de Desempenho dos Estudantes) decreased from 5 in 2010-2013 to 4 in 2016-2019. The student profile changed: from 2010 to 2020, the students’ mean age increased and the average family income and the proportion of students from private high schools decreased, in parallel with the adoption of the universal quota system at UEL from 2011-2012 onwards. The University has suffered a downsizing of the teaching and technical-administrative staff in recent decades, impacting the staff available for pedagogical activities. Finally, new rules and requirements for the course emerged, such as the DCN of 2014⁷ and the extension curriculum^11),(12.

The curriculum reform process: the “how”

Given the abovementioned reasons, the need for change was undeniable. But a great challenge was imposed on the NDE: how to reform a curriculum with more than 20 years of tradition, which served as a model for so many other schools? How to convince teachers to change again? How to enlist the support of students, many of whom had chosen UEL precisely because of the integrated curriculum and PBL?

The answer was the collective construction. Feuerwerker had already stated regarding the previous reform process of the same course, in 1997: “the change [...] starts in the very process of building the proposal for transformation, which must be done through the creation of collective spaces, enabling the participation of the greatest possible number of teachers and students, of the greatest possible number of areas and departments¹³.”

On the one hand, it was not that difficult: many teachers and students were dissatisfied with the situation, and the NDE had many arguments to justify the change. Moreover, the majority of the current faculty was in favor of redesigning the curriculum and adopting new active methodologies.

On the other hand, the intense course evaluation work in 2018-2019 had already been a collective construction. Discussing changes based on these evaluations ended up being the natural continuation of this work. In 2019, the NDE promoted workshops on active methodologies, medical internship and curriculum reform, with broad participation from the academic community, interested in helping to suggest new directions.

But it was necessary to define a place to start. As in the late 1990s, the reform received strong support from teachers of basic sciences¹³. Therefore, the NDE chose to start there. Meetings were held with teachers from the several areas of Biological, Exact and Human Sciences who participated in the course, where the NDE asked them the following question: “What do you think would be the ideal way to approach your content within the Medicine course?” Next, working groups were created, bringing together teacher from related areas (for instance: Cell Biology, Biochemistry and Genetics) to suggest joint proposals. Thus, curricular integration was preserved - but in a more focal manner, between closer areas.

After the reflection on the first two years, mainly adding content from the basic sciences, a similar approach was taken in the clinical areas. The new modules for the 3^rd and 4^th years were also planned aimed at a more focused integration, around specialties/areas of activity that are naturally close (for instance: Pulmonology, Pediatric Pulmonology and Thoracic Surgery), more similarly to the division seen in actual clinical practice. These new transdisciplinary modules are expected to stimulate the teachers’ sense of belonging and, consequently, their motivation (Problem 3).

The proposals of the areas were analyzed by the NDE and then repeatedly discussed with the teachers involved to negotiate adjustments, which were necessary to guarantee a macroscopic design of each year that was consistent among them and with the other years and that respected the workload limits.

At this stage, the contents of the 1^st to 4^th years were carefully mapped and ordered, to solve Problem 2 (disorganization of the sequence of contents). In the end, dozens of meetings were held over three years, with more than 200 teachers from 19 Departments and five Study Centers, until a curriculum design was attained that was accepted by all.

The solving of Problem 5 (reviewing teaching methodologies) was also challenging. When consulting the literature on health education, the NDE and teachers of the 3^rd and 4^th year modules became interested in Case-Based Learning (CBL) as a possible alternative to PBL as the course enters a more clinical phase. Like PBL, CBL also involves discussions in small groups with a tutor-teacher, but it is more clinically focused, is more structured, has clearer objectives, is more motivating for students and teachers (Problem 3) and seems to be more effective for promoting the development of clinical reasoning skills^14),(15. Another advantage of the CBL, in a context of progressive downsizing of personnel, is that it can be carried out in larger groups (15-20 students) than the PBL (8-10 students), requiring a smaller number of teachers¹⁵. Experiments were carried out in some modules, the results of which guided the proposition of a specific CBL method, meeting the needs of the course¹⁶.

Regarding the rest of the course, it was observed that the 1^st year was being especially affected by the paucity of teachers at that time, making difficult to maintain PBL. That was one of the reasons why Team-Based Learning (TBL) was adopted in this year, since this methodology allows carrying out activities with only 1-2 teachers for the entire class¹⁷ (instead of 6 or 10 teachers, as in CBL and PBL, respectively).

TBL, which is more structured than PBL, will also allow 1^st-year students to adapt more gradually to active teaching-learning methodologies, in which the student plays a central role (Problem 1).

Still on adaptation: thanks to the University’s quota policy, at least 40% of the current first-year students at the UEL medical course attended public schools, and there is a clear discrepancy in the educational background of these students when compared to their peers who attended private schools. In the current curriculum until then, these two sets of students were randomly merged into small groups and tasked with discussing problems in PBL from the first month of the course onwards. In addition to the natural difficulty in adapting to the new reality of being a university student, the students often felt the comparison with peers and the frequent feeling of “not being able to keep up” with the activities. It is the “impostor syndrome”, an important factor for the high prevalence of burnout and mood disorders among medical students¹⁸.

In the new curriculum, the 1^st-year students will have more activities (lectures and basic science practices) to level students in these fundamental contents, as well as the inclusion of mentoring as a curricular activity, providing socio-emotional support and educational guidance to freshmen.

Finally, regarding Problem 4 (need to include new contents): concepts for the practice of scientific Medicine will be addressed in a longitudinal module (from the 1^st to 4^th years) of Mandatory Scientific Work, in which students will learn scientific methodology and carry out a scientific project before starting the internship. LIBRAS and English became curricular disciplines, and other contents required by the DCN that were not fully contemplated before (ethnic-racial relations, history of Afro-Brazilian/indigenous culture and others) now comprise a module of Medicine, Health and Society. Family and Community Medicine gained an annual longitudinal module in the 3^rd year, including topics on health management and education. Free spaces were reserved on Friday afternoons throughout the course to organize participation in extension activities (extension curriculum)¹¹.

The new curricular matrix of the course is published on the UEL website and can be consulted freely at: http://www.uel.br/prograd/documentos/resolucoes/2022/resolucao_05_22.pdf

Chart 1 correlates the problems identified in the course evaluations and the curricular adjustments proposed for their respective solution.