Participation on academic leagues
The participation of students of our sample in AL is huge, with only one student claiming not to have participated in this experience. On the other hand, 35 students (39.3%) participated in three or more AL during graduation. This data is similar to that found in a 2018 study in Minas Gerais, where only 5.9% had not participated in any league and 35.3% had participated in three or more leagues during graduation (7). However, it is much higher than that found in newcomers to the 2017 medical residency in Bahia, where only 6.3% had participated in 3 AL (18).
Also, 16 students (22.5%) participated in 5 or more LA during graduation, with one of them participating in 10 leagues, showing that several students participate in several different AL during the period. In Juiz de Fora/MG, only one student (0.8%) had participated in 5 leagues (7).
Academic leagues exist in 97.8% of medical schools in Brazil (19). On the School of Medicine of PUCRS, there was 52 active AL on the time of this research (20), being that in 2013 there were only 5 (5). This diversification of AL pulverizes the actions and further increases student participation, increasing the chance of finding a league that meets their own interests.
In our sample, 43.7% entered AL in the first semester of the course, and 43 students (61.4%) who participated in an AL had their first experience in their 1st year. This particularity was not found in a 2018 study, where only one student entered an AL in the 1st period and only 10% participated in the league in the 1st year (7). Apparently, interest in AL is becoming increasingly precocious, bringing the concern with early specialization, since one of the motivations for participation in AL is the interest in the area of expertise, for future specialty choice (10).
This risk of early specialization is also more evident when analyzing the discourse of specialty societies by encouraging the creation of ALs in their area, as a way of making their specialty better known. Thus, they include undergraduate students in their own events and bring them closer to specialist professors, leading to an increase in the interest of recent graduates in specialties (8).
At the PUCRS School of Medicine, mostly of the ALs have only one professor, sometimes as many as three. The form of teacher participation in the AL was not questioned in our study, but in other study, the students mentioned that the teachers participated by helping in practical activities, as mentors or as guides for the discussion. In some AL, however, the teaching activity was delegated to a medical resident (10).
Other complementary activities
The student seeks to add experiences for professional performance with complementary activities, going after activities that differentiate him (2). Among these motivations, there is an attempt to fill curricular gaps, integrate with colleagues, supplement the course, obtain well-being, or respond to professional inquiries (21). In 2007, another Brazilian study found an average of 3.4 complementary activities per student, who dedicated, on average, 8.2 hours per week to them (22).
Almost all our students (95,77%) participated in extracurricular internships during graduation, compared to about 70% in a similar 2018 study (7). Among these activities, the teaching monitoring stand out (77.46% of students), along with scientific initiation (66.19%) and volunteer work (54.93%). Also, the student organization and Athletics were cited.
We can verify that, even with the oncoming of the AL, students continue to participate in other complementary activities. In fact, the profile of students who participate in different leagues is like those who participate in several different complementary activities, with a moderate correlation (r = 0.46) between the number of AL that the student participated and the number of other complementary activities.
Considering that AL are formed by the same group of students who can carry out research activities, similarly to Scientific Initiation, they include management and administration skills, such as student movement, organizing internships, holding events, schedules of theoretical classes. They can, united in a single activity, absorb the benefits of several complementary activities.
Recommendation of the participation on academic leagues
NPS is a measure of recommendation through one question. More clearly, with strong correlations, we found that the more AL a student participated, the higher his NPS, that is, his grade of recommendation. Also, the more satisfied the students reported being with the activity, the more they recommend participating in the AL. This finding corroborates the idea of a “virtuous circle”, in which the more satisfied the student is, the more AL he participates in, the more he recommends participation to his peers, increasing the overall participation of students in AL. This increase in participation causes more AL to be created, reaching more students, causing the AL to have reached this level of almost total student participation.
When using the NPS to assess how much a student would recommend to their peers to participate in AL, we had some groups that recommended more than others. Based on the recommendations, we can raise some hypotheses about the reasons, although these were not directly questioned in this study.
Students who have already entered an AL in the first semester of the graduation recommended it more than those who did not participate (NPS of 53.33 x 5.26). It is possible that due to the early entry into the AL, this student profile already has prior information about them, or due to the exposure time, it created a positive culture about the AL, recommending its participation.
Those who already had the defined specialty also recommended it more in relation to those who were still in doubt (NPS of 38.46 x 19.51). The cross-sectional nature of our research does not allow us to say whether the definition of the specialty makes the students participate and recommend the AL, or if the participation in the AL makes the student define the specialty. But in a study that sought to relate the AL to the specialty, about 80% of the students judged that the participation in the AL helped in the choice of the specialty, with 41.4% for the exclusion of the choice and 39.1% for the confirmation of the specialty (7).
Students with medical family members also recommended more (NPS of 42.5 x 3.70). We raised the hypothesis, although not tested, that those students with medical family members are already more inserted in the care context, knowing more about medical specialties and the job market itself. Thus, they could recommend more participation in the AL.
Also, students who are in their final year of graduation recommend AL more than those in their penultimate year (NPS of 57.14 x 17.31). As final year students are already in a phase of graduation in which the selection processes for medical residency are closer, they can recommend participation more in view of the score in selection processes, which usually score participation in complementary activities, in general, and AL, in particular.
So, in short, students who are now in the 6th year, who have already entered the first semester in an AL, who already have a doctor in the family and who have already chosen their specialty, recommend more the participation in AL. These are the groups that are closest to the job market, with a defined specialty, coming from a more traditional family profile. Would it be possible, then, for this group to associate the AL with a more traditional and conservative curriculum?
Publication of scientific papers
By understanding the Evidence-Based Medicine paradigm, as a conscious, explicit and judicious use of the best current evidence in making decisions about individual patients, it is imperative to train the future doctor so that he can read and evaluate new publications. As provided in the Guidelines themselves, graduation should make the future doctor able to “learn to learn” and prepare him for decision-making “based on critical and contextualized analysis of scientific evidence” (1).
In our study, more than half of the students had already published at least one paper, and most of them related it to their participation in an AL. Also, there is a correlation between the average of published papers and the number of AL in which the student participated, suggesting that the more AL he participates, the greater the tendency to publish.
Academic research during graduation, even among students who do not appreciate it, makes them acquire knowledge and relevant tools for professional practice, in addition to improving several other skills due to the effort for its execution (23). The elaboration of academic research also makes the knowledge about the scientific method solidify in the student.
Traditionally, in Brazil, participation in research projects and publication of academic works was restricted to students participating in Scientific Initiation programs. However, with the growth of AL, they are enhancing the inclusion of students in research projects. And, by the nature of ALs, there is an opportunity to dilute that knowledge and the development of knowledge building skills.
Student socialization through the academic leagues
Medical school is a period in which there is a great intellectual and emotional burden on the student, which can bring intense psychological suffering to the student. Among the potential stressors during graduation, the following are traditionally remembered: excessive workload, difficulties with studying and time management, conflicts in the balance between professional and personal life, relationships among colleagues, health concerns and financial problems. More recently, problems in the administration of medical schools, concerns about lack of support and guidance in career management, and pressure on performance in assessments are also included (24).
The relationship among colleagues, due to the competitive environment, can be harmful to mental health and generate performance anxiety. However, the existence of support groups, formed by “colleagues” that the student can call “friends”, relieves the tension. In this context, mentoring activities are used by several schools, as a process of orientation and guide the student in a longitudinal and transdisciplinary way during the course, which helps the student in decisions during the course, especially in the hidden curriculum (25). A specific type of mentoring is the peer mentoring, where mentors and mentees are students. Participation in peer mentoring programs facilitates students' adaptation to the academic environment at the higher level, helps professional development and, above all, personal performance, and reduces stress (26).
Following the mentoring objective, with benefits already studied and published (25, 26), ALs can work in a similar way, considering that they are groups of students, from different years, with the presence of one or more teachers. Thus, the AL would not be restricted to the study of the thematic area itself, but in its own personal growth and orientation around other activities during the graduation.
In American and Canadian medical schools, “learning communities” gain strength, which are longitudinal groups of students and/or professors with the objective of learning from each other. These groups are sustained by conveying a sense of belonging, influence, and shared emotional connection, while meeting the individual needs of each of their participants (27).
Another aspect to be considered in Brazil medical schools is the change that occurs in high school student, often still living with their parents, who, upon entering university, progress to an independent life, in another city, far away from family, friends and familiar surroundings. In our sample, more than half of the students were from another municipality, and only 52% were living with their families. This demonstrates how much the institution needs support, especially in the initial moments of the college.
The educational environment directly interferes with the quality of life of the medical student. A Brazilian multicenter study that evaluated quality of life found worse scores in the teaching environment, especially in the last years of the course. The authors suggest institutional interventions that improve the environment, encourage the formation of support networks and promote the well-being of students should be implemented and evaluated in medical schools. (28). Among these interventions, institutionalizing and encouraging AL can improve well-being.
The lack of leisure time is cited as a stressor, and extracurricular activities, in general, are listed as a form of relief. In fact, students tend to remember the figure of the doctor in popular ideas (as a priest fully dedicated to his neighbor) as something that hinders their dedication to free time during training, making a student who has leisure feel going against his or her nature (21).
In addition to the psychosocial support and friendships that inclusion in groups can provide, it is notable that undergraduate students are at an important time in creating personal and professional connections that can help them in their future professional careers, also known as networking (29).