João Eurico da Fonseca is currently the Professor who closely monitors the implementation process of the new Clinical Education Reform, providing support and follow-up to Professor José Ferro, the project coordinator. He focuses essentially on the structuring of the new Medicine-Surgery areas of years 4 and 5. “As anxious as I am for everything to go well, I have to limit myself right now to being close to support them,” he says.

For the Rheumatologist, several things are needed to be a good doctor: “the first is to enjoy studying. No student comes to the Medical Degree if they don't like to study; the second is that a good doctor has to have a minimum contact with different realities; and, finally, the third aspect, which is what will differentiate a doctor's career, concerns attitudes”. According to the Professor, attitudes are not only related to the practice of Medicine, but also to all professional areas. People are prepared with certain sets of information and then it is their attitudes that differentiate them.

For the Professor, this new Clinical Education Reform will provide students with greater contact with patients and doctors. Since there is a greater focus on the practical component, students will have the opportunity to get in touch with reality and thus develop their personal characteristics.

How important is the educational reform that will takes place from the next academic year onwards?

João Eurico da Fonseca: The big change that will take place is in the integration of content. For the first time, we will try to put students who are studying, for example, surgery, or the various surgical areas and the various medical areas together. This means that if a student is studying cardiology, he will be more focused on Cardiology and also on Vascular Surgery and Cardiothoracic Surgery, and so on. Therefore, when there is a medical topic that is easily paired with a surgical topic, this pairing is encouraged. Every effort will be made to ensure that there is no overlap in the description of symptoms, signs, laboratory changes, diagnostic aspects of medical and surgical areas. Therefore, everything is integrated. Then, naturally, the more medical areas will focus more emphatically about drug therapy and the surgical areas involving surgical approaches.

Of course, surgical areas also have many particularities from a general and patient management point of view - the postoperative patient, the patient during surgery, the patient's preoperative period, concerns about comorbidities, infections and so on. It has to be specifically addressed in various contexts, including medical-surgical trauma patients. In fact, the patient who comes from a traffic accident situation, for example, is primarily a surgical patient with various complications. However, he will quickly have medical complications because he already had previous illnesses that are complicated by trauma or because the trauma gives rise to a series of predominantly metabolic and medical instabilities.

Therefore, patients need this joint clinical approach, whether surgical or medical, and so this teaching must also be done in an integrated manner. This patient is traumatological, but he is a medical-surgical traumatological patient, where surgeons and intensivists have to provide input. This integration is a crucial aspect of change. And in this integration process, there will be a permanent search for alignment of vertical contents of training, with contents of the first 3 years of the Degree, whenever relevant.

Another aspect of change, which is very important, is the concept that, in order for students to be able to have close proximity to their daily clinical activity in years 4 and 5, they need time. Thus, we have to increase the percentage of time when students are focused on the so-called practical classes and which will be done in various slots in the various medical and surgical areas that are involved in teaching. These slots are intended to prevent students, who are in fact numerous, from being together in high numbers in the same place, which affects clinical activity and teaching. Therefore, when we think about how to place students on these mornings when they continuously have practical classes, we are very concerned about dividing them when it is possible to do practical teaching, namely, in the context of wards, day hospitals and consultations. The dispersion of students over several areas at the same time is a very important strategy to allow students to have close contact with clinicians and patients as much as possible. This is possible through interaction with hospitals affiliated with the Faculty of Medicine, in this case, the main one is Santa Maria Hospital. However, there are other hospitals, namely, Pulido Valente, Beatriz Ângelo, Fernando da Fonseca, and Garcia da Orta Hospitals, which will reinforce their participation, with more exposure time to students, precisely to offer them more clinical contact. And when we do these slots, we do it with a basic principle: in each unit the number of students cannot exceed the maximum limit of four, to allow greater contact with doctors and patients.

Additionally, and to maintain as much as possible the principle of small groups of students, there is another level of organization that is important: the theoretical-practical classes. Theoretical-practical classes are obviously different from the practical ones, but they still allow a sufficient control of the participants.

Before attending these mandatory classes, students will have knowledge support organized in the form of theoretical classes previously filmed and available in the Moodle. Students will have a list, as if it were a chapter in a book, which they can read according to their individual plan of theoretical-practical and practical classes. This will enable them to properly prepare these theoretical-practical sessions and practical classes, so that they are able to interact with the concepts behind these mandatory classes.

This concept is a little different from the usual because, classically, we had theoretical classes without mandatory attendance, seminars without mandatory attendance and practical classes. The scenario changes, with theoretical classes being filmed, students do not have to come. Still, they need to attend mandatory theoretical-practical and practical classes. This corresponds to the "flight time" that students need to have in order to be qualified at the end of year 5 to enter a more liberal year, year 6, which has a real clinical contact and does not have the formality of classes.

Can we say that there is an investment on the practical part?

João Eurico da Fonseca: It is an investment on the practical component and close contact with patients and clinicians. This is an important principle. Students have their study times, but later when they are in the Faculty and hospitals, they will not be attending a class, but involved in activities.

 

Does this reform also change the form of assessment?

João Eurico da Fonseca: Too much time was spent on assessment, because the subject areas were dispersed. Therefore, each had its separate assessment and a lot of time was wasted on it.

There is also a very different concept from assessment, which is centred on a single multiple-choice test that includes all areas of each module. For example, in the medicine-surgery module, there is a single multiple-choice test that encompasses all the medical-surgical subject areas, in year 4, first, and then in year 5. Then there will be a single practical exam structured using the OSCE method and which will test the various areas that are taught. Additionally, students will be continuously assessed based on the achievement of a series of objectives, in a portfolio that will have to be completed and that will contribute to the final classification. During the year, there will also be some forms of formative assessment, which do not count towards the classification, but which ensure that students know how their knowledge is evolving.

Will this new education reform take place in years 4 and 5?

João Eurico da Fonseca: Yes. The model is very similar in years 4 and 5. 

In this case, as of September of this year, the students affected by the new education reform are the ones who go from year 3 to year 4, right?

João Eurico da Fonseca: Students who in the next academic year (2021/22) enter year 4, in September, become involved in this system. Year 5 will only start this new methodology later, in the 2022/23 academic year.

What was the drive for this major change?

João Eurico da Fonseca: I think there were several reasons. The first is related to the evolution of the concepts of medicine, to how knowledge can be better transmitted. There have been major advances in medicine, but there have also been major advances in technology and information availability. Therefore, it was considered that students should have more autonomy, more time, so that they can manage their study more independently.  Hence the theoretical classes available are not face-to-face, to enable students to immerse themselves in them at appropriate times. At the same time, they are free to search multiple bibliographic sources. This time factor is another important aspect because the students will have free time most afternoons, thus able to use it to study.

There is also another circumstance that is unique to our medical school. Over the years, there have been reforms in the structure of education, but it has remained essentially the same in recent decades. The number of students has been increasing and the overload on the various structures, which can provide practical teaching, is big. Therefore, it was also necessary to change the teaching strategy to allow the number of students to have quality education related to contact with doctors and patients.

What consequences can the Education Reform have on students?

 João Eurico da Fonseca: Of course, a change as big as this one will inevitably have consequences. By having the clinical years under restructuring, we are pushing students towards a more intense, more autonomous clinical contact, right from the beginning of year 4. It is necessary that at least the second semester of year 3 has a future restructuring that enables these students to be more prepared for this change. This is already underway and there were several changes in the second semester of year 3 to force students to be closer to year 4, but there were limitations due to the pandemic and it hampered these changes a bit. But, over time, in year 3, there has to be a pre-preparation for students to enter year 4 with more knowledge and clinical attitude.

What needs to be reinforced and modernized in year 3 is the learning plan for semiology, symptoms and signs that is ongoing throughout the year. In particular, at least in the second semester of year 3, more time of practical contact with this same teaching is essential, but with the presence of patients, or at least with what is called a "standardized patient" (trained individuals, as if they were actors, to display symptoms and simulate some signs that are then evaluated by students in a practical way).

This kind of step forward in practical teaching in year 3 is important for students to be more capable of mature interaction with physicians and patients.

Basically, year 3 needs to undergo a clinical preparation upgrade. Currently, the time dedicated to clinical learning in year 3 allows students to know from a theoretical and a practical point of view the symptoms, signs of diseases and the main clinical syndromes. However, the contact with practice is based on models and has to be reinforced with "standardized patients" and also with real patients in a classroom environment, but including, in a controlled manner, a nursing environment. This will allow students to be more comfortable, more clinically fit as they enter year 4. Afterwards, this also has a consequence in year 6, when these students are expected to be more able to be almost professionals.

What will be your role in implementing the reform?

João Eurico da Fonseca: I have been following this reform implementation process, supporting Professor José Ferro in everything he needs and focusing essentially on structuring the medicine-surgery of years 4 and 5.

At the moment, the detailed implementation of year 4 is in the hands of the coordinators of the various areas of year 4. Specifically, medicine-surgery is in the hands of the coordinators, who are Professor João Lacerda, Professor Fausto Pinto and Professor Paulo Costa. I am currently concentrating on it, but regarding year 5, which has as coordinators Professor Helena Cortez Pinto, Professor Paulo Costa and myself.

We are very attentive to how year 4 is adapting because there are several concepts that were conceived on paper and when we approach the implementation day we discover several details that cannot be quite like that after all. And we are attentive to their experience and very curious about their first contact with the reality of everyday life, because we obviously want to value the best that happens and also prevent mistakes.

Although we currently have a well-defined model for year 5, if we see that the first impact of some of the new features, placed in year 4, is not going well, we will make adjustments to year 5. On the other hand, successful innovations that year 4 will bring, will be included in year 5.

It is, right now, my mental attitude towards reform. I am very attentive to following year 4, but aware that at this moment the fine tuning of the details has to be made by those responsible for the year and, therefore, as anxious as I am that everything goes well. At this point, I can just be close to them to support them. At the same time, transfer what is good to year 5 and remove what is less good and not take it to year 5.

 And how are the lecturers going to deal with these changes? Are there barriers?

João Eurico da Fonseca: Most lecturers listened to the evolution of concepts about this reform over several years and had the opportunity to discuss in larger or smaller meetings what the implications would be for their subject area. Therefore, this long maturation allowed people to gradually adapt.

I think these huge changes made quickly (snaps fingers) would cause huge resistance. As they were done progressively, this allowed for the conceptual and psychological adaptation of all participants. Additionally, because of this reinforcement of face-to-face teaching and the contact between students and lecturers, there was a restructuring of the teaching teams for the clinical years. For example, there were contracts at 40% and all these contracts disappeared and became 30% contracts, and those 10% that were released in multiple contracts allowed hiring new people, younger in most cases, who joined teaching again.

At the moment, lecturers are in a phase of great dedication to new concepts. They are very attentive to the changes that have been made. They have a huge sense of responsibility and are concerned that everything runs as smoothly as possible, so that the reform is an asset for teaching.

Since you are very close to the students, how do they look at these changes in medical education?

João Eurico da Fonseca: Students have had many opportunities to participate to clarify their doubts. Again, the timing was very positive. Why? Because it enabled preparing generations of students for reform. The students who are now in year 3 and will move on to year 4 are students who have known about the reform for a long time. Basically, they have already assimilated that they are going to be involved in this innovation. I dare say that they look at it with hope, curiosity, and motivation to have a higher quality education.

There are, of course, fears. We all are afraid of change, that is how human beings are. It's one thing to go from year 3 to year 4 knowing exactly how it's going to happen, because our older colleagues tell us how it went. It's another thing to suddenly start doing something that no one else has done. And that raises concerns about new assessment methods, for example. But I think the students are confident and willing to have a more innovative, creative education. So, the acceptability is very good.

How does one create a good doctor?

João Eurico da Fonseca: My view on creating good doctors includes several aspects. There is one that is most easily provided by a medical school because it is, in the end, what is done internationally. Students entering medical school, in general, are used to studying, otherwise they would have failed the demanding and competitive access system. Therefore, they are a group of people who are used to studying, which in itself is a reasonable basis for training good doctors. Nobody comes to the medical degree if they don't like to study or at least are not prepared to study. Students might not like to spend long periods on individual reflection, but they have to be prepared for it. This study allows students to gain knowledge that we might call basic. This knowledge is already very rooted in medical knowledge and which, despite the years, will remain, that is, a femur is always a femur, an aorta is always an aorta, the cardiac circulation is always the cardiac circulation. There are a number of issues that have remained unchanged for hundreds or at least dozens of years. And this corresponds to a large amount of what is already known and that has to be internalized within students with a minimum level of active memory capacity.

Then there is another aspect that has to do with patient contact and contact with clinicians. It is difficult for a good doctor to be just a scholar, a good doctor must have minimal contact with realities. Although throughout the life of doctors these realities will reinforce their knowledge, we cannot send doctors into clinical life if they have not had contact with older doctors, lecturers with clinical experience, and with patients. This has to be offered.

But these two aspects correspond to the package we already know. What will differentiate doctors' careers? Their attitudes. And here it's not just about the practice of medicine, it's about all professional areas. People are prepared with certain sets of information and then it is their attitudes that differentiate them. And this aspect is inherent to each one of us and that is difficult to change. This ranges from genetic aspects to behavioural aspects of children's psychomotor development, family development, school development. We are dependent on our own past. But during the years that students are in our Faculty, we can improve these characteristics and especially make them more aware. Often, we are not aware of how we  are and we need to make students aware of what they are, how they should be, and how they are expected to act.

And how is the doctor expected to act? It is essential that the physician be empathetic. No matter the specialty, the doctor has to be able to be close to someone and be able to communicate with that person. He has to have the ability to actively listen. If the doctor just listens (pauses and folds his arms), that won't do either. Despite the concern not to interrupt the patient too much, he will never be satisfied if he has a doctor like that looking at him (he makes another long pause and has a closed expression). The attitude of empathic listening includes not interrupting inappropriately the other person, and also giving any signal, as Leonel did at the time of my break, who shook his head to create an interaction. In other words, the doctor has to know how to dialogue with other people and this is essential to make the clinical history, to understand what the patient feels and to allow for the patient's education. No doctor can get an effective consultation if he doesn't educationally convey what he wants to say. If the doctor's communication is not effective and the doctor hesitates, what the patient will do is seek a second opinion and this is not beneficial for the doctor most of the time.

Then, the therapy guidance, whether it is medical or surgical, is very important. If empathy does not allow the translation of information that is understandable by the patient, he will not comply with the therapy, or will not want to be operated on. A good example is the current situation regarding SARS-COV-2 vaccination. When the patient expresses hesitation in relation to vaccination, the doctor will have to know how to take a stand in relation to the issue of vaccination, deconstruct the myths, be empathetic and, in some cases, be dramatic. And this has to be conveyed to the students. Students must know medicine and also communicate and be empathetic.

This is an attitude, and also a technique, which is part of the so-called soft skills. It is normal that young physicians, aged 23 and 24, who have just graduated, do not have the confidence they are supposed to have to deal with certain situations, as older individuals at the height of their professional activity. But part of that trust can be trained and will be included in this reform.

 

At this moment, which areas are under your coordination?

João Eurico da Fonseca: I am director of the Rheumatology University Clinic and of the Institute of Clinical Semiotics, two structural units.

At this moment, my responsibilities, in year 3, are teaching the subjects Introduction to the Clinic and Clinical Internship. These functions, from year 3, are transversal and impact on students and my day-to-day because it is a continuous activity that never stops. In year 3, I am also responsible for the area of diseases of the locomotor system, which is a biannual activity with a much lighter component for students.

In year 5, I am very involved in the Medicine II module, which I coordinate together with Professor Helena Cortez Pinto and also in my disciplinary area, which is Rheumatology.

This overlapping of year 3 with year 5 sometimes represents some overload, but looking at it on the positive side, it helps me to have a more holistic view of the clinical preparation of students. This is because I contact them at the beginning of year 3, still without any clinical contact, and I'm back with them later at the end of year 5, when they are supposed to have the peak of their clinical preparation. This helps me to better understand how clinical education progresses and have had a clearer notion of the students' insufficiencies, their difficulties, the demanding needs that we have to place and, also, maybe I have gained more awareness of the minimum level we have to demand. Future doctors will have an activity with a lot of autonomy and responsibility for human lives. The concept of a minimum score (10 out of 20) in medical education is complex to define and should be an ongoing conscientious exercise by lecturers.

Then I work in other medical areas, including the integrated master degree in biomedical engineering, in a more superficial way, giving some theoretical classes. It is normal and healthy within the faculty to have this sharing of technical knowledge in different areas.

 

Leonel Gomes

Editorial Team