Acuña, Leopoldo E. MD, PhD
he first university in the current territory of Argentina was founded by the Jesuits in 1613 and is still active today. The second to be founded and the largest by far is the University of Buenos Aires, dating from 1821. During the 19th century, teaching and learning followed closely the examples of European universities.
A milestone in domestic education was the so-called University Reformation of 1918.1 This was a huge national movement, led primarily by students from all over the country, that revolted against “the privileges for only a few.” The movement’s results were positive: from that time forward, every citizen was entitled by law to a free university education. In that era, Argentina was, relatively speaking, a rich exporting economy. Nonetheless, funding alone could not solve all of the difficulties associated with this massive change in educational policies. Students were now organized into powerful national associations, which had a strong voice regarding educational issues. Because education was now free and few to no entrance requirements existed (other than completion of secondary education), public universities had to admit enormous numbers of students each year, students of very diverse educational backgrounds and levels. Not surprisingly, management problems at the universities increased. Still, for many years, the educational system in Argentina was strong overall.
During the periods corresponding to the two great world wars, Argentina was economically prosperous, and its medical schools enjoyed a reasonably stable political situation. By this time, there were eight medical schools in the country, three in Buenos Aires, and five scattered in the interior. Two of those eight were private, run by members of the Catholic church, and the other six were supported by the government
Beginning in the 1940s, however, political conditions changed. Furthermore, coups d′état, in the 1950s, 1960s, and 1970s, and the governments established by them, created increasing social problems to which few solutions were offered. Educational policies also became erratic.
In 1983, after the Falklands War (or Malvinas War, as it is known in Argentina), the country returned to democracy and entered a steady period of national reconstruction.
In the 1980s and 1990s, new medical schools were created. In this country of 37 million inhabitants, there are now 23 schools of medicine, 11 of which are state-supported universities--probably still the more prestigious--and 12 of which are private. Half of all schools are located in or near Buenos Aires.
National University of La Plata School of Medicine, Argentina
Length of medical school program: Six years; will change to five years in 2004-2005.
Level of education required for admission: Secondary education.
Average number of students who matriculate each year: 350-500 (from a pool of 1,500 applicants).
Average number of students who graduate each year: Unknown; there is no “deadline” for the completion of medical school, and the number of “chronic” students makes it difficult to determine how many students who matriculate ultimately graduate.
Cost of medical education per student: Free at all public universities.
Number of medical schools in Argentina: 23 (11 state-supported, 12 private).
The National University of La Plata School of Medicine
The National University of La Plata was founded in 1897, and its School of Medicine was created in 1905, with a curriculum following the example of the most prestigious medical schools in Europe and the United States. In the first years of this century, medical education flourished. However, as I stated above, this situation decayed during the following decades and eventually fell below the prevailing international standards for excellence, sharing the national collapse in education that started in 1940s. This situation continued for half a century.
In an attempt to improve the quality of its medical education program, in 1993 La Plata pioneered new policies for admission to medical school. Despite complaints and legal refutations from students’ associations, La Plata now requires applicants to pass a written assessment of high-school knowledge in order to be admitted to the university and its medical school. Approximately 1,500 students apply each year, and about 350 to 500 enter medical school.
In 2004-05, La Plata will implement a new curriculum in which the total number of hours for education and training increases from 4,200 distributed along six years to 6,000 distributed along five years. In 2005, students will have the opportunity to train in practice (something like U.S. clerkships) and to take elective courses, including humanities courses. One goal of this new curriculum is to encourage students to study medicine full-time, not part-time as most do today. Unfortunately, two problems may jeopardize the achievement of our goals. First, in spite of La Plata’s admission requirements, there remain about 5,500 “chronic” or unsuccessful students attempting to complete their studies. This situation severely interferes with normal teaching and training activities. Second, and more significant, is the severe financial crisis in Argentina, which has seriously jeopardized this project.
The annual budget of the School of Medicine is the equivalent to about US $2,000,000. Of that amount, roughly 90% is devoted to the salaries of about 1,400 people: 150 professors, 1,000 teaching instructors, and 250 other staff and employees.
Looking Back in Joy: The Introduction of Medical Humanities at La Plata
In 1976, elective courses in the medical humanities were added to La Plata’s curriculum. Subjects covered at that time were philosophy, anthropology, and medicine and the arts. This expansion of the curriculum was justified on the grounds that studies in the humanities had successfully been implemented in medical schools in developed countries, where this innovation was seen as highly relevant to medical education and health care.
In 1980, with the dean’s support, the Institute of Medical Humanities was officially created. Alas, there was not a budget assigned to it. Nonetheless, four faculty members joined the institute: a medical doctor and philosopher who became the institute’s first chair; myself, a general surgeon interested in the relationships between medicine and the arts; a well-trained but unemployed medical anthropologist; and an expert in medical education who worked part-time in the medical humanities program and was paid by another department of the university.
The activities in the Institute of Medical Humanities were originally described as being “complementary” to medical education. Courses and seminars were attended by medical school graduates who were attempting to gain specialty-level academic credits. Medical students were also encouraged to participate freely, in the hopes of promoting this new discipline.
The curriculum implemented by the institute expanded on the curriculum first offered in 1976. It included a variety of subject areas: behavioral sciences (psychology, sociology, law); literature and the arts; and the history and philosophy of medicine, which encompassed courses in medical anthropology, medical epistemology, and medical axiology.
Difficulties with this scheme, however, soon arose. In general, participants had no theoretical background in philosophy, no real interest in anthropology, and were reluctant to consider the arts as a priority in medical education. Axiology and epistemology--understood respectively as a general theory of values and as the foundations of scientific knowledge--seemed attractive global paradigms but proved complicated for an everyday approach to the humanization of medical practice. Participants’ negative attitudes were further reinforced by the fact that the nonmedical professors responsible for teaching some of these subjects were not held in very high esteem by the prospective doctors. Oddly enough, prospective faculty apparently were not bothered by this; many people teaching humanities elsewhere thought our experience was valid and expressed their interest in joining the faculty, even when the positions were still “ad honorem.”
In addition to the above problems, funding remained an issue. The university did not fund the institute’s faculty positions. We trusted this would be solved promptly, but this did not prove to be the case. Obviously something had to be done to salvage the humanities program. The faculty decided to (1) find alternative means of financial support, (2) encourage incoming faculty to go abroad to study the medical humanities field, and (3) develop and implement a single course in a classic humanities discipline, ideally one in some way already familiar to students.
We achieved each of these objectives. Financial support, although scarce, was soon obtained from such private institutions as foundations and pharmaceutical companies.
The institute initiated relationships with prestigious universities in both the United States and Europe (mainly Spain and Germany) and sent faculty there for further study. This decision proved particularly wise because, apart from providing enhanced academic skills to new teachers and professors, such international links represented, both then and now, the basis for domestic acknowledgment of the academic value of medical humanities. Finally, the annual course that inaugurated our program was the history of medicine, with a total of 50 hours a year, a length of time that ensured the awarding of credit hours to participants.
Implementing the Revised Curriculum
For the history of medicine course (which was first offered in 1983), short texts (about three pages long) from well-known medical writings were chosen. Participants were expected to comment on each selection. Whenever possible, texts were analyzed during a single session, thus allowing participants, the majority of whom were young doctors, to finish the work in less than an hour. This approach did not result in deep analyses, but it proved appropriate nevertheless: participants contrasted these sessions--and favorably so--with their daily medical activities in the office or at the hospital. The course also seemed to promote students’ extensive voluntary reading of nontechnical literature.2 The course was, and still is, well accepted and at that time provided a wide range of teaching and learning possibilities.
Soon, participants, who enjoyed their work with historical texts, suggested that texts of another kind might provide another fruitful area of study. Therefore, in addition to continuing this course with its orientation around medical texts, a course on medicine and literature was created and offered during subsequent terms. This was soon followed by courses in medical anthropology, bioethics, and what we call medical kalology on a similar schedule as the one used for the history of medicine. Each is described in greater detail below.
Medicine and Literature
Fine literature proved useful in defining more clearly the humanistic as opposed to humanitarian aspects of our institute. Our early experiences in developing this course can best by summed up by a line of a poem by the Spanish wordsmith Antonio Machado (1875-1939): “Caminante no hay camino, se hace camino al andar” (“Wayfarer, there isn’t any road; you make the road as you go on”).3
In 1983, a regular course on medicine and literature was offered to students and young doctors. The analysis of theater proved particularly effective, since participants were able to take the parts of characters in play-reading performances during the sessions. Each class thus turned into a sort of “medical drama” with noteworthy personal involvement on the part of the participants. Plays we have used in this course are Man with a Flower in His Mouth (in fact, a case of epithelioma of the lip) by the Italian Nobel laureate in literature, Luigi Pirandello, and The Doctor′s Duty (a moral dilemma of a country doctor).4 Students also read fiction and poetry, the latter represented mainly by works of the Argentine poet Almafuerte, Seven Medicinal Sonnets.5
This course has been the most successful and longest running of all the humanities courses. A good part of its success can be attributed to the participation of a professional anthropologist who addresses the students using language from the natural sciences as well as medical terminology.6 The regular annual course on medical anthropology is considered by young professionals to be the most relevant to everyday medical practice. This perception led the institute to propose a more rigorous method of performance assessment for this particular course, and consequently multiple-choice exams were implemented in 1993.
Although this was not part of our original plans for the humanities program, a course in bioethics based on the guidelines issued by Georgetown University was established in the mid-1980s. During the academic terms that followed, this innovative course established its own momentum. Eventually the study of bioethics broke away from that of medical humanities, a split that also took place in other universities throughout the world.
Under the broad rubric of “medical aesthetics,” the general features of the fine arts and music have been used for the purpose of teaching medical humanities.7 However, we found the term “aesthetics in medicine” too ambiguous for teaching purposes. Therefore, an attempt was made to delineate more clearly the relationship between the arts and medicine. The faculty felt that a good starting point was to try to find an alternative wording. Medical “kalology,” which is an as-yet-unrecognized term, was introduced by the institute for its heuristic application.8 Kalòs is the ancient Greek word for “beautiful,” specifically beauty in music and dance.9 Because medical kalology follows the conventions of medical terminology,10,11 we hope the term will be less ambiguous (and more “scientifically medical” as students usually demand) than “medical aesthetics.” (We describe our definition of this term in greater detail in our original Journal of Medical Ethics article.12)
Medical kalology seminars were first held in 1993 both in La Plata and--as a result of an international agreement with the Ruprecht-Karl Universität--at the Naturwissenschaftliche Fakultät in Heidelberg, Germany. A course on music and medicine was offered under the title “The Physician on Stage: Opera,” in which the roles of medical characters in opera were analyzed. Participants read through librettos while listening to the music.13 Both the German and the Argentine participants found this use of opera to be a valid and original way of depicting different aspects of medical practice, aspects rarely seen in other artistic genres.
The Institute of Medical Humanities Today
More than 20 years have elapsed since the first attempts at teaching medical humanities. In La Plata, the Institute of Medical Humanities is alive and well. History of medicine continues to be the core course; medicine and literature has gained a place as a valid alternative; bioethics and medical anthropology are being taught by more than one department of the medical school; medical kalology is striving to be accepted under that name.
Course attendance has been stable for over two decades. The number of participants per year is around 50. It must be stated that this is not a required subject in the syllabus, but one that nonetheless provides credits to those attending the courses. A drawback, however, has been the lack of adequate course evaluation. Effective systems of assessment are yet to be designed. While the number of faculty has grown very little, a permanent exhibition of medical instruments has been incorporated into the institute, together with its curator and a rare books librarian.
The underlying essence of the teaching of medical humanities as an academic discipline at La Plata continues to be aimed at shifting the concept of medicine as a healing art toward the more humble, less pompous (though absolutely realistic) depiction of medicine as an alleviating art. Our program is no longer the only one in Argentina; although most focus primarily on bioethics, other medical schools have found a place for the humanities in their medical curricula. Sadly, the economic crisis that struck Argentina at the beginning of 2002 is conspiring against the continuation of the medical humanities program as well as all other teaching activities.