Proliferación de escuelas de medicina en Latinoamérica: causas y consecuencias / Proliferation of medical schools in latin America. Causes and consequences

Significant changes in university education have occurred in Latin America, caused by the strategic importance that it has on economical and social development. The educational system expanded and science, technology and informatics, experienced an important development. The eighties were characterized by a reduction in government expenditures, a more efficient use of resources, an increase in the number and variety of universities and university students. The creation of new universities, mostly private, was favored by a highly unregulated market. In Latinamerica, more new universities were created during the eighties than in the previous one hundred years. Since 1981, the number of universities in Chile increased from 8 to 60, the type of institutions was diversified, the government financing of public universities decreased substantially and the regulatory role of the market was emphasized. These changes have been quantitatively understandable but qualitatively unsatisfactory. Since 1981, the number of university students between 19 and 24 years old has triplicated. The number of medical schools and the annual admission of students has duplicated. In most Latin American countries, there is an insufficient number of physicians (Chile has one physician per 783 inhabitants). Since the decade of the nineties, an effort has been made to regulate the market, to introduce new barriers for the acceptance of new educational institutions, to improve the transparency of the system and to preserve the quality of teaching. The quality control of medicine and health is one of the most serious problems in Latin American countries. This includes accreditation of medical schools, health centers and specialists. In Chile there have been some progress in these topics but quality control is still unsatisfactory.

[Quality control in Medicine. Position of the Chilean Academy of Medicine]. / Control de calidad en medicina. Posición de la Academia Chilena de Medicina.

In the last two decades, important changes in medical training and care have occurred in Chile. The number of medical schools has been doubled, exceeding the national availability of professors and qualified training fields. The quality assessment and accreditation of medical training and care is insufficient in Chile. A National Autonomous Corporation of Certification of Medical Specialties, has certified more than 4,000 physicians in 44 specialties. The Chilean Association of Faculties of Medicine has accredited training centers during the last four decades. The National Commission of Undergraduate Training Accreditation, has developed a voluntary system for medical school accreditation. The Academy supports these strategies and considers that accreditation does not threaten institutions or individuals. It is rather a mechanism that identifies strengths and weaknesses of institutions and programs. This will finally result in better quality in medical training and patient care.

[Sources of error in clinical practice]. / Fuentes de error en clínica.

The clinical setting is everything that contact us with the patient's reality, including physical, instrumental and laboratory exploration, and we use it for diagnostic and treatment purposes. Diagnosis is the synthesis by which physicians conclude an elaborated analysis of subjective and objective data, obtained by physical exam and technology. This procedure involves data collection about the patient and his disease, the results of various tests and laboratory findings, the interpretation of the data and a diagnostic summary. Medical errors may be derived from insufficiency in any of these phases. It is evident that technology will never replace the intellectual data recollection, analysis and reasoning that is the physician's art. This contribution underlines some of the defects frequently observed in clinical practice that may cause medical errors.

[It is time to think about patient's rights. An introduction]. / Es hora de pensar en los derechos de los pacientes. Una introducción.

The underlying purpose of the Hippocratic oath and most medical ethics codes dictated during the twentieth century, is patient protection. Nowadays, however, clients of health services do not conform themselves with ethical declarations of the medical profession but demand that the rights that arise from those declarations, become legal instruments that force professionals, health authorities and governments to satisfy their health needs and respect their individual rights. Probably this is a consequence of the depersonalization of medical care, the weakening of ethical bases of physician-patient relationship and the emergence of new economical and social philosophies. Now, clients also have more expectations and a better knowledge about medicine than in yesteryears. Citizen organizations to defend health rights should not be seen as a threaten to medical profession and health institutions but as an opportunity to improve health care and respect towards people. They should not either harm the mutual confidence between the physician and his patient, nor the beneficial spirit of medical act, two fundamental components of medical acts.

[Availability of physicians in Chile and its medium-term projection. 5 years later]. / Disponibilidad de médicos en Chile y su proyección a mediano plazo. Cinco años después.

According to a prospective study performed in 1993, Chile had 14,400 active physicians (excluding those over 70 years of age) and a physician/inhabitant ratio of 1:960. The estimated projection for 1998 was of 16,244 physicians and a ratio of 1:921. However, during the present decade, the number of medical schools in Chile has duplicated, increasing by 38.4% the number of available posts in Medical schools. Also, 1,297 physicians graduated abroad, have been incorporated. Therefore, previous projections must be revisited. The present study shows that in 1998, Chile has 17,441 physicians (1:850), will have 20,610 (1:765) in 2003 and 24,449 in 2008. This last figure means a physician/inhabitant ratio of 1:679, similar to that of countries with a consolidated market economy. The foreseen medical population increase rate of 3.5% doubles the general population increase rate. To assure the quality of medical training, a Medical School accreditation process is being held. This study highlights the need to review bilateral agreements subscribed with five countries, that recognize the physician degree without assessing the medical skills of foreign graduates.

[Claudio Costa Casaretto M.D. (1914-1999) in Revista Medica de Chile]. / El Dr. Claudio Costa Casaretto (1914-1999) en la Revista Médica de Chile.

The work of Dr. Claudio Costa Casaretto covers a broad field in the history of Medicine in Chile. He contributed with the historical aspects in the Centennial issue of Revista Médica de Chile in July, 1972. He published 85 papers in this journal in a lapse of 20 years. In his works, he investigated about medical personalities with the highest relevance for Chilean medicine such as Dr. William Blest, graduated in Edinburgh and director of the first Medicine Course in Chile in 1833, the French obstetrician Dr. Lorenzo Sazie, first Dean of the Faculty of Medicine of the University of Chile in 1843 and Dr. Eloisa Díaz, first physician graduated in Chile and South America in 1887. He published the translation from Latin of Juan Ignacio Molina's verses "Elegies to smallpox", Chilean writer and erudite of the XVIII century. He also undertook the origins of Universidad de San Felipe (1737), Universidad de Chile (1842) and Pontificia Universidad Católica de Chile (1889) and the main educational events occurred in the Faculty of Medicine of the University of Chile, during the past century. He also published about the public health situation and sanitary care during the XIX century, about the conflict between private and public teaching and other political events of the past century. The work of Dr. Costa as a whole, is a real history textbook of Chilean Medicine. Dr. Costa and Dr. Enrique Laval are the most important Chilean medical historians of the XX century.

[Trends in current medicine]. / Tendencias de la medicina actual.

Predicting the future of medicine is daring. One can speculate about some of its future traits at the most. The spectacular progress in biological sciences has nurtured the hope that medicine will be able to dominate all ailments, improve the quality of life and longevity. Physicians are uncomfortable with the weak knowledge that they have about some diseases such as cancer, connective tissue diseases, degenerative diseases, mental and psychosocial conditions. They are also worried about the aggressive and mutilating surgical procedures that are required nowadays. One can foresee that molecular medicine and applied technology will advance at a great speed and will modify the therapy of several diseases and the social organization of health care. Scientific progress will also change our values and will pose new political and economical challenges. I believe that medical ethics and bioethics will become a growing concern for medical education and professional organizations. The so called biotechnology century will also be the bioethics century. The revision and elucidation of the fundamentals of medicine will differentiate, in the future, a medicine devoted to mankind with a solid ethical background from an impersonal health care that considers man as an object or maybe a merchandise. The second option will cast medical care through the abyss of decadence, to its end.

[The Hippocratic Oath]. / El Juramento Hipocrático.

The impact of Hippocratic Oath on medical practice is universally recognized. However, some physicians raise questions about its validity and few medical schools use it in graduation ceremonies. It is postulated that this oath does not harmonize with present bioethical concepts and that the principles of beneficence, lack of harm, autonomy and justice, elaborated by Anglo-Saxon philosophers, would do so. The Hippocratic Oath contains these principles and many others, such as gratitude, compassion, justice, honesty, humbleness, sanctity, integrity, confidentiality, fidelity to the bond, and respect for human life and dignity. These are ethical values that apply to modern dilemmas in medicine. As a whole, the oath expresses an ideal of medical behavior and a life project. It must be interpreted in the context of ancient Greek culture and history. Some uncertainties about its relevance are due to a lack of understanding of its exceptional content of values. Modified versions of the oath or original texts presumptuously pretend to replace a document that has lasted 2500 years and that meant a revolution, not only to medicine, but for all mankind. Students should have the opportunity to analyze its content and the way its values are related to concrete situations of present medical practice. Medical schools should shelter it without objections, as the expression of a reflexive compromise acquired by physicians during their studies and to be applied in medical practice.

[Revista Médica de Chile: a long and beautiful educational task]. / Revista Médica de Chile: una larga y hermosa tarea educacional.

Revista Médica de Chile is one of the oldest medical journals in the world. Since its foundation in 1972, it had an educational character. Its successive editors and members of editorial committees have been distinguished clinicians, investigators and teachers. The diffusion of this journal among physicians and students for more than a century, renders it as a pioneer form of continuous distance education and could be considered as a "silent and peaceful campus". Through the years, this journal has coped with the progress in medical and biological knowledge,the perfecting of graphic arts and editorial processes and the development of computing. It has improved its management and professionalized the editorial process. In the near future, this last aspect will need further improvements due to its increasing complexity. The journal adheres to international publication norms for scientific manuscripts and is connected to international associations of medical journal editors. The editors have assumed the professional and ethical responsibility of controlling that publications provide valid information in a language intelligible for most readers. This compromise implies an independent work and the rejection of any form of undue pressure. We can state that Revista Médica de Chile, as a whole, is a historical document and that its pages reflect the capacity and intelligence of several generations of Chilean physicians.

[Bioethics in contemporary medicine]. / Bioética en la medicina contemporánea.

Bioethics arose in a delicate social and political moment in the United States of America. With time, it has become a social and perhaps political movement. Its scope is wider and different than that of medical ethics. Bioethics appeared in the second half of the twentieth century, in the middle of a spectacular advance in biological knowledge and technology. Meanwhile, medical ethics was formulated in the fifth century B.C. in relation to medical care. This defines the main focus of their respective interests. Anglo-Saxon philosophers, deriving from moral philosophy, applied the principles of beneficence, no maleficence, justice and autonomy to medicine. The Hippocratic oath refers specifically to the first three and to a number of other ethical principles. Nothing in its contents, contradicts the principle of autonomy. The emphasis in the principle of autonomy that some specialists in bioethics pose, even over the principle of beneficence, is determined, according to our judgment, by inherent factors of the North American culture. We believe that medical ethics should be distinguished even though not separated from bioethics. Physicians should go back to the Hippocratic oath as the fundamental guide for their professional activity.

[The care of the terminally ill patient]. / El cuidado del enfermo terminal.

Drs. Alejandro Goic (internist), Ramón Florenzano (psychiatrist), Bernardino Piñera (physician and Catholic Bishop), Sergio Valdés (internist) and Rodolfo Armas (internist) participated in a round table about the care of the terminally ill, during a Postgraduate Course organized by the Chilean Society of Gastroenterology. After a general introduction, participants discussed the psychological aspects of terminally ill patients, about the sense of death from a Christian anthropological perspective, the terminally ill in intensive care units and finally about the education of medical students in this frequently neglected aspect of medical practice.

[Physicians' strikes and health services: an ethical perspective]. / La huelga médica y del sector salud: una perspectiva ética.

For the public opinion, medical strikes are a controversial issue; physician's ethical judgments are also different. The present article analyses the requisites to consider legitimate a strike and, based on these, the ethical duties of physicians; the features of medical unionism; the ethical duties of authority; the manipulation of ill people by the strike and the social factors that may cause these conflicts. In a medical strike, universal ethical values based on the Hyppocratic oath and promoted by the profession, are endangered. This article concludes that a medical strike may be explainable due to different reasons, but it is not ethically justifiable beyond any doubt. The health profession that is not prepared to give up strikes as gremial pressure tool, should not choose a profession that takes care of the ill. The best way to avoid medical strike is to prevent them: the society and the authority have the ethical obligation to create work conditions that elude conflicts. To settle disputes between physicians and health institutions, the creation of a permanent arbitral instance agreed by physicians and the authority, i.e. a high level committee integrated by respected individuals and physicians, could be necessary. This committee should send forth veredicts that would be obeyed by the contending parties.

[Training of internists]. / Formación del médico internista.

The role of internists has been extensively debated in the last decades. Chile has a 40 years experience in specialist training, based on USA hospital residency programs. The universities have tuition of programs and financing comes from the Ministry of Health. The Chilean Association of Medical Faculties accredits training centers. The present paper proposes a profile for internists (referred as an adult general physician) in the areas of attitudes and behaviors, knowledge and skills. The features, training areas and educational experiences that the internist should have, based on the described profile are also pointed out. Current training programs should be modified, since they have become the vestibule for super-specialization rather than conducting to the practice of general internal medicine. The internist's amplitude and integration of knowledge, fine clinical skills based on medical interview, physical examination and therapeutic mastery, differentiates him from sub-specialists.

[Who finances medical research in Chile?]. / Quién financia la investigación médica en Chile?

To identify those institutions granting medical research in Chile, every issue of Revista Médica de Chile published between 1987 and 1994 was reviewed, under the assumption that a vast majority (over 70%) of papers released by Chilean authors in topics of internal medicine and related subspecialties would have been submitted for publication in this journal. This assumption was based in the solid prestige of Revista Médica de Chile among Chilean physicians and investigators: it is one of the oldest medical journals in the world (founded in 1872) and its inclusion in the most important international indexes (e.g. Index Medicus, Current Contents) qualifies it in the "mainstream literature". Papers classified as "Original Articles", "Clinical Experiences", "Review Articles", "Public Health", "Case Reports", "Clinical Laboratory", "Special Articles" and "Medical Education" were screened for acknowledgment of financial support beyond the resources needed for routine clinical work. Among 1,528 manuscripts published, 344 were "Original Articles" and 61.3% of them acknowledged special financial support. Five hundred and one manuscripts were "Clinical Experiences" and 21.5% of them received special financial support; similar proportions were detected in "Review Articles" and "Public Health" topics. The institution ranked as providing support most often was the "Fondo Nacional de Ciencias y Tecnología" (FONDECYT), a governmental fund that assigns resources to research in all areas of science and technology through a peer-reviewed nationwide annual contest. FONDECYT was identified as provider of financial support to 45.2% of the "Original Articles" and "Clinical Experiences"; Chilean universities were mentioned by 33.6% and other entities (including pharmaceutical companies, other national and foreign organizations) by 23.1%. The University of Chile was the main Chilean university mentioned in the acknowledgments. The proportion of papers receiving special financial support was lower in Revista Médica de Chile than in three leading journals from developed countries (70% of Articles published in Annals of Internal Medicine, 74% in Lancet and 78% in The New England Journal of Medicine) but this proportion has been steadily increasing since 1987. The increase has been due only to FONDECYT and it would be unreasonable to expect that this institution will maintain such an expansion indefinitely. Therefore, Chilean investigators should attract more resources from the universities, the pharmaceutical companies and other non-governmental institutions.

[Geographical distribution of physicians in Chile]. / Distribución geográfica de los médicos en Chile.

In 1994, Chile had 15,451 active physicians (less than 70 years old) for a population of 14,027,344 with a ratio of 1 physician per 908 inhabitants, a satisfactory figure compared to other countries of similar socio-economical development. Ratios of 1:880 and 1:843 are projected for 1999 and 2004 respectively. The annual rate of physician's population growth (2.2%), that is superior to the general population's growth rate (1.6%), will increase to about 2.5% per annum in 2001 as a consequence of the creation of three new medical schools. However, the distribution of physicians along the country is unsatisfactory. While the capital (Metropolitan Region) has a ratio of 1 physician per 629 inhabitants, the figure for the Region of Maule is 1:2,113. Only two of ten regions, excepting the capital, have a ratio lower than 1:1,000. Sixty percent of physicians live in Santiago while only 40% of the general population does so, illustrating their high concentration. Median ratio in Chile, that better reflects the reality than the mean, is 1:1,280. The heterogeneous distribution of physicians in Chile is a sign of social inequity that must be corrected. In a free society a better physician distribution is achieved with economical and professional incentives given by health institutions.

[Development of traditional careers at new universities. The case of medicine]. / Creación de carreras tradicionales en nuevas universidades. El caso de medicina.

In 1981, the educational system in Chile was diversified characterizing Universities, Professional Institutes and Technical Training Centers. The provincial seats of traditional Universities were transformed in independent universities, which strongly increased its number. A number of private universities also emerged. This strategy was quantitatively successful, duplicating the number of youngsters between 19 and 24 years old that were following superior studies (from 88 to 199 per 1,000) and duplicating the registers at higher education institutions (from 118,000 to 244,000). The quality of the education is a matter of concern at the present time. In the case of Medicine, the Medical Schools Association has proposed to the Higher Education Council an accreditation system for programs that pursue the M.D. degree, based on explicit standards for all medical schools. Considering that teaching, research, laboratory and library resources in Chile are limited, accreditation is even more important. The splitting relationship between Medical Schools and the Ministry of Health, whose establishments are used as training centers, is also worrisome. Finally the physician:inhabitant relationship in Chile is adequate for its development level (1:960). Its geographical distribution, however, is highly unsatisfactory (1:657 in Santiago and 1:2,200 in some Regions). The implementation of professional and economical incentives could reverse this situation.

[160th anniversary of the Chilean school of midwifery: in the path of Sifra and Pua]. / 160o aniversario de la carrera de obstetricia: en la senda de Sifrá y Puá.

Midwifery is one of the oldest professions. However, the first attempts to train midwives appeared only in the seventeenth century and the first maternities, that become training centers, arose in the eighteenth century. Legal Norms for training and practice of midwifery began to be dictated during nineteenth century in Holland, Scandinavia, Germany and France. It is thus noteworthy that a young country as Chile is celebrating the 160th anniversary of the School of Midwifery, one of the oldest in the world. After the Independence, Chile gave great impetus to education, numerous european professors were hired and the school of midwifery was founded in 1834 by Dr Lorenzo Sazie, a french surgeon and obstetrician. Due to its nature, midwife education must emphasize the ethical aspects of the profession. Since ancient times, midwives are committed with human life. Hebrew midwives Sifrá and Puá, disobeyed the Egyptian King's order to kill all male newborns, and were rewarded by god, as mentioned in the Old Testament. On the other hand, during the Obstetrics course opening in 1835, Dr Sazie underscored the ethical demands of the profession, exhorting students to be "mankind ministers".

[Establishing new medical schools in Chile]. / Creación de nuevas escuelas de Medicina en Chile.

In Chile there are six established medical schools at public (Chile. Valparaiso and Temuco) or private (Catholic. Concepción and Austral) universities created between 1833 and 1971. Since 1990, three new medical schools (two private) were created and a fourth is projected, concerning the chilean medical corps. We present three position articles on the subject written by Dean Pedro Rosso, from the Catholic University, Dr Pedro Castillo, Chief of Human Resources of the Ministry of Health and Dean Alejandro Goic from the University of Chile. Dean Rosso emphasizes the need to have assessment procedures that guarantee quality standards in the new medical schools. Dr Castillo attracts attention on preserving the compromise with the society, inherent to chilean medicine. Dean Goic analyzes systematically the reasons to prevent the proliferation of medical schools in the country, maintaining an equilibrium between freedom of teaching and public faith protection.

[Availability of physicians in Chile and its middle-term projection]. / Disponibilidad de médicos en Chile y su proyección a mediano plazo.

The availability of active physicians in Chile and its 5 and 10 years projections were studied. The number of inhabitants was estimated using the 1992 National Population Census and the number of physicians, using the 1980 records of the Chilean College of Physicians (year in which enrollment was mandatory for all physicians). A 1.6% annual population growth rate and a 5% physician mortality rate was applied (slightly lower that the general population mortality rate). The annual retirement from professional practice was estimated in 0.5% and physicians over 70 years old were considered retired. According to these figures, in 1993 the population is 13,816,990 and there are 14,400 active physicians, a physician/inhabitant relationship of 1:960 (in 1980 it was 1:1,407). The estimated number agrees with that of the 1992 National Population Census and the 1993 income tax declarations. According to projections, in 1998 Chile will have 14,958,292 inhabitants, 16,770 physicians and an inhabitant/physician relationship of 1:921. The figures for year 2003 will be 16,193,867; 18,597 and 1:871 respectively. On the other hand, the study reveals a reduction in the number of admissions to medical schools and of graduated physicians and a reduction in the annual physician population growth rate from 5 to 2% (slightly higher than the general population growth rate). Depending on the economic growth estimations and the needs for medical attention for the next decade, the admission shares for medical schools should be revisited.