Surgery course load in Brazilian medical schools

Introduction: Surgery is an important curricular component of undergraduate medical courses. This study was conducted because the surgery course load in Brazilian medical has not been systematically explored at the national level. Objective: To analyze the surgery course load in Brazilian medical schools. Method: A cross-sectional, descriptive study was carried out with Brazilian medical schools acknowledged by the Ministry of Education, which had begun their activities prior to December 31, 2017 and, as of September 2018, had their curriculum matrix and/or political-pedagogical project with the surgery course load available on the internet. The variables studied were total medical curriculum course load and surgery course load before and during clerkship, as well as the schools’ geographic region and fee status. Data analysis was performed using descriptive statistic Student t-test, analysis of variance, and Mann–Whitney U and Kruskal–Wallis tests, with the null hypothesis rejected for p < .05. Results: The study included 205 of the country’s 323 existing medical schools, of which 175 had available information on the surgery course load during the clerkship, 157 before the clerkship, and 129 had information on course load before and after the clerkship. The median total surgery course load in hours was 815.0 (P25 75 = 677.5 – 992.0; minimum = 340.0 h; maximum =1,665.0), while the mean surgery course load before clerkship in hours was 268.7 (SD = 140.3; minimum = 32.0; maximum = 780.0), with no difference between geographic regions or fee status. During the clerkship, the median course load was 540.0 hours (P25 75 = 400.0 – 712.0; minimum = 170.0 h; maximum = 1,410.0), with no difference between geographic regions, but with higher values in medical schools with no tuition fees. Regarding the total curriculum course load, the mean percentage of the surgery course load before clerkship was 3.2% (SD = 1.7), the median percentage during the clerkship was 6.4% (P25 75 = 5.0 – 8.2), the median percentage of the total surgery course load was 6.4% (P25 75 = 5.0 – 8.2%, and the median percentage of surgery course load (both periods) was 9.7% (P25 75 = 8.3 – 11.8%). Conclusions: Despite the considerable variation in the surgery course load limits, the median of total surgery and the mean of surgery course load before clerkship were similar across geographic regions and fee statuses. The median surgery course load during clerkship was also similar across regions but higher in tuition-free medical schools. The values found in this study can help schools’ administrators to assess and plan the surgery course load in their institutions.


INTRODUCTION
Surgery is one of the major areas of medicine and is a component of the undergraduate medical curricula around the world 1 . In the past, a newly trained doctor was expected to be able to perform surgeries. However, the current expectation is that time spent on learning the details of specialized surgical techniques will be a relatively minor part of the curriculum, with advanced training taking place during a residency in surgery 1-4 .
Several factors have contributed to this change in medical education and other areas of knowledge. In the 1970s, Bohoslavsky pointed out inadequate features in the existing model of university education in most parts of the world. There was a discrepancy between educational organization and the productive structure that generated professionals whose training was not aligned with the country's needs. There was also the segmentation of knowledge into fragments due to an ideological inability to see a more integrated reality in its complexity, which resulted in the formation of specialists in fragments of reality. As a consequence, there was a significant schism between knowing and doing, cognition and action, and university and reality 5 .
In medical education, this fragmentation was exacerbated by the curricular reform proposed by Flexner in 1910 6 , which was adopted by a majority of medical schools. In parallel, the acceleration in knowledge production has resulted in a progressive increase in medical curricula course load (CL) and students' overburdening with theoretical concepts 7,8 .
In this context, global movements have been organized to align medical training to students' learning needs and the population's individual and collective healthcare needs. Building strength through the 1970s and 1980s 9 , these processes led to a series of initiatives, with projects, recommendations, and guidelines to medical courses beginning in the 1990s, such as Tomorrow's Doctors in the UK 10,11 , CanMEDS in Canada 12 , Outcome-Based Education 14 and the Bologna Process 15 in Europe, and Core Entrustable Professional Activities for Entering Residency in the USA 16 . The recommendations comprised the inclusion in the mandatory curriculum only of content considered essential, content integration, and pedagogical approaches that bridged theory and practice and provided meaningful learning, focusing on the competencies required for the practice of future medical professionals 17,18 .
In Brazil, a national movement to change medical education resulted in the formation of a commission consisting of various institutions involved in medical education, called the National Interinstitutional Commission for the Evaluation of Medical Education (CINAEM), to evaluate medical schools at the national level 19 . The findings of this evaluation supported the collective dialog on necessary changes in medical education and resulted in the creation of the National Curricular The surgery CL and content have been the subject of international debates and studies. In the United Kingdom, a consensus among surgeons on the surgery content of undergraduate medical curricula stated that the surgery CL in their medical schools' curricula was insufficient, and more time was needed to ensure that students who received training would be competent in basic surgical procedures 22,23 . In the US, an additional concern regarding the surgery CL was the reduction in the number of doctors choosing careers in surgery following a 30% reduction in the mandatory surgery CL in medical school clerkships in the 1990s 24,25 .
In Brazil, the NCG do not set out CL limits before the clerkship for surgery or any other area 21 28 .
A study including 153 US medical schools conducted by the Association of American Medical Colleges (AAMC) found that the mean surgery CL was 270.0 hours before the clerkship and 720.0 hours during the clerkship, for a mean total surgery CL of 990.0 hours 29 .
In Brazil, the undergraduate medical course at the Federal University of Santa Catarina (UFSC) changed its curriculum in 2003 to align it with the NCG 21,30 . The curriculum is integrated and divided into modules. Adult surgery is taught throughout the Adult Health Module and pediatric surgery in the Child Health Module. The medical course curriculum has 7,670.0 hours, with a total surgery CL of 968.0 hours, comprising 355.0 hours before the clerkship, which includes 90 hours of surgical techniques and experimental surgery (STES), and 613.0 hours during the clerkship.
The literature gap on the surgery CL in Brazilian medical schools, important part of undergraduate medical curricula, has led us to the following research question: • "How has the surgery CL been distributed in Brazilian medical schools?" To answer this question, this study was conducted with the objective of analyzing the surgery CL in Brazilian medical schools.

Design and Ethical Principles
This study was cross-sectional and descriptive. The research project was not submitted to the ethics committee because the data used are in the public domain. There are no conflicts of interest.

Population and Sample
The universe comprised all 323 existing Brazilian medical schools until September 2018, acknowledged by the Ministry of Education (MEC) and listed as of September 2018 on the e-MEC website http://emec.mec.gov.br 31 . The inclusion criteria were having started academic activities before December 31, 2017 according to the e-MEC records, having a curriculum matrix or political-pedagogical project (PPP) available on the internet, and having information on the surgery CL.

Data Collection
The data were collected between March and September 2018, with the information available on the official website of each institution listed on the e-MEC website 31. In cases where we did not find the curriculum matrix or PPP on the official school website, we searched for them online with the terms "university name" and "medicine" and ("curricular matrix" or "political-pedagogical project" or "course pedagogical project").
The variables collected were curriculum organization, the school's geographic region, administrative affiliation, curriculum organization, total mandatory CL, and mandatory surgery CL before and during the clerkship. We included the surgery CL, the General Surgery discipline, as well as the disciplines listed in the National Commission of Medical Residency (CNRM) matrix of the general surgery medical residency programs and the basic surgery prerequisite program 32 . These subjects comprised digestive tract surgery, plastic surgery, head and neck surgery, oncological surgery, vascular surgery, thoracic surgery, pediatric surgery, cardiac surgery, colorectal surgery, and urology. In addition, we included subjects that were part of STES and outpatient surgery, which were clearly surgery-related subjects.
The CLs were standardized as "clock/hours", corresponding to an actual 60-minute hour. When the school specified that the class duration was different from the clock/hour, that time was calculated for the corresponding time in an actual hour.
Before the conversion, some schools had one hour of class corresponding to 60, 50, or 45 actual minutes.

Data Analysis
The data were entered into a database and analyzed with SPSS Statistics 26.0 Premium software.
Data analysis was performed using descriptive statistics,    Table 2 shows the surgery CLs and the total curriculum CL. Table 3 shows the percentages of surgery CLs concerning the total curriculum CL. Table 4 shows surgery CLs at the 129 medical schools with these data available on the internet, divided by      geographical region and fee structure. There was no statistical difference in the CL between geographic regions. There was no difference between schools with and without tuition in total or before clerkship surgery CL. The only significant difference was a higher median surgery CL during the clerkship in the tuitionfree schools.

DISCUSSION
In this study, we found that the minimum and maximum values of surgery CL before and during clerkship vary across the Brazilian schools studied. However, the mean surgery CL before clerkship and the median total surgery CL were similar across geographical regions and schools' fee statuses. The only significant difference we found was the higher median surgery CL during the clerkship in tuition-free schools. In the study with 16 medical schools in southeast Europe, five institutions had a mean surgery CL before clerkship lower than the 95% CI of our study, while nine were higher and two within the confidence interval: one of them in Mostar (Bosnia and Herzegovina), and the other in Pristina (Kosovo) 28 .
In the European study with 26 schools, seven had a mean surgery CL before clerkship that was lower than the 95% CI of our study, while 13 were higher and six were within our confidence interval. The latter group was comprised of Split (Croatia), Brno (Czechia), Vienna (Austria), and Rome, Florence, and Naples (Italy) 4 .
The mean surgery CL before clerkship in a survey with 153 US medical schools was within the 95% CI of our study, while the median surgery CL during clerkship was above the P 25 -75 ranges in our study and the median total surgery CL was within the P 25 -75 ranges in our study 29 .
Therefore, we notice that the surgery CLs also vary considerably in European countries and that the P 25 -75 ranges of Brazilian schools' total surgery CL are consistent with values found in Cuban and American schools. The mean surgery CL before clerkship and the median surgery CL during clerkship in our study are within the levels found in Cuban schools and lower than American ones.
The limitations of our study included the impossibility of finding the surgery CL in schools with integrated curricula that did not specify the surgery CL, as well as the impossibility of finding complete documentation in the CLs of all surgery disciplines. Despite the aim of achieving an integrated curriculum in several knowledge areas, the CL dedicated to specific content should ideally be specified in the interest of providing objective parameters for comparison. Another limitation of our study was that we collected data available on the internet, although these data should ideally be collected directly from the medical schools to better understand the theoretical and practical CL distribution and the content covered. Our study on CL of Brazilian medical schools identifies the value/weight that the schools assessed attribute to surgery in their curricula and provides medical school administrators with information on the surgery CL distribution. However, these findings should be considered as the "tip of the iceberg" and are not sufficient to analyze the quality of these medical courses and the factors that influence the decisions regarding surgery CL at each school 34,35 .

CONCLUSIONS
Regarding the objectives of our study, although we found considerable variation in the range of surgery CL, there were no significant differences in the mean surgery CL before clerkship, nor in the median total surgery CL across schools' geographic regions or fee statuses, or the median surgery CL during clerkship across geographic regions. However, the median surgery CL was significantly higher in tuition-free schools.
Our results can help those responsible for medical education to understand the surgery CL distribution in Brazilian medical schools and help medical school administrators to assess and plan the surgery CL accordingly in their institutions.
We suggest further studies including more information, from the political-pedagogical course conception to the surgery instruction scenarios, as well as assessment methods for teaching and students, with data collection including both the schools' existing documents and interviews or focus groups with individuals involved in the teaching and learning process. design, data collection and analysis, and drafting of the manuscript, which was the term paper that he presented as the undergraduate medical course requirement at UFSC. Sofia Romay Oliveira participated in the project design, data collection and analysis, and drafting and review of the manuscript. Suely Grosseman participated as Mr. Martini's advisor and in the project creation, data collection and analysis, drafting, and review of the manuscript.