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Rev.bras.educ.med.vol.38no.4RiodeJaneiroOct./Dec.2014
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ABSTRACT

Thetransformationsthatmedicalpracticehasundergoneinrecentyearsespeciallywiththeincorporationof
newinformationtechnologiespointtotheneedtobroadendiscussionsontheteachinglearningprocessin
medicaleducation.Theuseofnewcomputertechnologiesinmedicaleducationhasshownmanyadvantagesin
theprocessofacquiringskillsinproblemsolving,whichencouragescreativity,criticalthinking,curiosityand
scientificspirit.Inthiscontext,itisimportanttohighlightartificialneuralnetworks(ANN)computersystems
withamathematicalstructureinspiredbythehumanbrainwhichprovedtobeusefulintheevaluationprocess
andtheacquisitionofknowledgeamongmedicalstudents.Thepurposeofthiscommunicationistoreview
aspectsoftheapplicationofANNinmedicaleducation.

Palavraschave:EducaoMdicaRedesNeuraisArtificiaisMedicina.

INTRODUCTION
Themanyfacesofmedicinecareandprevention,episteme/knowledgeandtechne/art,reasonandintuition
havebeenwalkinghandinhandintheWestsincetheirbirthinAncientGreece1.Technologicaladvancementsin
thelasthundredyearshavemadeincreasinglynecessarytodebatetherelationshipbetweenmedicineand
biotechnoscience2highlightingtheissuesconcerningtheaccesstonewinformation.Suchdebatesmustinvolve
generalistsandspecialiststhatwilldeal(actuallyinmanyacircumstancehavebeendealingalready)inthe
nearfuturewithnumberlessadvancementsuntilrecentlyunimaginableincludingnewmethodsoftransplant,
minimallyinvasivesurgeries,nanomedicine,telemedicineandroboticsurgery3,4.Thesefrontierscertainly
appearaspossibilitiesofmaximizingqualityofcaretotheill,adimensionpursuedbythosewhowithart,
zeal,humanandsocialcommitmentpracticemedicine.

Asinanytechne/episteme5,theprogressandtheactoffindinganswersbringintowatangleofnewquestions
thatpreviouslycouldnotevenbeformulated.Itbecomesindeedcrucialtoapproachmedicaleducationwithin
thescopeofthecurrentbiotechnoscientificchanges,discussingtheconceptsthatarenowadaysrelevant,
despitethefactthattheymayseemdistanttothecolleaguethatpracticesmedicinedaily.

Inthiscontext,ArtificialNeuralNetworks(ANNs)aformofnonalgorithmiccomputationalmodels
characterizedbysystemsthattosomedegreeresemblethestructureofthehumanbrain6,7gainrelevance
duetotheirpotentialtomedicine.TheANNareparalleldistributedsystemscomposedofsimpleprocessing
unitsusuallycalledartificialneuronsinanalogytobiologicalneuronsarrangedinoneormorelayersand
interlinkedbymultipleconnections8.

Itsarchitectureprovidesoutstandingperformancesincetheusualprocessofproblemsolvingisbasedon
learningandgeneralizations,whichareprovidedbyadaptingitsparameterstoasetofpatternspreviously
presented9.Theabilitytogeneralizeinotherwords,tolearnthroughasetofexamplesandgivecoherent
answerstounknowndatamakesitpossibletosolvecomplexcomputationalproblems.

TheexcellentperformanceofANNswhichforseveraltypesofproblemsprovetobefarsuperiorto
conventionalcomputermodelshascontributedtotheadvancementofvariousplayingfieldsintheclinical
practice10.ExamplesofsignificantresultswiththeapplicationofANNsinproblemsofthemedicalfieldare:
Supportindiagnosis,predictionofriskandprognosis,interpretationofdiagnosticmethods,developmentof
epidemiologicresearches,amongothers11,12.

Basedonthesebriefconsiderations,theobjectiveofthispaperistopresentaliteraturereviewaboutthe
applicabilityofANNsinmedicaleducation.

METHODS
Thepresentworkwasbuiltbasedonaliteraturereviewwithdefinedsearchstrategy.TheU.S.NationalLibrary
ofMedicine(PubMed)andtheScientificElectronicLibraryonLine(SciELO)wereconsultedfortheperiod
between1/1/1990to31/12/2013.Thetermsusedwere:

Strategy1:MedicalEducation+ArtificialNeuralNetworks

Strategy2:ArtificialNeuralNetworks

Strategy3:ArtificialNeuralNetworks+Medicine.

Besidesthearticles,referencebooks,PhDtheses,Mastersdissertations,guidelinesandofficialdocuments
relatedtothethememorespecificallytomedicaleducationandthehealthfieldwereconsulted.

Theresearchallowedtoidentify3.578citationstheirdistributionisfoundontable1amongwhich35
manuscriptswereselected.

TheeligibilitycriterionofchoicewastheexpositionoftheANNapplicabilityinmedicaleducation.

RESULTSANDDISCUSSION
Afterreadingandanalyzingthechosentexts,thecollectednoteswereorganizedinthreesectionsmedical
educationandthenewtechnologiesartificialneuralnetworksartificialneuralnetworks:Usesinmedical
educationpresentedhereafter.

MEDICALEDUCATIONANDTHENEWTECHNOLOGIES

ParticularlyinBrazil,theConstitution13,promulgatedinOctober5,1988,showsamarkedlyprogressive
dimensionconcerninghealth,statedparticularlyinthearticle196whichdeterminestheStatesroleasfollows:

HealthisarightofallandadutyoftheState,guaranteedbymeansofsocialandeconomicpolicies
aimedatbothreducingtheriskofillnessesandothergrievancesandensuringtheuniversaland
egalitarianaccesstoactionsandservicesthatpromote,protectandrecoverit(p.33).

InthissamevanguardmovementTheUnifiedHealthSystem(SUS)14iscreated,havingforfoundationthe
article198thatstates13:

Thepublichealthactionsandservicesintegrateahierarchicalregionalizednetworkandconstitutea
singlesystemorganizedaccordingtothefollowingguidelines:

Idecentralization,withoneonlydirectionineachsphereofgovernment

IIcomprehensivehealthcare,withprioritygiventopreventiveactions,withoutprejudicetocare
services

IIIcommunityengagement(p.3334).

Inordertoestablishparametersabletoguaranteewithexactnessthetrainingofaprofessionalapttoofferthe
envisagedqualityservices,theResolutionCNE/CESNo4,November7,2001,thatinstitutestheNational
CurriculumGuidelinesfortheUndergraduateCourseinMedicine15,initsarticle3,proposestheprofile:

TheundergraduateCourseinMedicinehasastheegressgraduate/professionalprofile,the
physician,trainedasgeneralist,humanist,criticalandreflexive,abletoactguidedbyethical
principlesinthehealthdiseaseprocessinitsdifferentlevelsofcare,withhealthpromotion,
prevention,recoveryandrehabilitationactions,inacomprehensivecareperspective,withsenseof
 socialresponsibilityandcommitmenttocitizenship,asapromoterofthehumanbeingintegral
health(p.1).

Toachievetheseobjectivesoneshouldhaveaclearunderstandingoftheneedtobroadentheindispensable
skillsforthepresentrealityoftheworkingworld,whichinaglobalizedcontextofrapidlyspreadinformation
andincreasinglycomplexsciencedemandsdifferentcompetenciesfromtheonespreviouslyconsideredfor
practicingtheprofession16.Thisisnotexclusivelyabouttheabilitiesforthemedicalpractice,butalso,about
thecapabilitiesthatarerelevanttoallhealthcareprofessionals,likeanewapproachtointerpretingreality,
dealingwithscientificconceptsandbenefitingfromthetechnologicalpotentialitiesinaresponsibleway,vital
conditionstofollowtherapidpaceofadvancementsinsociety.

Educatingisessentiallyforming17,18.Thus,therolebothoftheeducatorandtheEducationalInstitutionsis
certainlynotrestrictedtoofferinginformationandmuchlessreducingtheeducationalexperiencetomere
technicaltraining17.Itfallstotheman/womanwhoteaches/learnsanotherman/womanthebuildingofatrue
subjectsubjectrelationship,educator/pupil 19.Itisthepraxisthatimpliesaction/reflectionfrommen/women
upontheworldtotransformit.Thisscenarioprovidesroomfornewteachinglearningmethodologiesand,
equally,newformstocreate,teachandpracticemedicine20,2122.Indeed,itisimperativetothetwentyfirst
centuryprofessionaltocoadunatehumanandtechnologicalknowhow22,23.

Inthelastthreedecadesthehealthcaremodelhassufferedseveralchanges,mainlybytheincorporationof
computersciencetomedicine,withconsequencesbothtotheproductionofknowledgeandthemedical
practice24.Theunfoldingofnewnuancesinunderstandingthehealthdiseaseprocesstheholisticapproachto
thehumanbeing,theenvironmentalroleindeterminingsickness,theadvancementsinscientificknowledgeand
thedevelopmentofincreasinglycomplexguidelinesandprotocolsfordiagnosisandtreatmentofdiseasesall
pointtothechallengeofcreatingwaystoapprehendthem25.

TheusesofANNsinmedicinegainrelevanceinsuchcontext,insofarastheirpotentialforthesolutionof
problemsinvariousbiomedicaldomainshasbeeninvestigated26,27.Thistechnologicalresourcehasreached
growingrelevanceandapplicabilitybothinteachingandevaluationinmedicalschool,beingusedinnumberless
situationswhenthereisarelationshipbetweenvariablesinputsandpredictiveresultsoutputs8.Fourbasic
fieldsarenoteworthy:Modulation(simulationofbrainfunctionandneurosensoryorgans)processingbioelectric
signals(filteringandevaluation)diagnosis(controlandcheckingofanswersandinterpretationofresults)
prognostics(retrospectiveanalysisofstoredinformation)11,28.

ARTIFICIALNEURALNETWORKS
ANNsarecomputationalsystemswithamathematicallogicstructureinspiredinhumanneurophysiology6.Data
processingstartswithalearningphaseinwhichasetofdataofalreadyknownanswersispresented,altering
theforcesofconnectioninthenetworkinsuchawaythattheANNanswersareassimilaraspossibletothe
answersobservedinthetrainingdata.ItisexpectedthatsubsequentlytheANNacquirestheabilityto
generalize,thatis,thecapabilitytofurnishanswerstopreviouslyunknowndata8.

ThestudyofANNsisanattempttoimitatebiologicalneuralsystems,withtheobjectiveofbuildingpowerful
automatedlearningtechniques29,32.InawaysimilartotheH.sapienssapiensbrain,anANNiscomposedofa
setofnodesinterconnectedbyroutedlinks.ThefirstmethodproposedforanANNwascalledperceptron33.In
thismodeloffairlysimplearchitecture,onlytwotypesofnodesarepresent:Inputnodesandoneoutputnode.
Nodesofthefirsttyperepresenttheattributesoftrainingexamplesaswellastheinstancesthatwillbe
submittedforclassificationbythenetwork.Theoutputnoderepresentstheclassificationoftheinstancein
question.Besides,eachinputnodeisconnectedtotheoutputnodebyaweightedlink.Theweightsrepresent
thestrengthofthesynapticconnectionsbetweenneurons.Notethatthehumanteachinglearningprocessalso
consistsofalteringthestrengthofsuchconnections,basedonarepeatedlyproducedstimulus.Inthe
perceptron,theoutputnodecomputestheweightedsumofinputs,includingatermofinfluence,orbias,that
servestoproducesomevalueinthecaseallweightsarenull.Thus,alinearcombinationofinputvaluesis
conducted.Subsequently,theoutputnodemakesuseofasimpleactivationfunction,verifyingthesignofthe
valuetoproducethefinaloutput.Ifthevalueisnegative,thentheoutputis1,otherwisetheoutputis+1.
Thesevaluesindicatetheclassoftheinstancebeinganalyzed.Therefore,theperceptronlearningprocessisthe
adaptationofweightvaluesuntilanacceptablerelationbetweeninputandoutputisobtained,accordingtowhat
isobservedintheinstancesoftraining33.Oncetrained,itisexpectedtheANNtobeabletogeneralizethe
knowledgeabouttheelementsinquestion,soastoclassifycorrectlyfutureexamplesforwhichthe
classificationisstillunknown.

Inordertoallowmodelingmorecomplexrelationshipsbetweeninputandoutputvaluessoasto,forinstance,
permitnonlineardecisionboundariesormorethanonedecisionboundarytherewasasignificantevolution
fromtheperceptrontoamorecompletenetworkarchitecture,themultilayerartificialneuralnetwork.Inthis
model,anANNcancontainseveralintermediatelayers,thehiddenlayers.Furthermore,itcanusemore
complexactivationfunctions,suchashyperbolictangentfunctionsandsigmoidfunctions32.Itisalsopossibleto
includemorethanoneoutputnode.AllthesefeaturescombinedprovidemorepowerfulandflexibleANNs.

Anotherelementthatlendspowertoartificialneuralnetworksisthepossibilityofmoreelaboratetrainingssuch
astheapplicationofthebackpropagationmethodinwhichthedeviationbetweenobservedandexpected
outputsisusedinasophisticatedformulaofweightcorrectionwherealterationsareappliedinreverse
direction,i.e.,weightsatlayerd+1aremodifiedbeforeweightsatlayerd32.Figure2showsanANNwithonly
onehiddenlayer,forthesakeofimagesimplification.

AnotherinterestingcharacteristicofANNsisthepossibilitytoprovideprobabilityvaluesasoutput,insteadof
justclassvalueslikepositiveandnegativeoryesandno30,31,32.Forexample,toperformthetrainingofan
ANNthatwillindicategivensomeonesattributessuchasweight,height,age,andthepracticeofphysical
activitywhethertheriskofcardiacproblemsexistsornotforacertainindividual,suchoccurrencesinprevious
patientsmustbeprovidedtotheANN.However,itisverycommoninsuchscenariostofindindividualswith
exactlythesamecharacteristicsbutdifferentresults,namely,despitebothshowingthesameattributevalues,
onepresentsheartproblems,whiletheotherdoesnot.Insuchcases,itmakesmuchmoresensetopresentthe
tendencyofoccurrenceofaneventthaninformthatitdoubtlesslywilloccur.Theideaisthatalthoughthereare
manyindividualswithidenticalcharacteristicsbutdistinctresults,thenetworkwilldetectwhichofthose
possessingsuchattributevalueswillbemoreorlesslikelytopresentcertainclinicoutcomesuchasamorbid
cardiovasculareventbased,forinstance,inthefrequencyofacertainresultintheseindividuals.Toprovide
probabilityasoutput,itiscommontousesigmoidfunctions,sincetheyperformamappingbetweenoutput
valuesandthecorrespondingvaluesintherange[0,1]thatcanbeinterpretedasprobabilities30,31,32.Figure3
exhibitsasigmoidfunction.Onecannoticeinthefigurethatnegativevaluesaremappedtoprobabilities
smallerthan0.5,whilepositivevaluescorrespondtoprobabilitiessuperiororequalto0.5.Thishappens
becauseclassifiersthatexhibitprobabilitynormallyconductthetraininginsuchawaythatthevalue0.5isused
todecidetowhichclassaninstancebelongs.However,althoughthevalues0.6and0.9,forexample,indicate
thesameclass,thesecondvalueprovidesagreaterdegreeofconfidence.

Anotheradvantageintheuseofprobability,concerningtheANNs,regardstheperspectivefortheuserof
analyzingvariouscutoffvaluesnotonlythevalue0.5beingabletoverifytheratesofmisclassificationthat
themodelpresentswithrespecttothetrainingdatainquestion.Thereat,itispossibletostudythecost/benefit
ofusing,forexample,ahighercutoffvalue,thuslosingsomeinstancesbut,ontheotherhand,reachinga
higherpercentageofprecisioninthedetectedinstances30,31,32.

ARTIFICIALNEURALNETWORKS:USESINMEDICALEDUCATION
NumerousstudieshavedemonstratedtheroleofANNsinmedicine,fromthestudentseducationtothe
physicianspractice(Table2).

Theuseofnewcomputertechnologiesinmedicaleducationhasbroughtcountlessadvantagestotheprocessof
acquiringskills34.Inthisperspective,theANNshavebeenincreasinglyusedinmedicalteaching,sincetheyare
acomputermodelextremelyusefulforsolvingcomplexclinicalproblems35.Moreover,positiveeffectsinthe
studentsteachinglearningprocesshavebeendescribed,withhighercapacityofinformationstorage,
systematicdataanalysisandthedevelopmentofnewapproachestosolveeachproblempresented35,36.
Thereat,medicaleducationcanbefavoredwithagreatervarietyofknowledgeandwaysoflearning,meeting
theneedsthatthepresentimposes:Amyriadofabilitiesthemedicalprofessionalrequirestoact15,37.

ANNshavealsobeenusedinthestudentsevaluationprocess,whentheyreexposedtothesimulationofa
clinicalcase38.Anotherstudysuggestedtheopportunityofstudyingthedynamicsofthelearningprocessin
clinicalandlaboratorialdiagnosis,bothindividuallyandcollectively36,38,39.

ComputerprogramsweredevelopedusingthelogicofANNsandhavedemonstratedthecapacitytobuild
severalskillsliketheproficiencyinthesolutionofclinicalproblemsassociatedwiththeconveniencesofboth
beingportable,offeringinteractivityandimprovinglearningwithsimulationsandgraphicresources40,41.These
programsofferanalternativetolabclassesoncetheyallowtosimulatesituationswithvariablesofdifficult
handlingorthatcannotbealteredjointlywithothers40.Itshouldbenotedalsothatthecomputermodelsthat
simulateneuralfunctioningaregainingincreasedapplicationinmedicine,enhancingscientificresearchhelping
tobroadknowledgeaboutcountlessmorbidconditionsandfurtheringthedevelopmentofnewdiagnostic
methodsaswellasnewapproachestoprognostics41,51.Researchesaimedatsituationswithbioethics
implications52includingtheprocessofdecisionmaking53,54havealsobeenconducted.
Suchobservationspointtothenecessityofchangingmedicalcurriculumandtrainingstudentsinthesenew
technologies24.Infact,incorporatingANNstomedicaleducationwillonlymakesenseanddemonstrate
applicabilityalongwithpedagogicalchangeineducationalinstitutionsandareflectionontheactofteaching55.

FINALCONSIDERATIONS
TheANNtechniquerepresentsamultidisciplinarycooperationinvolvingthefieldsofneuroscience,
mathematics,computerscience,andstatisticsbeingappliedtovariousproblemsindifferentareas,including
medicine.Itsabilityinrecognizingpatternsiswidelyappliedinimagerecognition,spectralanalysis,decision
makingincomplexproblemslinearandnonlinearamongothersubjects.

ResearchtargetingANNshasenabledthedevelopmentofhighperformancecomputingwithnetworked
processorsassumingtheroleofneuronswithemphasisonitshighprocessingcapacity.Furthermore,the
advancementsinthecognitivecomputationalareacontributetothebuildingof"intelligent"machines,skilledin
controlandsignalprocessing.Itshouldnotbeexpectedasinglemachinetosolveallproblems.Buteach
intelligentmachinecanacquireaspecificapplicationnotably,inthiscontext,theapplicationofANNsinthe
fieldofmedicineandthemedicineteaching.

AUTHORSCONTRIBUTIONS
RodrigoSiqueiraBatistadesignedwithFbioRibeiroCerqueirathestructureofthepresentpaper,and
contributedequallyinthiswork.SubsequentlyRodrigoRogerVitorinodevelopedundertheirsupervisionthe
firstversionofit.AndriaPatrciaGomes,AlcionedePaivaOliveira,RicardodosSantosFerreira,Vanderson
EsperidioAntonioeLuizAlbertoSantanaundertookthefinalrevision.

CONFLICTOFINTEREST
Theauthorsdeclarenoconflictofinterest.

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CORRESPONDENCE
RodrigoSiqueiraBatista
UniversidadeFederaldeViosa
CampusdeViosa
DepartamentodeMedicinaeEnfermagem
AvenidaPeterHenryRolfs,s/n
CampusUniversitrio
ViosaMG
CEP:36570900
Email:rsbatista@ufv.br
FbioRibeiroCerqueira
UniversidadeFederaldeViosa
CampusdeViosa
DepartamentodeInformtica
AvenidaPeterHenryRolfs,s/n
CampusUniversitrio
ViosaMG
CEP:36570900
Email:frcerqueira@gmail.com

Recebidoem:28/03/2013
Reencaminhadoem:20/04/2014
Aprovadoem:20/08/2014

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