The experience of Universidade São Francisco with the medical internship in psychiatry using the problem-based learning method

Abstracts

Nos últimos anos, o ensino médico vem sofrendo modificações pedagógicas e curriculares, visando promover a formação de um novo profissional de saúde. Uma das alternativas pedagógicas propostas é a educação problematizadora, que trabalha essencialmente com a construção de conhecimentos a partir da vivência de experiências significativas. Tal modelo de aprendizagem tem viabilizado mudanças curriculares, em que a psiquiatria vem conquistando espaço significativo para o desenvolvimento de uma prática médica mais humanística e integral. O artigo se propõe a discutir a experiência do Curso de Medicina da Universidade São Francisco, em Bragança Paulista (SP) referente à implantação do internato de psiquiatria pela metodologia da aprendizagem baseada em problemas, desde 2003. O internato de psiquiatria ocorre no quinto ano do Curso de Medicina, com carga horária de 320 horas, correspondendo a 8 semanas de 40 horas. As atividades são desenvolvidas no hospital-dia e no ambulatório, e a interconsultoria é realizada no hospital geral. Observa-se significativa evolução no conhecimento adquirido dos alunos, que conseguem, ao término do internato, desenvolver raciocínio clínico e sedimentação de conceitos e práticas psiquiátricas adequadas à formação médica generalista, compatíveis ao que o curso de graduação propõe. A experiência relatada pode servir de modelo para a implantação de uma proposta de aprendizagem em saúde mental inserida nos preceitos da reforma psiquiátrica no Brasil, buscando-se implementar o desenvolvimento de práticas comunitárias e interdisciplinares.

Educação médica; método; internato; ensino; psiquiatria

THEORETICAL-CLINICAL COMMUNICATION

The experience of Universidade São Francisco with the medical internship in psychiatry using the problem-based learning method

Luiz Fernando Ribeiro da Silva Paulin^I; Regina Caeli Guerra Poças^II

^IPhD. Associate professor, Psychiatry Course, School of Medicine, Universidade São Francisco, Bragança Paulista, SP, Brazil.

^IIMaster's degree student in Psychiatry, Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, Brazil. Assistant professor, Psychiatry Course, School of Medicine, Universidade São Francisco, Bragança Paulista, SP, Brazil.

Correspondence

ABSTRACT

In the last few years, medical education has been going through curricular and pedagogical changes with the purpose of educating a new health professional. One of the pedagogical alternatives is the education based on problem-solving, which works essentially with the construction of knowledge using significant experiences. Such learning model has enabled curricular changes, which, in the field of psychiatry, reflect the conquest of significant space for the development of a more humane and integral medical practice This article aims to discuss the experience of the Medical School of Universidade São Francisco (USF), in Bragança Paulista, concerning the implementation of the psychiatry internship using the problem-based learning (PBL) methodology since 2003. The psychiatry internship is undertaken in the fifth year of Medical School, and it consists of 320 hours, which correspond to 40 hours a week for 8 weeks. Activities are developed at the day hospital, at the outpatient clinic and at the general hospital during delivery of consultation-liaison psychiatry service. There was significant increase in the knowledge acquired by the students who, upon completing the internship, were able to develop clinical reasoning skills and had consolidated concepts and psychiatric practices adequate to the general medical education and compatible with the purposes of the undergraduate program. The reported experience can serve as a model for the implementation of a learning methodology regarding mental health based on the principles of the psychiatric reformation in Brazil, trying to develop community and interdisciplinary practices.

Keywords: Medical education, method, internship, teaching, psychiatry.

Introduction

The School of Medicine of Bragança Paulista was founded in 1971, concomitantly with the creation of several other schools of medicine in Brazil, and it was very similar to the other undergraduate medical schools. Its pedagogical and curricular model was based on the Flexnerian concept and it was divided into basic and clinical cycle, with little integration of knowledges.^1,2 Such model was characterized by fragmentation, lack of articulation and uncritical teaching, and the students' training included predominantly theoretical and demotivating activities during the first 5 years of medical school. Practice learning was limited to the last year of the program, which forced the students to go through a fast process of maturation, receiving mainly hospital-based training.

The internship, during the sixth year, was based on the traditional model in which students had to participate in a rotation system in the four main areas (clinical medicine, clinical surgery, gynecology-obstetrics and pediatrics).

In the early 1990s, a group of professors and medical students, motivated by a new socio-educational project implemented by Universidade São Francisco (USF), launched a broad debate about the curricular guidelines of the medical school and concluded that there was need of designing a pedagogical and curricular model that complied with the fundamental propositions of the project. After almost 1 decade of debates and discussions, the pedagogical project started to be implemented in the medical school of USF, basing its curricular organization on the Problem-Based Learning (PBL) method.

About problem-based learning

During the last few years, there has been evidence of the ineffectiveness of the traditional model of medical education. It is characterized by students with a passive profile, basically focused on achieving the scores necessary for approval by memorizing information whenever required.³ At the same time, the professor plays a controlling role in the learning process, using theoretical classes as the most important, and often the only, teaching method. The traditional medical curriculum includes an excessive number of courses, mainly theoretical, with little time for deeper analysis of the contents and without defined criteria regarding how thoroughly they must be taught. In addition, courses are not correlated, that is, there is neither interaction among them nor an effort to provide education focused on the professional training.

Several analyses and actions have been developed with the purpose of offering better education to medical students, enabling them to be trained within a context that values equity, integrality, interdisciplinarity and critical vision, as well as professional competence. Since the 1980s and mainly during the 1990s, entities related to the medical education have tried to implement such changes; therefore, pedagogical innovations have become the fundamental pillars in the education of this new health professional.

One of the pedagogical alternatives suggested is problem-based learning, which basically involves the acquisition of knowledge through significant experiences. It is based on the learning processes by means of discovery, as opposed to the passive processes of receiving information. Teaching contents are not made available for students as closed theories, but as problems, whose relations must be discovered and established by the student.⁴

One of the proposed methods of problem-solving education is PBL. PBL emerged within the educational context as a teaching/learning method at the end of the 1960s at McMaster University, in Hamilton, Ontario, Canada. Afterwards, it was spread to other educational centers such as the Universities of Maastricht, in the Netherlands, and Harvard and Cornell, in the USA. In Brazil, the first schools to adopted such method were Faculdade de Medicina de Marília (1997), Universidade Estadual de Londrina (1998) and USF (1999).^5,6

It consists in an educational strategy that promotes the acquisition of knowledge, skills and behaviors by teaching small groups. The method is focused on individual learning, and the teacher serves as a facilitator and tutor. The learning process (the path to knowledge) is more valued than the content (knowledge).⁷

For Cyrino & Toralles-Pereira,⁴ PBL should be considered one of the most significant innovations in medical education developed in the last few years. It was created as a reaction against the curricula of medical schools that suffered a strong influence of the Flexnerian model, which was focused on biomedical profile and education focused on the hospital. "It can be considered the main axis of theoretical learning in a medical curriculum, aimed at acquisition of cognitive contents and integration of courses. It intends to promote the creative work of the teacher, who will be concerned not only with 'what,' but basically with 'why' and 'how' the student learns"⁴ (free translation based on the original text in Portuguese).

At USF, the courses included in the new curriculum of the medical school are organized as follows: integration unit (including essential knowledge about morphological sciences, physiological sciences, internal medicine, clinical surgery, pediatrics, gynecology-obstetrics, anatomic pathology, legal medicine and professional ethics); medical practice and society unit (including knowledge about epidemiology, social medicine, occupational medicine and biostatistics); medical propaedeutics unit (including elements of doctor-patient relationship, principles and techniques of nursing and medical semiology techniques); and an optional course that covers the complementary knowledge stimulated in the other units. These courses are offered during the first 8 academic terms of medical school. From the first to the fourth academic terms, it approaches the conception of "normal man," and "pathologies and therapeutic treatments" are covered from the fifth to the eighth academic terms.

The learning resources, in addition to classroom, labs, outpatient clinics and hospital, are focused on the availability of a library containing a collection of books and journals, computers with multimedia software, access to databases such as LILACS and MEDLINE, and internet connection.⁵ However, the main learning environment is the interface between teaching and community health services, developing a new model that moves the learning axis from the hospital to the community.

Medical internship at usf according to the pbl model

With regard to the internship, the new pedagogical project presents a 2-year proposal, highlighting the following guidelines:

a) The 2 years are part of a continual and articulated process in which the skills progressively developed complement themselves from a lower to a higher level of complexity;

b) There are three hierarchical levels of activity (low, intermediate and high complexity) in which interns receive training by participating in the Family Health Program at primary care units, specialized outpatient clinics, and hospitals;

c) Internship I (fifth year) has a community-oriented profile, while internship II (sixth year) includes activities focused on hospital procedures;

d) Internship I is divided into six modules, as follows:

1 - Adult health (8 weeks);

2 - Child health (8 weeks);

3 - Women's health (8 weeks);

4 - Mental health (8 weeks)

The total number of class hours is 2,024 hours;

e) Internship II consists in the traditional model of four main areas. However, the emergency internships (emergency room and optional internship) were added. The total number of class hours is 2,024 hours. In 1999, the medical school constituted the first class of students trained according to the PBL method. In 2003, this class started Internship I.

Psychiatry course at the school of medicine of usf

Psychiatry teaching according to the traditional model

With a small number of class hours (68 hours), the psychiatry course offered to the medical students from USF was taken in the fourth year, and the classes, which were exclusively theoretical, were given on Fridays afternoons. Since there were not any kind of practical activity, at the end of the course, which lasted for a whole academic term, students were invited to visit a large public psychiatric hospital, where most patients had chronic diseases. Such teaching situation, which lacked a didactical approach, certainly made the students believe that psychiatry was a specialty basically focused on this type of patients.

According to Dalgalarrondo,⁸ quoting Shukla et al., with regard to the experience of teaching psychiatry to medical students in a typical specialized hospital: "the traditional psychiatric hospital presented a distorted and pessimistic vision of psychiatry, showing only chronic psychotic and deteriorated patients to students. Students left the hospital thinking that psychiatry was something interesting but basically useless and powerless." (free translation)

Psychiatry teaching and day hospital (DH)

Throughout the years, those responsible for the psychiatry course kept trying to demonstrate to the appropriate departments of the medical school and university that there was need of creating a psychiatry service at the teaching hospital, preferably an outpatient clinic. The reasons provided for not implementing psychiatry service were lack of physical space, as well as the existence of other priority services.

This official excuse not only reflected the real problems of the hospital but also revealed the difficulty of some medical sectors, even those related to the university, in accepting the implementation of a psychiatry service at a general hospital. The internal resistance was only dissolved in 1994, with the regulation of the Directive FIDEPS

Due to the lack of physical space, the possibility of creating a DH using a facility attached to the hospital, in an area of approximately 300 m2, next to the service of diagnosis support was suggested. And this was done: the DH was installed next to the chemotherapy service and the department of pharmacology research applied to gastroenterology.

Obviously, the triggering factor for the implementation of the DH was the financial support. However, would not it be a historical moment to put into practice an audacious project in a teaching hospital where psychiatry barely existed? Such opportunity could not be missed: to adapt the interests of the hospital to the creation of a qualified and ethical service capable of promoting care experiences and professional training. Therefore, in January 25 1995, the Teaching-Day-Hospital in Mental Health of USF had its doors opened.¹⁰

After the DH was installed, it was possible to make significant changes in the psychiatry course, although the small number of class hours (68 hours in the fourth year) remained the same. Theoretical classes were replaced by theoretical-practical activities. First, students interviewed a patient under the supervision of a professor and then they discussed the case based on the topic to be learned in that specific class.

The implementation of the DH certainly promoted changes in psychiatry teaching. However, with a quite small number of class hours, without interaction with other courses and being disconnected, the psychiatry course reproduced the traditional model of medical education.

PBL method and psychiatry teaching

In 1999, the PBL method was implemented in the school of medicine of USF. The medical psychology course, which was taught in the first year of medical school, was included in the Medical Propaedeutics Unit in the first fourth academic terms, with 8 class hours per week.

During the seventh academic term, the optional course of psychiatric propaedeutics was included in the curriculum, consisting in 32 class hours. The objective of this course was to introduce the basic concepts of psychiatric semiology by means of interviews with patients hospitalized at the DH.

With the expectation of creating a medical internship in psychiatry, it was possible to elaborate a work proposal by means of which some guidelines would be launched. The intention was to implement an internship program focused on the proposals presented by the PBL method, as well as by the experience resulting from the teaching activities developed at the DH.

It is worth mentioning that studies on the experience of psychiatry teaching using the PBL method are rare,¹¹ as well as studies related to psychiatry internship.¹²

Psychiatry internship

In 2003, the psychiatry internship began its activities. With a 240 hours/internship, corresponding to 40 hours in 6 weeks, it meant that there was a three-fold increase in the number of class hours compared to the psychiatry course in the traditional curriculum. Since 2006, the psychiatry internship lasts for 8 weeks, totaling 320 hours. Throughout the year, eight groups of around 10 students undertake this internship, and some students choose to take it again as an optional internship both in the fifth and sixth years.

The psychiatry internship is aimed at improving medical students' training by providing concepts of mental health and psychiatric disorders that are prevalent in the Brazilian population, in addition to enabling the development of mental health interdisciplinary and community activities. Certainly, the role of this internship is to absolutely avoid reproducing the traditional models disguised by modern methods, nor be based on a classical speech about the need of educating a generalist physician, showing a specialty-oriented practice instead. The main focus is on requiring that students are familiar with concepts of mental health that enable them to provide the patient with care according to a humanistic and integral conception.

The psychiatry internship is focused on two basic axes of knowledge and practice, the conceptual and the deinstitutionalizing.

The conceptual axis is the one presenting concepts that are essential for the development of a clinical reasoning in mental health. This axis includes topics of psychopathology, clinical psychiatry, psychopharmacology and basic notions of psychoanalysis. The acquisition and consolidation of such knowledge are very important for undergraduate students, even if they do not become psychiatrists, since mental disorders account for 12.3% of the causes of diseases and disablement in the world. There might also be a lack of psychiatrists in Brazil, being necessary to train general practitioners to provide basic psychiatric care, which might be initiated during the undergraduate program.¹³

The deinstitutionalizing axis is responsible for revealing the whole process of restructuring of the psychiatric care in Brazil. It has been implemented by means of the gradual replacement of the hegemonic model of psychiatric hospital by health care models in which the DH and psychiatry in the general hospital are essential elements. In this axis, there is also the experience of interdisciplinary activities involving non-medical professionals who are part of the health care team and activities involving students from other majors, such as nursing and psychology, who also undertake professional internships at the DH.

Also in the deinstitutionalizing axis, the need of having the students perform practical activities that go beyond the traditional setting (medical office and/or hospital ward) is also emphasized, trying to establish new environments for contact and follow-up of patients. The inclusion of other actors other than the patient, such as the family as a reference in the therapeutic process, is also stimulated.

Functioning

The internship is divided into two groups (A and B) which are offered during a period of 4 weeks, when the groups exchange their activities.

Group A develops its daily activities at the DH (Table 1). Each student is responsible for following-up one to three patients since admission. Their daily tasks include checking patients' progress, performing clinical evaluation and providing prescriptions, always under the supervision of a professor and a resident physician‡.

Table 1 - Click to enlarge

The group activities are the predominant therapeutic model at daily health care services. The students' participation enables them to experience methods of care that have a peculiar dynamics, sometimes including stressful situations in which the doctor-patient relationship presents characteristics and situations that rarely occur in the individualized care. Students also take part in other group activities such as family meeting, medical visit, occupational therapy and screening.

Another important moment is related to the citizenship group. Students, under the supervision of a first year resident, analyze general topics suggested by the patients, experiencing the possibility of coordinating a group activity. The student who is undertaking the internship at the DH is also responsible for preparing the clinical case to be discussed in a weekly clinical meeting with the whole team.

The B Group develops its activities at the outpatient clinical and at the HUSF, where the consultation-liaison psychiatry service is delivered (Table 2).

Table 2 - Click to enlarge

The activities performed at the outpatient clinic take place twice a week, involving new cases and follow-up visits. Students see the most prevalent cases of psychiatry, such as anxiety disorders, somatizations, depression and alcoholism, with the purpose of training a general practitioner. More complex cases are referred to the outpatient clinic where resident physicians see the patients.

The patient is seen by the intern. After that, the intern discusses the case with the preceptor and then both of them decide how to deal with that patient. Next, a group of interns and the preceptor review all the cases seen during that day, highlighting the most significant aspects for learning.

In our outpatient clinic, we have avoided adopting the methodology used in most schools of medicine, that is, creating homogenous outpatient clinics where symptoms and diagnosis are checked, such as, for instance, outpatient clinics of phobia, mood disorders, schizophrenia, etc. We have chosen to build a small structure where it would not be reasonable or possible to implement a quite large number of outpatient clinic hours. We also believe that such outpatient clinic models, in spite of being effective in terms of clinical researches, run the risk of transforming the care provided into an oversimplified practice. In other words, assessment scales and diagnostic criteria would overlap the patient-oriented care that does not consider only the patient's symptoms. The activities related to outpatients are performed at the DH and the Outpatient Clinic of Mental Health of Bragança Paulista, enabling the integration of the health care provided by the Health Department of the city and by the University.

In addition to the outpatient clinic, there is also the consultation-liaison psychiatry service at the general hospital. The consultation-liaison psychiatry service is the main element of the integration between psychiatry and general medicine, having become an important model of integration of psychiatric practice in an environment where it was ignored or even rejected.¹⁴ The hospitalization of psychiatric patients in clinical medicine hospital beds has been implemented whenever possible and recommended.

The consultation-liaison psychiatry service is provided once a week. It is focused on showing the possible integration between psychiatry and other medical areas.

Since the consultation-liaison psychiatry services are not sufficient to fulfill the time allotted to these activities, we have chosen to debate prevalent topics in the routine of the general hospital. Delirium, suicide attempt, psychiatric emergency cases, pregnancy and puerperium, and eating disorders are some of the topics planned for discussion.

During this period of the internship, students also take part in interdisciplinary activities, such as family individual care, in which the family of a hospitalized patient is interviewed. Such activity is aimed at promoting a deeper analysis of the basic notions of familial dynamics within the context of mental disorders. Such work is done by the social worker of the service.

During the psychiatry internship, 15% of the weekly class hours (6 hours per week) are saved for pro-student time, one of the main aspects of the PBL method.

Known in some schools of medicine as "green areas,"¹³ the pro-student time is available since the first academic term of medical school. Its objective is to be a period of time for studying and problem-solving activities. In the psychiatry internship, specifically, the pro-student time intends to stimulate the development of study and research activities related to mental health and topics suggested for debate.

Evaluation

The evaluation is carried out by means of three different methods:

a) Conceptual evaluation: the professors and the technical team evaluate the students based on their performance and participation in several activities. Criteria are as follows: punctuality, attendance, interest, initiative, responsibility, theoretical and technical knowledge and intern-patient relationship and student-professor relationship.

If, during the internship, an intern had difficulties to perform the activities, the problem is discussed with the purpose of solving it.

This weight of this evaluation is 1 (one).

b) Practical exams: students take two practical exams in the fourth and eighth weeks of internship. If the student is an intern at the DH, a case that the student is following-up will be discussed on these exams. If the student is an intern at the outpatient clinic, the exam will be about the outpatient care it provided on the day of the exam.

The examination board will comprise at least two professors who teach the course and the weight of each exam will be 2 (two);

c) Theoretical exam: it is taken at the end of the internship, and this exam is based on clinical cases, stimulating the student to develop a clinical psychiatric reasoning.

The weight of this evaluation is 5 (five).

Conclusion

Since its creation as a medical specialty, psychiatry has been an isolated specialty that has been kept apart from medicine. Such situation was reproduced in the school of medicine of USF, where the psychiatry course had a small number of class hours, offered at inappropriate hours and predominantly including theoretical activities. When practical activities were developed, they would take place in large psychiatric hospitals.

With the increasing need of considering and applying methods compatible with the new reality of medical teaching, the problem-solving education consists in one of the most promising methodological alternatives because it is based on interactive, democratic and pluralist pedagogical teaching principles.

The psychiatry internship in the medical school of USF, during its seventh year of foundation, has been consolidated to the point that, in 2006, its duration changed from 6 to 8 weeks. There was significant increase in the knowledge acquired by the students who, upon completing the internship, were able to develop clinical reasoning skills and had consolidated concepts and psychiatric practices adequate to the general medical education and compatible with the purposes of the undergraduate program. Indirect signs of improvement of the psychiatric knowledge have been observed, such as appropriate referrals of patients from other medical areas made by students that undertook the internship in psychiatry and request of consultation-liaison psychiatry service. We were also able to notice that there is an increasing number of students who wish to undertake the optional internship in psychiatry, as well as a larger number of sixth-year students who apply for residency programs in psychiatry.

Obviously, such findings must be measured. However, the aim of this study is only to present the experience of the internship. Constant reassessment performed both by professors and students is necessary with the purpose of improving medical education, guaranteeing a medical practice without segregation of patients with mental disorders.

References

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*

;

5 - Community health (6 weeks);

6 - Optional internship (6 weeks).

†

, which enabled the implementation of a psychiatry service at Hospital Universitário São Francisco (HUSF).

Publication Dates

• Publication in this collection
  24 Aug 2009
• Date of issue
  2009

History

• Received
  13 Feb 2009
• Accepted
  17 Feb 2009