The traditional curriculum model was developed with reference to the Flexner report of 1910 [8
]. In this, medical education was considered to be a process of initiation in a science. The teachers' role was to establish what students must learn, to transmit information that was considered relevant, and to evaluate students' capacities to retain and reproduce the information presented. Theory would be dealt with before practice, with the aim of preparing students for the use of theory during students' internship and subsequent professional lives. In this model, medical practice is detached from scientific practice, thereby promoting fragmentation of knowledge and neglect of the psychosocial and cultural aspects of medical activities [9
]. This teaching approach has been criticised for the excessive value given to content and for its low efficacy, which brings about the subsequent need for re-qualification. We believe that this "banking concept of education" that Freire [10
] refers to is conclusively condemned to history.
On the other hand, the teaching concept of meaningful learning calls for linkage between the roles of universities, health care administrators and social services. It suggests that there should be co-operation in the selection of content, production of knowledge and development of professional competence. In meaningful learning, the teacher is no longer the main source of information, but the facilitator of the teaching-learning process. The teacher's aim is to stimulate the learner to take on an active, critical and reflective attitude in the knowledge building process. The content dealt with must have the potential to be meaningful (functionality and relevance for professional practice), giving value to matters that are pertinent and correlatable with students' cognitive structure. However, the absorption by students of knowledge of the so-called basic subjects in this context presents a great challenge [11
The curricular directives for medical courses (Report 583/01, of August 7, 2001) from the Brazilian National Education Council (part of the Ministry of Education) give guidance on the changes to be made to the teaching model for courses. They indicate that courses must involve students in practical activities from the outset and promote active integration between health care service users and professionals from the beginning of their instruction, using methodology which reinforces students' active participation in knowledge-building, thereby bridging the gap between academic medical learning and the social needs of Brazilian health care. It is evident that the new curricular directives have used the concepts and logic of problem-based learning as their reference point. They have been based on various American and European curricula that, over the past decade, have been giving emphasis to free time for self-study instead of traditional lectures [12
]. Thus, more than half of the medical schools in the United States are at present undergoing a process of curricular reform [15
], as are a large proportion of the medical schools in the United Kingdom [16
In the "problematization" methodology based on Maguerez's Arch, as presented by Bordenave [18
], five phases develop from reality: observation, key points, formulation of theory, putting forward of solution and application to reality (Figure ). This is an alternative methodology that is appropriate to higher education. It differs significantly from problem-based learning in some points that are summarised in Table (adapted from Berbel, 1998 [19
Main differences between "problematization" and problem-based learning.
In problem-based learning, the cognitive objectives are all previously established, while in "problematization", total control over the resultant knowledge does not exist. The essence of problem-based learning is that the problems define objective concepts to be learned and non-objective concepts that can be excluded from the learning because they are not relevant to the study in question [16
Although it may be difficult and scientifically dangerous to compare results from conventional curricula (lecture-based learning) and models like problem-based learning or "problematization" [20
], this was not our intention. Our only objective was to evaluate a teaching tool that is already well known and make a contribution towards discussions on curricular reform.
The present study does not prove that the "modernised" curriculum is better than the previous one, but it emphasises that the strengths of the "new" curriculum are worthy of more exploration. In our opinion, the perception that a qualitative improvement in students' learning has taken place during the course is the first step towards a more substantial and effective change in the teaching-learning process. In the present study, the intention was to transform a totally theoretical course into a more stimulating and efficient course. In this, concepts acquired during classes would be applied clinically to real cases obtained by the students themselves in the wards. A recent study at Manchester University [16
] has shown that changing a conventional course into a new integrated course, using problem-based learning throughout, has significantly improved recently graduated students' perceptions of their preparedness for entering the professional market.
There was no significant difference in students' evaluations of the use made of the time available for the subject between the two groups, because there was already a positive assessment among the 2002 group (Table – item 1). Likewise, students gave positive evaluations regarding their perception of lecturers' concern for their learning. Although there was no significant difference between the groups in relation to this question, there was a mild tendency towards increased positive evaluation among the 2003 group (Table – item 2).
An improvement in the assessment of the course can be seen from item 3 of Table onwards. From 2002 to 2003, there was a significant increase in the positive rating given to clarity and teaching abilities in the classes taught. At first, this seemed odd to us, considering that the teaching material used and the staff who taught the theory classes were identical for the two groups. We concluded that the insertion of clinical cases and practical classes into the traditionally theoretical course was the decisive factor in students' perception that the 2003 lessons had improved. Although the fact that the questionnaire was administered at the time of the final assessment test may have had an influence on the data, the questionnaire was administered on the same occasion for each of the two year-groups.
The decrease in the rating of lecturers' punctuality can be easily explained by the fact that the theory classes were always predictably held in the same place in 2002 (group I), while group II used various locations that were specially booked for them. On some occasions in 2003, unexpected events occurred at the beginning of the activities (Table – item 4).
Assessment tests for Obstetrics and Gynaecology are traditionally considered to be difficult. There was a perception in our school that they did not reflect the overall knowledge of the subject that is required. The tests consist of forty to fifty multiple-choice questions (each with five alternatives presented) and five essay-type questions. The former perception can be seen among the 2002 year-group in item 5 of Table , alongside the significant improvement among the 2003 group. This indicates to us that the 2003 year-group studied with greater satisfaction and interest, stimulated by the new process, and that this group consequently made the interpretation that there was greater coherence in the preparation of tests. Nonetheless, the tests did not undergo any substantial change from 2002 to 2003. Despite this improvement in the rating, we are still far from achieving the desired positive evaluation rate for the quality of our tests, and the present study shows us that the tests need to be improved.
One of the most important objectives in a change in the teaching system is to obtain greater course efficiency and increased student learning. Items 6 and 7 of Table show us that, at least with regard to student perceptions, this aim has been achieved. Our assessment is that the change in the teaching system was very stimulating for the development of students' study routines. The holistic concept of modern education directs us towards integrating knowledge, understanding and practice for learners. In this, learning is taken to be an ongoing part of life and not just a preparation for it [24
]. In keeping with this view, the medical curriculum needs to drum into students the ethos of self-evaluation [7
Students responded well to the new method, as shown by the positive rating of 89% given by the 2003 year-group. This provides us with the basis for further advances in this subject in the years to come. It gives the staff the confidence to institute significant changes in the curricular reform that has been under discussion for three years.
Although the staff's level of satisfaction was not an objective of our study, initial observation of this indicates great commitment to the course and, probably, better performance. However, it will only be through future longitudinal studies that we will know whether there has really been greater consolidation of knowledge and course efficiency.