Active Teaching-learning Methodologies : Medical Students ’ views of Problem-based Learning

– Medical Education. ABSTRACT The prevailing undergraduate medical training process still favors disconnection and professional distancing from social needs. The Brazilian Ministries of Education and Health, through the National Curriculum Guidelines, the Incentives Program for Changes in the Medical Curriculum (PROMED), and the National Program for Reorientation of Professional Training in Health (PRO-SAÚDE), promoted the stimulus for an effective connection between medical institutions and the Unified National Health System (SUS). In accordance to the new paradigm for medical training, the Centro Universitário Serra dos Órgãos (UNIFESO) established a teaching plan in 2005 using active methodologies, specifically problem-based learning (PBL). Research was conducted through semi-structured interviews with third-year undergraduate students at the UNIFESO Medical School. The results were categorized as proposed by Bardin’s thematic analysis, with the purpose of verifying the students’ impressions of the new curriculum. Active methodologies proved to be well-accepted by students, who defined them as exciting and inclusive of theory and practice in medical education.


RESUMO
A formação oferecida em boa parte das escolas médicas perpetua, ainda hoje, o distanciamento do pro- Training in Health (Pro-Saúde) [1][2][3] .Based on these guidelines and programs, in the second semester of 2005, the Centro Universitário Serra dos Órgãos (UNIFESO) implemented an in-depth change in its medical school undergraduate curriculum 4. 5 .The change allowed a transition from the traditional biomedical training model to pedagogical processes contemplating the intricacy and interdependence of biological, social, psychological and environmental dimensions, among others 6.7 , thus stimulating the restructuring of teaching-learning practices from the perspective of the healthcare work setting 8 .The background for this change dates to the debate forums promoted by the Brazilian Association of Medical Education (ABEM) and the CINAEM project, in which UNIFESO took part since the first phase 9 .UNIFESO was also approved in the PROMED preliminary selection, which led to the drafting of the "EDUCACTION" project, thereby launching a new educational model, integrating related fields of knowledge, with active teaching-learning methodologies (ATLM), specifically problem-based learning (PBL), as the main focus of the new curriculum.This process enabled interaction among various players, with a community-centered teaching focus and favoring students' autonomy for building knowledge and intervening in reality 4. [10][11][12][13][14][15][16][17] .
The active teaching-learning methodologies were chosen to situate students at the center of the pedagogical process, as the protagonists of their own training 11 .Active methodologies in medical education were developed in Canada through the work of professors at the McMaster University School of Medicine, who created problem-based learning, officially instituted in 1969 after preliminary studies on curriculum change dating to 1966.
Since then, PBL has been adopted by the Universities of Maastricht in the Netherlands, Harvard in the United States, and Sherbrook in Canada, among a total of 60 other schools and universities.8][19][20] Active methodologies (notably PBL) [21][22][23] have been used both for curricular improvement and to implement educational processes within specific areas of knowledge.Within this framework, in October 2005 the Brazilian Society of Family and Community Medicine (SBMFC) held the first Exposition on Family and Community Medicine at UNIFESO, featuring experiences from the South and Southeast of Brazil and highlighting the potential of active methodologies for promoting comprehensive health care. 21ased on the above, a study on the use of active methodologies, specifically PBL, was conducted with undergraduate students at the UNIFESO School of Medicine.The objectives were: (1) to identify and analyze the reasons why students had chosen UNIFESO and whether the choice had been influenced by the adoption of the new teaching methodology and (2) to identify and analyze students' perceptions towards active methodologies/PBL.The current article presents the results of this research.

METHODS
Research setting: UNIFESO, a teaching institution located in the municipality of Teresópolis, Rio de Janeiro State, Brazil, 90 kilometers from the State capital (Rio de Janeiro city).
Study population: students regularly enrolled in the third year of the UNIFESO School of Medicine.The justification for the exclusive inclusion of this group was its reported experience with PBL (the students had already completed two years under this teaching-learning strategy).
Data collection tools: data were collected using individual semi-structured interviews (with one closed and two open questions) applied by the researcher with the voluntary cooperation of a sixth-semester medical student, previously trained in the interview technique.The questions were: (1) Why did you choose UNIFESO to study medicine?
(2) When you made your choice, were you aware that UNIFESO had adopted a new teaching method?Yes () No ()  In case your answer to question 2 was "yes": "Did this influence your choice?"Yes () No ().Why?
(3) UNIFESO has adopted active teaching-learning methodologies in the medical curriculum.How would you describe your experience with active teaching-learning methodologies at the UNIFESO School of Medicine?
The student's gender and age were also recorded on the questionnaire..25 Analytical strategy: The content analysis technique was thematic analysis (Minayo, 1999).Three operational stages of thematic analysis were used: .25 15

José Roberto Bittencourt Costa et al.
Students' Views of PBL 5][26][27][28][29] The sample was defined according to "saturation of equal or similar answers" (from that point on, data collection was over), recognizing that a research sample must meet validity standards such as representativeness, exhaustiveness, and pertinence.Importantly, although this was a qualitative study, quantitative strategies were also used, including relative frequencies, in order to compare the answers.
According to Bardin 25 (2004), categorization is an operation involving classification of elements that constitute a set, by differentiation and then by regrouping, according to gender (analogy), using previously defined criteria.Selltiz et al. indicate three classification principles to establish categorical sets: 1) that they be established from a single classificatory principle; 2) based on the notion of exhaustiveness, that they allow the inclusion of any answer in one of the sets; and 3) that the categorical sets be mutually exclusive, such that one answer cannot be included in two or more categories.][26][27][28][29] Equally important is that the general analysis took into account the absolute frequency of the above-mentioned expressions to create each category, as well as the combination of the number of these expressions by the student, thus analyzing the number of interviewees and their categories in relative frequencies, which were then divided into categories related to positive impressions and categories related to negative impressions.This time the frequency of categories according to their expressions was determined in absolute frequencies (AF) and relative frequencies (percentages), as shown in the tables below, which were created for purposes of comparative analysis.
The final analysis considered the category with the largest number of expressions or the highest relative frequency, as well as the sum of expressions from all categories, with their positive or negative connotations, besides the number of interviewees and their categories in order to construct the interviewee's profile.
The research project leading to the article was approved by the Institutional Review Board of UNIFESO, case number 166/08, in compliance with Ruling 196/96 of the Brazilian National Health Council and related complementary legislation. 30

RESULTS AND DISCUSSION
There were a total of 29 interviewees, 15 male and 14 female.All students regularly enrolled in the fifth semester (72) were potential candidates, such that the sample represented 40.3% of the total universe.Age varied from 20 to 27 years and was predominantly in the 20-23-year range..25

Choice of Medical School
The first open question, on the choice of the particular medical school, aimed to determine whether the student had chosen to study at UNIFESO based on his or her awareness of the adoption of active methodologies by the UNIFESO School of Medicine.Twenty-four of the interviewees had opted for the institution based on the category "references" (i.e., 82.8% expressed the idea of reference in their discourse), while 44.8% (n=13) expressed the idea of privileged geographic situation (location category).Table 1 shows the analysis and creation of categories from the ideas/expressions in the students' discourse.

The teaching method's influence on students' choice of the medical school
The second question (in closed format) deals with the role of the pedagogical proposal in the students' choice of the specific medical school, verifying whether the student had prior knowledge of the institution's adoption of active methodologies and whether such awareness had influenced their choice.The tables below concern students who had been aware of the implementation of a new teaching model by UNIFESO (Table 2) and the potential influence on their choice (Table 3).Also shown are tables of categories created from students' ideas and/or expressions related to UNIFESO's adoption of active methodologies and the role in their decision, that is, whether the issue was (Table 4) or was not (Table 5) taken into consideration.The data show that the choice of UNIFESO was influenced by the school's adoption of active methodologies, for four of ten students that were aware of the implementation of the new teaching model.The justification was "curiosity" or "good news" about the method, or a "positive impression" of it.Among the students who were aware that the institution had implemented the change in its curriculum but were not influenced in their choice, other references about the institution were sufficient to "compensate" for any potential feelings of insecurity towards the method.• "I thought it was utopia, distant from practice."• "At first I preferred the old way." • "I had a lot of difficulty at first." • "I felt somewhat uneasy and insecure."• "Scared initially, didn't feel at comfortable with the method."

Need for improvement
• "There's a lot to be improved.Two negative categories were created, "initial uneasiness" and "need for improvement", expressed in Table 7, which shows the relationship between negative categories and the ideas/expressions in the interviews.Most of the students had a positive impression of the new curriculum, while emphasizing the need to improve the teaching method.

FINAL REMARKS
The need to improve medical education in Brazil has led various Schools of Medicine in the country to revise their curricula so as to ensure that medical school graduates will display the characteristics recommended by the National Curriculum Guidelines, Article 3: Undergraduate Medical Education aims to provide graduating physicians with generalist, humanist, critical, and reflexive training, preparing them to act according to ethical principles in the health-disease process at the various levels of care, through the prevention of disease, promotion and recovery of health, and patients' rehabilitation, from the perspective of comprehensive healthcare, with social responsibility and civic commitment, thereby promoting comprehensive human health.(Brasil 1 , 2001, p.1) Proposals for changes in the medical curriculum change include the adoption of active teaching-learning methodologies 31 ..33The current study was designed to investigate the impact of this change at UNIFESO.Data analysis suggests that most students chose the institution based on other references, and did not take the curriculum change into consideration.However, they showed positive impressions towards the active teaching-learning methodologies, which they referred to as stimulating, although needing improvement, which could be explained by the effective organization of the tutorial module in the UNIFESO undergraduate medical course, based on problem-solving related to biological, psychological, social, cultural, and environmental aspects of the health-disease process.Furthermore, the new curriculum facilitates the replacement of traditional medical teaching (teacher-centered and based on fragmentation of subjects) with a student-oriented model, where students are the protagonists in the construction of their own knowledge, conceived as non-dissociation between theory and practice, from an inter-(and eventually intra-) disciplinary perspective.This may well be the first step towards training physicians with a broader understanding of bio-psycho-social-environmental determinants, an essential element for the provision of appropriate healthcare for all.
Medical education inBrazil has undergone profound changes, promoted mainly by the Ministries of Education and Health and based primarily on the National Curriculum Guidelines for Undergraduate Medical Education (DCN), the Incentives Program for Changes in the Medical Curriculum (PROMED), and the National Program for Reorientation of Professional das necessidades da sociedade.Estratégias têm sido pensadas em resposta a tal contexto, destacando-se a publicação das Diretrizes Curriculares Nacionais do Curso de Graduação em Medicina e a implementação do Programa de Incentivos a Mudanças Curriculares em Medicina (PROMED) e do Programa Nacional de Reorientação da Formação Profissional em Saúde (PRÓ-SAÚDE).Inscrito neste novo movimento, o Centro Universitário Serra dos Órgãos (UNIFESO) realizou uma profunda transformação curricular, em 2005, baseada no uso das metodologias ativas de ensino-aprendizagem (MAEA), especialmente a Aprendizagem Baseada em Problemas.Para aferir a visão dos estudantes

TABLE 1 .
Categories created from students' responses to Question number 1: "Why did you choose UNIFESO to study medicine?"Teresópolis, Rio de Janeiro State, Brazil, 2008.

TABLE 2 .
Interviewees' prior knowledge of the adoption of a new teaching model by the UNIFESO School of Medicine, Teresópolis, Rio de Janeiro State, Brazil, 2008.
Source: primary research data

TABLE 3 .
Interviewees' prior knowledge of the adoption of a new teaching model by the UNIFESO School of Medicine and its influence on their choice of the school.Teresópolis, 2008.
* Considered only the 10 interviewees from Table2who knew the institution had adopted a new teaching model.Source: primary research data

TABLE 4 .
Category created from ideas and/or expressions on the importance of the adoption of active methodologies by UNIFESO in students' choice of the school, when this issue was taken into consideration.Teresópolis, 2008.

TABLE 5 .
Category created from ideas and/or expressions on the importance of the adoption of active methodologies by UNIFESO in students' choice of the school, when this issue was not taken into consideration.Teresópolis, 2008.
6Active teaching-learning methodologiesThe third question, an open one, deals with students' impressions concerning the role of active methodologies in undergraduate medical training at UNIFESO.Two major groups of categories were created: (1) those with a positive classification and (2) those with a negative classification.Table6shows the positive categories created from ideas/expressions mentioned in the interviews.

TABLE 6 .
Positive categories created from ideas/expressions by the students in response to Question 3. Teresópolis, 2008.

Table 8
shows the relationship between positive and negative impressions towards the active methodologies.Most part of the students (62.1%; n=18) perceived the change positively.
Source: primary research data

Table 9
summarizes the undergraduate medical students' views towards active methodologies in the new UNIFESO curriculum, based on an analysis of the categories and prevailing expressions.
* Questions analyzed by percentage of interviewees and categories.** Question analyzed by percentage of interviewees, categories, and relative frequency of positive and negative expressions.Terms in italics represent categories.Source: primary research data.