Keywords
neurosurgery - educational assessment - undergraduate medical education - student
leagues - neurology
Palavras-chave
neurocirurgia - avaliação educacional - curso de graduação em medicina - ligas acadêmicas
estudantis - neurologia
Introduction
In the National Curricular Guidelines for Undergraduate Medical Courses, the Federal
Council of Medicine (Conselho Federal de Medicina[CFM, in the Portuguese acronym])
determines that the undergraduate medical courses aim at training general practitioners
capable of acting at different levels of health care, with an emphasis on primary
and secondary care. It also determines that a mandatory competency of graduate professionals
is the ability of acknowledging their limitations and adequately referring patients
that are beyond their generalist training.[1] Furthermore, one of the principles guiding the Unified Health System (Sistema Único
de Saúde [SUS, in the Portuguese acronym]) is hierarchization, which is in agreement
with the organization of services in increasing levels of complexity. Adequate referral
plays a fundamental role in following this principle.[2]
Neurologists and neurosurgeons are frequently considered “superspecialists,” acting
mainly at the tertiary care level. According to this misconception, during undergraduate
medical courses, these specialties should focus on themes with higher prevalence on
the daily practice of general practitioners. However, their coverage in medical courses
is small when compared with their epidemiological relevance.[3]
[4]
The analysis of data obtained from the Computer Science Department of the Unified
Health System (Departamento de Informática do Sistema Único de Saúde [DATASUS, in
the Portuguese acronym])[3] showed that neurological and neurosurgical disorders are highly prevalent in Brazil,
with a highlight for traumatic brain injury (TBI). Traumatic brain injury was responsible
for more than 100,000 hospitalizations in Brazil over a 1-year period (from July 2014
to June 2015), 24,000 of which took place in the state of São Paulo. In other words,
almost 300 patients with neurological disorders are treated per day. These patients
require, at least, a complete initial evaluation so that appropriate action can be
taken, and possible immediate referral. This initial consultation is not performed
by neurologists or neurosurgeons, but by general practitioners and emergency doctors
at emergency rooms (ER) or mobile care units. This shows the importance of theoretical
and practical studies of neurology and neurosurgery during undergraduate medical courses.
Student leagues are non-profit scientific civil associations managed by students under
teacher guidance,[5] based in the teaching institutions with which they are affiliated. Their goal is
to supplement the studies of specific areas of medicine.[3]
[4] They are structured in accordance with the triad teaching, research and extension,
and provide their members with educational, scientific, cultural and social activities.
In the present study, we aimed at describing the choice of medical specialty by members
of the Neurosurgery Student League of Escola Paulista de Medicina - Universidade Federal
de São Paulo (EPM/UNIFESP, in the Portuguese acronym), beginning from the implementation
of an attendance check system, in 2007. In addition, we investigated the existence
and composition of neurology and/or neurosurgery courses and student leagues in medical
schools in Brazil, which has not been studied previously. Combining the two parts
of the study, we tried to understand the real role and ramifications of participating
in student neurosurgery leagues, with a focus on understanding whether student neurosurgery
leagues truly influence the choice of medical specialty, or only aim at filling a
gap due to lack of neurosurgery courses.
Material and Methods
We surveyed all medical students who were effective members of the Student League
of Neurosurgery of EPM/UNIFESP (founded in 2002) between 2007 and 2015. The survey
was performed by consulting the minute book of the league, used for attendance check.
Because the records between 2002 and 2007 are incomplete, we chose to analyze the
data beginning in 2007, when the systematic weekly record of activities on the minute
book began.
After obtaining the full names of the members of the Neurosurgery Student League of
EPM/UNIFESP, we looked for their current stage of medical training: graduation, residency,
medical specialist, or graduation without beginning of residency. For students attending
or that had concluded medical residency, we surveyed their chosen specialty through
search on social networks or personal contact. At UNIFESP, there are two other student
leagues related to neurology: the Student League of Neurology, and the Neurological
Emergencies Student League, recently created in 2015. The present study, therefore,
did not intend to analyze the influence of student leagues on the choice of neurology
residencies, but only on neurosurgery residencies.
On the second stage of the study, we evaluated the presence and composition (theoretical
and/or practical) of neurosurgery and neurology courses, and of student neurosurgery
and neurology leagues, in faculties of medicine in Brazil. We initially tabulated
all Brazilian medical schools registered with the CFM[4]
[5] in February 2015 and contacted the university secretary offices using a standard
email, explaining who was responsible for the study and its aims, and requesting them
to fill out a simple online questionnaire ([Fig. 1]).
Fig. 1 Questionnaire sent to university secretary offices and medical students.
We waited 1 month for the reply of the university secretary offices. We then began
directly contacting the students of the faculties of medicine that did not reply to
the email. The students were contacted through social networks and were sent the same
questionnaire ([Fig. 1]). At first, we prioritized contact with presidents and members of the neurology
and neurosurgery student leagues of each university (or group of universities, when
the student league was affiliated with more than one). When no response could be obtained
from this group, we contacted the remaining medical students, prioritizing those who
were already attending internship (5th and 6th years), and therefore, had a more comprehensive knowledge of the composition of the
medical course of their faculty. We gave the students the possibility of indicating
another student, if they did not feel able to answer the questionnaire.
It was considered a definitive response to the questionnaire, by order of importance:
response by the university secretary office; response of at least one president/member
of the neurology or neurosurgery student league; response by at least two students
who were not members of a student league, with consultation of a third student if
there was divergence in the answers to the questionnaire.
Results
Epidemiological Evaluation of the Neurosurgery Student League of EPM-UNIFESP
Between 2007 and 2015, the Neurosurgery Student League of EPM/UNIFESP had a total
of 88 effective members, participating on the league for at least 1 year, of which
57 were medical students and 31 were nursing students.
The student contacts through social networks and/or email revealed that, of the 57
members of the Neurosurgery Student League of EPM/UNIFESP, 45 (79%) had graduated
and were attending, or had already concluded, the medical residency. No student within
our sample opted for not undergoing medical specialization following graduation. Of
the 45 graduated doctors, 6 (13%) attended or were attending neurosurgery residencies.
The medical residency specialties selected by former members of the Neurosurgery Student
League of EPM/UNIFESP are presented on [Fig. 2].
Fig. 2 List of residencies chosen by members of the Neurosurgery Student League at the EMP/UNIFESP.
Analysis of the Responses to the Questionnaire
A total of 173 medical schools in Brazil were registered with the CFM in February
2015.[5] The initial effort of sending the questionnaire via email to all the university
secretary offices yielded only two responses after a 1 month wait.
Therefore, we began an active search for presidents and/or members of neurology and
neurosurgery student leagues, and undergraduate medical students (prioritizing those
already attending internship), according to the method adopted. During this stage,
which lasted 2 months, we obtained responses from more than 140 medical schools in
the country, with a total 82% of the sample population answering the questionnaire.
Of the 142 questionnaires filled, 14 were excluded due to inconsistent answers, resulting
on a final number of 128 medical schools (that is, 74% of the total faculties of medicine
in Brazil).
The answers to the questions regarding presence and distribution of neurology and
neurosurgery courses revealed the existence of structured neurology courses on 91%
of the medical schools (116). Of these, 32 were only theoretical, of which 12 covered
neurosurgery, and 84 were both theoretical and practical, of which 51 covered neurosurgery
([Fig. 3]).
Fig. 3 Structure of neurology courses in medical schools.
Structured neurosurgery courses were only present in 19% of the faculties (24), of
which half were only theoretical, and the other half was both theoretical and practical.
In total, neurosurgery courses (theoretical or theoretical and practical), either
alone or combined with neurology, were only present in medical courses in 68% of the
faculties (87). For the remaining 41 medical schools, if the students depended only
on the subjects covered in the undergraduate courses, they would leave without any
knowledge of neurosurgery.
Student leagues of neurosurgery or neurology, combined or alone, were present in 66%
of the universities (85). Of these, 81% (69) were combined neurology and neurosurgery
leagues, and only 34% (19) were exclusive neurosurgery leagues.
A separate data analysis revealed that 50% of the medical schools in Brazil do not
possess a neurosurgery program, out of which 44% offers no practical course and 6%
offers no theoretical or practical course.
Discussion
Student leagues are associations organized by university students under teacher guidance,
with the aim of studying a given subject,[6] in accordance with the triad teaching, research and extension.[7]
[8] Their activities are extracurricular, in order not to compromise the curricular
activities of the medical course and aim at supplementing or introducing the apprenticeship
of a given subject. However, it is questioned whether these activities are an early
superspecialization of undergraduate medical students, who should be focused on learning
general medicine, and whether Student Leagues influence future choices of medical
specialties.[9]
The Neurosurgery Student League at EPM-UNIFESP provides weekly theoretical classes
(2 hours long), a monthly discussion of a clinical case (2 hours long), and practical
activities, with members participating in monthly 12-hour shifts at the neurosurgery
service of the Hospital de São Paulo, accompanying residents, heads of service and
teachers. League members are also encouraged to participate and help organizing neurosurgery
congresses and student league meetings. In addition, they are invited and encouraged
to perform scientific research in neurosurgery. Finally, the extension activities
include participation in community health work.
The survey of student members of the Neurosurgery Student League at EPM-UNIFESP during
the period when weekly records of activities were kept (2007 to 2015) revealed that
there were 57 active members, 45 of whom were already attending or had concluded residency.
Of these, only 13% chose neurosurgery as specialty. This does not allow us to conclude
that participating in neurosurgery student leagues determines or even predisposes
students to choose this specialty, due to cause and effect bias, and the fact that
participating on a given student league, in addition to overcoming undergraduate course
shortcomings, meets the student interests and future projects.
Our study did not allow us to evaluate whether student enrollment on neurology and
neurosurgery student leagues affected the choice of neurosurgery as specialty, or
if both the enrollment and choice of specialty were due to a prior interest on neurosurgery.
In addition, both factors— prior interest and student league participation— often
concomitantly affect the student choice.
Furthermore, according to the Brazilian Society of Neurosurgery, there are ∼ 2,000
neurosurgeons in Brazil out of a total of almost 400,000 medical doctors (CFM), that
is, only 0.5% of medical doctors pursue a career in neurosurgery, showing that this
market is not yet saturated with professionals.
Given the massive presence of neurology and neurosurgery student leagues, present
in 66% of the investigated universities, the hypothesis can be advanced that their
existence is due to a gap in including these contents in the academic curricula of
undergraduate medical courses. Only 19% of the faculties of medicine evaluated in
our study include a neurosurgery program in their undergraduate course, and even fewer
possess a theoretical-practical neurosurgery course (9.5%). The National Curricular
Guidelines for Undergraduate Courses in Medicine do not specify mandatory neurology
and neurosurgery structured courses in undergraduate medical courses, which disagrees
with the high prevalence of neurological and neurosurgical diseases encountered on
a daily basis by general practitioners and emergency doctors.
Conclusion
The present study showed that 13% of the effective members of the Neurosurgery Student
League at EPM/UNIFESP chose neurosurgery as a specialty. In addition, we observed
that the student neurology and neurosurgery leagues, present in 66% of Brazilian medical
schools, are often used to supply theoretical-practical knowledge that should be covered
in the undergraduate course. However, unfortunately only 9.5% of medical schools include
a theoretical-practical neurosurgery course in their curriculum. This is worrisome,
since neurosurgical diseases have a high prevalence within the epidemiological landscape
of Brazil, and therefore, neurosurgery should be taught at all medical schools. In
schools already teaching neurosurgery, the workload should be sufficient to allow
learning about these diseases.
