Challenges for learning neuroradiology in undergraduate medical school: analysis from the students’ point of view

Introduction: The teaching of neuroradiology in undergraduate medical school must be seen as an integration tool for the interdisciplinary study of radiology, anatomy and neurology. In practice, there is a limitation on the part of students in acquiring such knowledge, either due to “neurophobia”, or due to the lack of previous anatomical-radiological knowledge and also due to the lack of integrated didactic materials aimed at undergraduate school. However, there are few studies reporting the difficulties encountered by students in learning neuroradiology. Objective: To assess the perception of medical students about learning difficulties in neuroradiology. Method: Quantitative study, carried out with medical students enrolled in the second and seventh semesters of a university in Fortaleza. Data were obtained through a structured questionnaire with 12 yes or no answer questions. The questions addressed the possible difficulties encountered in acquiring neuroradiological knowledge, among them: the lack of targeted didactic material, the lack of integration with neurology, the need for basic radiological and anatomical knowledge, the large volume of content to study, and the limitations of active and traditional methodologies. Results: 181 questionnaires were analyzed. Most students report as difficulties: the need for basic knowledge of radiology (80.1%); neuroanatomy (77.5%); and to correlate radiology and neuroanatomy (70.9%). When comparing the 2nd semester and 7th semester groups, there was a greater tendency to point out the lack of practical knowledge of neurology by 2nd-semester students as a factor of greater difficulty in learning neuroradiology (82.6% versus 67.4 %, with p <0.0018). When asked about the usefulness of creating an e-book aimed at undergraduate students for learning neuroradiology, 85.6% of the students answered affirmatively; in the case of a mobile application, 92.3% agreed. As for the correlation between neuroradiology and medical practice, 98.3% answered that it is useful and necessary knowledge. Conclusion: In the students’ opinion, previous knowledge of neuroanatomy and clinical neurology is important for learning neuroradiology. The development of material such as an e-book or mobile application focused on integrating the teaching of these disciplines is considered a good alternative to facilitate the understanding of neuroradiology.


INTRODUCTION
The teaching of neuroradiology to undergraduate medical students can be used as a tool for interdisciplinary and transdisciplinary integration within the curricular matrix of universities, introducing the development of care skills since the beginning of its use in the medical course 1,2 . The early inclusion of radiology in the first semesters of the medical course has a positive effect, since this area allows the clarification of pathophysiological processes and morphofunctional alterations even during the basic semesters of the medical course [1][2][3][4][5][6] .
A major limitation pointed out by students for the fixation of knowledge in basic areas is precisely the lack of integration with medical practice 2 . The lack of knowledge about the possible practical applications of what is being studied generates disinterest [7][8][9] . Radiology, in this context, can assist in introducing clinical concepts in an introductory manner within the course, establishing a link with practical questions of everyday medical practice 10 .
It is increasingly common in medical courses to change the curricular matrix aiming to adopt active methodologies as the mainstays of teaching, allowing students to freely search for the necessary contents, empowering them through their own knowledge 11,12 . For the method to be successful, however, it is necessary for the student to be comfortable with and trust the numerous bibliographic sources available. In addition to scientific articles and books, it is currently possible to find e-books, websites, mobile applications and even social networks. However, regarding the latter, less traditional sources, although they are often even more didactic, they also tend to raise doubts about their reliability, somewhat limiting their use in a broader way 2 .
In teaching practice, neuroradiology is considered a complex subject by students. Some factors may be implicated, such as neuroscience-related neurophobia 8,9,13 ; the limitations in understanding the most basic aspects of radiology itself, such as Physics Applied to Medicine and the correct use of radiological terminologies 2 ; in addition to the concept of three-dimensionality of the anatomical aspects. There is also a lack of material aimed at undergraduate students, limiting learning in the absence of a professional radiologist as a mentor, something that goes against the foundations of learning through active methodologies 2 .
Although much has been proposed, there are few national studies aimed at this evaluation, limiting the feasibility of solutions to possible problems. Therefore, it is essential to evaluate the students' opinions about their difficulties with the learning of neuroradiology, aiming to support the acquisition of knowledge in this field 14,15 .
The aim of this study was to analyze the perception of medical students about the challenges in the teaching of could contribute to the difficulty in teaching neuroradiology to undergraduate students. The first two sought to investigate whether the need for basic knowledge about radiology and neuroanatomy could represent a difficulty in the study of neuroradiology. The next two questions were about the importance of integrating radiology and neuroanatomy, as well as with the practice of neurology and regarding the study of the discipline. The fifth question evaluated whether the volume of content for the short time available could be seen as a difficulty for the study of neuroradiology.
Most of the students mentioned as a difficulty in understanding neuroradiology the need to have previous basic knowledge of radiology (80.1%), knowing neuroanatomy (77.5%) and correlating radiology and neuroanatomy (70.9%).
When comparing the 2 nd semester and the 7 th semester groups, there was a greater tendency among the students from the 2 nd semester to point out the lack of practical knowledge of neurology as a factor of greater difficulty in learning neuroradiology (82.6% versus 67.4 %, with p <0.0018). These questions aimed to assess whether the students themselves had the ability to identify the role of interdisciplinary integration in their education. Moreover, most students (89.9%) pointed out the large volume of content for the short time available within the curricular matrix as a factor of neuroradiology learning difficulty.
Next, four questions were asked to assess which teaching methodologies would be preferable, in the students' opinion, for learning neuroradiology: PBL (problem-based learning), TBL (team-based learning), expository class (passive methodology) and display of neuroradiology exams in a report workstation.
When asked whether PBL and TBL were considered good methodologies for learning neuroradiology, 2 nd semester students were more likely to respond positively, when compared to 7 th semester students (p <0.004), with 51.7% of 7 th semester students answering that they did not consider these methods adequate for learning neuroradiology. A total of 78.2% of the students answered that the expository class would be a good methodology for learning the discipline; however there was no significant difference between the semesters. In addition, most students reported that the use of workstations with real exams (91.1%) would be useful for learning.
The next two questions aimed to understand whether an e-book and a mobile application aimed at undergraduate students could be useful in learning neuroradiology. When asked about the creation of an e-book, 85.6% of students answered affirmatively, agreeing that it could help in the study of the discipline. In the case of an application, 92.3% agreed with an expected beneficial effect.
Finally, the last item sought to assess in a more incisive way whether the more explicit correlation with medical practice could be useful in learning neuroradiology. A total of 98.3% of the students answered that this correlation is useful and necessary knowledge.

DISCUSSION
The link between difficulty in understanding neuroradiology and the need to have previous basic knowledge of radiology, neuroanatomy and to correlate radiology and neuroanatomy corroborate the need for integration between these contents. These perceptions strengthen the introduction of radiology in the curricular matrix since the beginning of the medical course, in an integrated way with anatomy 16,10,17-23 , as well as its maintenance in the clinical cycles, together with neurology 15,19,[24][25][26] .
Another critical point of these data is the lack of knowledge of the radiological bases, something that should be viewed with concern. In practice, it is observed that very often, the medical school curriculum does not have specific modules for this approach, creating an important knowledge deficit for the students, which may be resolved at the internship, or only after graduation, in medical practice, limiting the learning of numerous subjects during undergraduate school due to the lack of knowledge about radiology terminology and physical principles.
Moreover, neuroradiology can be seen as a mainstay of the active methodology teaching for learning neuroanatomy.
In addition to the technical difficulties in obtaining corpses 27 and the costs of an anatomy table with three-dimensional resources, it is possible to identify anatomy, physiology and pathology in vivo in magnetic resonance and computed tomography exams 19,28 . A practice that has been carried out in some universities consists in the use of previously selected anonymized clinical case work lists, where all students can see the sequential images in "workstations" appropriate for reports. Moreover, the availability of online anatomy atlases brings the students closer to the practice, without the need to be inside the anatomy laboratory. It is evident that the visualization of the images allows the practical application of multidisciplinary theoretical concepts 29 , being a true treatment for "neurophobia" 8,9,13,19 . because there is no connection with practical applications 8,9,13 .
One point that deserves to be highlighted is the detailed choice of the fundamental neuroradiology and neurology content for undergraduate school, something that deserves to be discussed inside and outside the universities, since the introduction of these subjects as early as in the basic cycle must be stimulated for greater fixation of this content. 8,9 Sporadic meetings on curriculum analysis, including coordinators, teachers and students from different years in undergraduate school, could bring a meaningful discussion on how to proceed in the construction of contextualized content. Neuroradiology can be seen as a teaching mainstay of the active methodology for learning neuroanatomy, both due to the technical difficulties for the acquisition of cadavers by the universities, but also because of the costs of a digital anatomy table with three-dimensional resources 16,22,35,36 . It is possible to identify anatomy, physiology and pathology in vivo using magnetic resonance imaging and CT scans, even allowing pre-surgical planning 19,28 , leading the student to integrate theoretical concepts 29 into medical practice 8,9,13,19 .
It is necessary to introduce some neurological and neuroscience clinical aspects during the teaching of neuroradiology, so that the basic cycle students can understand the importance of what is being presented to them. Another equally fundamental point is the correlation of anatomical aspects during the teaching of neurology. These two strategies are true mainstays for the treatment and prevention of "neurophobia" 8,9,21,32,33,36 .
In the students' opinion, previous knowledge of neuroanatomy and clinical neurology is important for learning neuroradiology, showing that multidisciplinary integration is perceived as a fundamental tool, both for the fixation of content, as well as for the arising of interest in less attractive subjects.
The creation of materials directed to undergraduate courses, such as an e-book or a mobile application focused on integrating the teaching of neurosciences is considered a good alternative to facilitate the understanding of neuroradiology, something that can reduce students' resistance to the topic and, consequently reducing neurophobia. This result allows the assumption that, the more the real radiologist's daily life is brought to the classroom, using lists of complete exams, visualization of images in "workstations", the more interesting the contents of neuroradiology and related sciences will become.
This study was carried out in only one institution, which can limit generalizations.