Adherence of the Medical Course PPCs to the parameters of the Brazilian medical education policy

Introduction: Recent studies have been dedicated to analyzing the PPCs of the medical course and their degree of alignment with what is determined by the Brazilian legislation for the opening and operation of the course in the country. However, there are no nationwide studies that have investigated whether the pedagogical projects for the medical courses are in compliance with current Brazilian legislation. Objective: In this study, we analyzed the adherence of the Pedagogical Course Projects (PPCs) of medical schools in Brazil based on the National Curriculum Guidelines (DCNs, Diretrizes Curriculares Nacionais) of medical education and the “Mais Médicos” Program (PMM, Programa Mais Médicos) for Brazil. Method: To achieve this objective, we collected 157 PPCs from medical courses in Brazil and categorized them in a Likert Scale of adherence, ranging from non-adherent (1) to strongly adherent (5), based on three dimensions of analysis: guiding aspects of training, curricular aspects, teaching-service aspects. Subsequently, using the Principal Component Analysis, we created the PPC Adherence Synthetic Index. After the database was created, descriptive statistics and relational graphs were applied to describe the situation in Brazil. Results: The results show that: I) the Midwest region is the one with the best performance in the three analyzed dimensions; II) public institutions (39% of the total) have greater adherence of PPCs to the analyzed normative parameters; and III) the teaching-service dimension shows greater variation between the types of institution administration, with less adherence by private institutions. Conclusions: Therefore, ultimately, this study raises an alert regarding the adequacy of medical courses in private institutions to the normative and legal parameters required for medical training in Brazil. In addition, it contributes to the literature by presenting an evaluation model for pedagogical course projects through the Synthetic Index of Adherence of PPCs as a suggestion for future studies.


INTRODUCTION
Although it contributes to provide doctors for Primary Care, initiatives such as PROVAB in 2011 were not enough to meet the population's growing demand. Additionally, due to the fact that the demand was not adequately met, the More Doctors Program (PMM) in Brazil was created, regulated by Law N. 12,871/2013 6 . The PMM was structured to act on three axes: allocation of doctors in regions where there is a shortage or lack of these professionals (emergency provision axis); investments for the construction, renovation and expansion of Basic Health Units (infrastructure axis); and creation of new undergraduate and medical residency vacancies for the training and qualification of these professionals (education axis) 7 . Regarding the latter, the PMM determined significant changes towards the reorientation of medical training, which resulted in the creation and publication of new DCNs for the medical course.

MATERIALS AND METHODS
To achieve the objective of this research, an analyticaldescriptive study was carried out based on collected secondary material. As proposed in the studies by Bardin  c) Data processing and interpretation -at this stage, the material is analyzed in depth, which increases knowledge about the study object and the necessary judgments are applied in order to describe the processed data. The careful analysis of the PPCs was based on the assumption of the judgement of the items through a Likert Scale, consisting of five points, with an increasing, ordinal, two-dimensional disposition -nonadherent to strongly adherent -and without the option of using the neutral point, since the study objective requires a judgment decision, as recommended by the literature [17][18][19] . Thus, these were the scale points: 1. Non-adherent; 2. Weakly adherent; 3. Regular adherence; 4. Moderately adherent; 5. Strongly adherent. The explanation for each point is described below: 1. Non-adherent: It means that the PPC does not have information about the item.
2. Weakly adherent: It means that the PPC has information that is cited, without description or detailing of actions.
3. Regular adherence: It means that the PPC has information that is cited, with a description, but without information on the action. 4. Moderately adherent: It means that the PPC has information that is cited, with a description, but with insufficient information to understand the action. Subsequently, aiming to observe a possible relationship with the course workload or their longevity with performance, the mean descriptive statistics were used, with the division again by quartiles 22 . Finally, in the last stage, hierarchical cluster analysis was applied to all observations in the sample using the three dimensions created 21,22 . When the clusters are created, the analyses can be carried out regarding the macro-regions in which they are located.
In all the above mentioned stages, the results were presented graphically and in a simplified way, aiming at making the analysis understandable and easily replicable.

RESULTS AND DISCUSSION
In this section, the research data are presented and discussed, according to the perspective of the analytical proposal discussed in the method.   Rezende et al. 10 shows, in their qualitative study, that the lack of support from municipal management, lack of internship areas and qualified instructors are among the main obstacles for the institution to adhere to what the PMM establishes on the teaching-service practice in the institutions. Another complicating point observed in the literature is the lack of teachers with specific training in the area 9,10 . It is necessary to analyze, in future studies, the reality of private institutions in relation to the lower adherence of PPCs regarding this dimension.

Aspects of collection
Graph 2C shows that there is a variation between the three dimensions regarding the type of administration (Private, Federal public, State public, Municipal public), showing that PPCs of federal institutions tend to have a better performance. On the other hand, the ISAPPC-MED synthetic index indicates that municipal public institutions show less adherence in relation to other types of administration. This finding is in contrast with the result of the study by Oliveira et al. 23 , which compared the PPCs of medical courses in public institutions at the municipal and federal levels, showing that there were no differences between them. Because this study has a national scope, innovation of data is observed, as well as relevant information for future studies.
Cyrino et al. 11 indicate in their study that the legislation flexibilization regarding the construction of medical training models consistent with local characteristics and the requirements of the Brazilian Unified Health System (SUS) concerning its role of organizing the training of health professionals can contribute to the reduction of health inequalities. show that there is no tendency for newer or older courses to have higher or lower performance, that is, the year of course accreditation does not influence the adherence of PPCs to the current legislation.

CONFLICTS OF INTEREST
The authors declare no conflicts of interest.

SOURCES OF FUNDING
This article is part of the SIMAPES project (Research, development and implementation of the health education mapping, monitoring and evaluation system), developed from the Federal University of Goiás (UFG), through FUNAPE, and with funding from the Ministry of Health, Brazil.