An innovative model for mental health care and educational support in Brazilian medical education context: Personal Development Planning (PDP) Framework CURRENT STATUS: POSTED

Background The prevalence of mental health problems among medical students have significant proportions worldwide. The spirit of time ( germ. Zeitgeist) is to “Act” in favor of health promotion. Methods Conception of a PDP-Framework in a Brazilian Medical School based on medical students’ needs and curriculum reform. PDP definition and model were based on QAA Guidance Document (2009). The PDP-Framework received approval from the rector of the University, and was endorsed by the students’ representations. PDP-Framework were included in the Course Pedagogic Project and shared with academic community. The implementation of the PDP started in the first-semester of the medical program in 2018. Results The main issues of the medical students were lack of time for extra-curricular activities, lack of mental health care and educational support. Based on these results we performed a curricular reform that reduced the hours of curricular activities in 30% and conceived the PDP-Framework. Our model was to embedded PDP into mainstream curriculum as a subject discipline one hour per week in tutorial groups of ten students, facilitated by two psychologists and one doctor specialist in all years of the medical program. We defined two main competences that foresee transitional skills, self-regulation, self-care, professionalism, resilience and personal, educational and career planning. Learning outcomes were defined for each semester. The PDP privileges active methods of learning based on the process of reflection and transformation of reality. Assessment of student performance includes both formative and summative manner with self-perception questionnaires, reflective writing, ePortfolio, and peer and teacher feedback. The PDP evaluation will be based on Kirkpatrick’s Model. Conclusions Evidence on interventions in educational environment for the promotion of medical students’ mental health is limited and the quality of the studies is generally low. Partial results of a national survey on support models for medical students in Brazil point to three mains models: psychopedagogical, mental health care and mentoring, optional and parallel to curriculum. The PDP-Model embebbed into mainstream curriculum in all years of the course seems to bring a new concept of mental-health care and educational support for medical students in Brazil.


Results
The main issues of the medical students were lack of time for extra-curricular activities, lack of mental health care and educational support. Based on these results we performed a curricular reform that reduced the hours of curricular activities in 30% and conceived the PDP-Framework. Our model was to embedded PDP into mainstream curriculum as a subject discipline one hour per week in tutorial groups of ten students, facilitated by two psychologists and one doctor specialist in all years of the medical program. We defined two main competences that foresee transitional skills, selfregulation, self-care, professionalism, resilience and personal, educational and career planning.
Learning outcomes were defined for each semester. The PDP privileges active methods of learning based on the process of reflection and transformation of reality. Assessment of student performance includes both formative and summative manner with self-perception questionnaires, reflective writing, ePortfolio, and peer and teacher feedback. The PDP evaluation will be based on Kirkpatrick's Model.
Conclusions Evidence on interventions in educational environment for the promotion of medical students' mental health is limited and the quality of the studies is generally low. Partial results of a national survey on support models for medical students in Brazil point to three mains models: psychopedagogical, mental health care and mentoring, optional and parallel to curriculum. The PDP-Model embebbed into mainstream curriculum in all years of the course seems to bring a new concept of mental-health care and educational support for medical students in Brazil.

Background
The evidence shows that concerns about undergraduate students' mental health exist for decades and the prevalence of mental health problems among medical students has significant proportions worldwide. 1 The estimated global prevalence rate for depression was 27% and 34% for anxiety among medical students . 2,3 In Brazil, the results of a multicenter study including 1350 Brazilian medical students from 22 medical schools on the prevalence of anxiety and depression symptoms showed a prevalence of 41% of depression symptoms, 82% of state-anxiety 86% trait-anxiety symptoms. 4 Ripp and colleagues published at Academic Medicine in 2017 an article with the title "Well-Being in graduate Medical Education: a Call for Action", which outlined initial recommendations at the national, hospital, program, and nonwork levels and were meant to inform stakeholders who have taken up the charge to address trainee well-being. 5 The spirit of time (germ. Zeitgeist) seems to be to "Act" in favor of health promotion also in undergraduate Medical Education. 5 The question is how?
The evidence on interventions for medical students' well-being, according to a systematic review of 28 studies, concluded that limited evidences suggested that some specific learning environment interventions were associated with improved emotional well-being among medical students. However, the overall quality of the evidence was low. The interventions associates with better quality of life were Pass/Fail Grading system, Mental health Programs, Wellness Program, Faculty advisor/mentor, Curriculum structure, Multicomponent Program Reform. 6 Partial results of a national survey on support models for medical students in Brazil point out to three main models: psychopedagogical, mental health care and mentoring frequently offered optional and parallel to curriculum. 7 The International Guidelines for Undergraduate Medical Education, as defined in chapter 4.3, by the World Federation for Medical Education (WFME), outlines that every medical school should have a system of social, financial and personal student counseling and support, with a guarantee of confidentiality. In addition, it should monitor student progress and assist with academic and personal planning. 4,8 The National Committee of Inquiry in Higher Education recommended in 1997 that UK universities introduce so-called "progress files" to document students' personal, academic and professional development. (relatórios de Derick e Garrick). 9 The Quality Assurence Agency for Higher Education (QAA) adopted this recomendation and solicitou para as Universidades a implementação dos arquivos de progresso em duas partes: 10 Transcription: a formal record of student performance maintained by the University Personal Development Planning (PDP): an informal personal record and developed by the student with teaching support.
The transcription is equivalent to the Brazilian's educational history that register grades and frequency of the students in the disciplines of the undergraduation' programs. 10 Personal Development Planning (PDP) is defined by QAA as "a structured process carried out by a student, with teacher support, of reflection on one's own learning process and academic performance, as well as planning for personal, educational and professional development. 10 Based on this evidence we aimed to concept an innovative model for mental health care and educational support for medical students in Brazil: The Personal Development Planning -Framework.

Methods
The conception of a Personal Development Planning -Framework (PDP) for medical students began with the definition and model design performed by a group of specialists on medical education and psychology. This process was based on medical students' needs accessed by a questionnaire, on curriculum reform and on the Quality Assurance Agency for High Education Guidance Documents of United Kingdom. 9,10,11 The questionnaire was developed and performed by the students´ representation CAMMA (acronym

Results
The results of the survey showed that the main issues of the medical students were lack of time for extra-curricular activities, lack of mental health care and educational support.
Based on these issues the hours of curricular activities were reduced in 30%. In the reform to a competency-based-curriculum, seven competencies were defined for the medical program. PDP-Framework based on two of them: Competence A and G ( Table 1). The two main competencies in which the PDP in based on foresee transitional skills, self-regulation, self-care, professionalism, resilience, personal development, educational and career planning.
We conceived a PDP-Model embebbed into mainstream curriculum as a discipline, with activities one hour per week in tutorial groups of ten students facilitated by two psychologists and one physician for all years of the medical program. The facilitators defined the learning outcomes for the semester and privileged active methods of learning based on the process of reflection. The assessment of students' performance includes formative and summative manners with national validated self-assessment questionnaires, reflective writing, ePortfolio and feedback (peer and facilitator).
The medical program in Brazil has six years (12 semesters) and it is divides into basic sciences, clinical sciences and clerkship.
We consider the periods between these three phases as transitions points including the transition from college to faculty as first transition and undergraduation to graduation as fourth transition. In these four transitions' points we emphasize the development of transitions' skills. In basic sciences period we emphasize also adaptation to medical education and personal planning. In the clinical sciences the emphases is on socioemotional skills' development, academic and career planning and in the last semester of the clerkship on the enhancement of the skills, career planning and transition to graduate life. (Figure 1)

Results Of The Peer-review
The peer-review of the PDP-Educational plan contributed to the enhancement of the learning outcomes ( Table 2)  prepares students for life beyond university; 6. it fosters belief-by sending a clear message that PDP is valued. 11 The voluntary approach seems to equate to "less important", and students have demonstrated that they will prioritize other "more important" activities. 11 The conception of PDP-Framework of the school of Medicine of PUC-PR considered this evidence and designed a model as a discipline embedded in mainstream curriculum from the first to the eighth and twelfth semester.
Evidence suggested that mentoring-model is also effective to support the students. 6 The group of specialists considered this evidence and designed for the PDP-Framework activities one hour per week in tutorial groups of maximal 15 students facilitated by one.
Peer-review of teaching is one tool that provides rich, qualitative evidence for teachers, quite different from closed-ended student evaluations. It has the potential to facilitate reflective change and growth for teachers. 13 The peer-review process of PDP-Educational plan carried out by teachers from different fields improved the learning outcomes and mental map providing significant reflective changes for the teachers as suggested in the AMEE Guide (2007).
Ron Thereza May (2008), ex-minister from UK, affirmed that young people want to grow to be confident and resilient, supported to achieve their goals and ambitions and we need to emphasize resilience development, health and well-being promotion, prevention and early intervention and to understand how we can do more to prevent mental health problems before they arrive. 12

Competing interests
The authors declare that they have non-financial competing interests concerning the study Consent for publication Not applicable Ethics approval and consent to participate This study is part of a research project entitled "Análise de programas de desenvolvimento professional docente voltado à implementação de metodologias para aprendizagem ativa na PUCPR" approved by the Ethical Committee of the institution (CAAE 65161317.0.0000.0020). All participants in the study signed the informed consent.