Centeno, Angel M. MD
International medical education is gaining interest worldwide because of the globalization of societies and the increased mobility of physicians. The World Health Organization (WHO) has stated that there is a shortage of well-trained health workers, mostly in the countries that need them most. With that need in mind, in 2003 the WHO launched the Global Standards for Medical Education initiative in conjunction with the World Federation of Medical Education.1,2 This has led to a new interest in setting international standards for each medical school, to allow physicians from one country to work more effectively in another one. Although it is necessary to accept and respect local characteristics of medical schools and to avoid imposing a model from one setting onto another, it is also necessary to achieve and maintain standards of scientific rigor and educational quality around the globe.
Transferring human resources (i.e., health professionals) is a new issue to be considered when planning for a health system. The increased mobility of trainees and physicians to different areas and countries has also created ethical problems, because significant numbers of health professionals from less wealthy countries (where their numbers are scarce) choose to continue their training and even their practice of health care in wealthier societies. As an example, in the United States, physicians who are international medical graduates represent 25% of practicing doctors.3
Because of this new interest in international medical education and the other issues mentioned above, Academic Medicine has included several articles in the present issue to provide readers with more information about the medical education systems in various countries outside North America. In this article, I present a brief overview of medical education in Argentina and the context in which it has evolved.
The first medical schools in Argentina were founded at the beginning of the 19th century, at the University of Buenos Aires in 1821 and at the University of Córdoba in 1877. During the 20th century, three national medical schools were created, and in 1958 national educational laws authorized the establishment of the first two private medical schools, the University del Salvador and the Catholic University of Córdoba (both founded by the Jesuits). The number of medical schools remained steady until the 1990s (seven total); in that decade, there was an explosion of new schools. Twelve medical schools were created during the 1990s, and another 10 opened at the beginning of the 21st century, bringing the total for the country to 29 today. Each of these medical schools is affiliated with a different university. Ten of the schools are state owned, and 19 are private universities. There is no single answer as to why this has happened in Argentina, a country with an oversupply of physicians, or why it has happened in other countries similarly oversupplied with physicians. One of the factors in Argentina may be the interest in creating medical schools with specific and definite profiles, different from the existing ones. This goal has not been achieved, however, and most medical schools still show more common features than differences in their approaches to teaching medicine.
To understand the teaching environment in Argentina's medical schools, it is important to know the context of academic medicine in Argentina. I will briefly present this context by describing four key components of the medical education system in Argentina: the institutions, the medical school faculty members, the medical students, and GME.
Of Argentina's 29 schools, 10 are located in the heavily populated capital city of Buenos Aires or its surroundings. Most of the rest are in big urban cities of the inner provinces. The creation of a new medical school has to be approved by the National Ministry of Education. There is no government policy on the number and characteristics of schools; as long as a school receives accreditation, the ministry authorizes it to begin operation. Schools can be authorized to function transiently under the scrutiny of the Ministry until they become accredited, when predetermined academic standards have been met (see below for details about accreditation).
The curriculum is based on a 6-year study program. There are 3 years of basic sciences, 2 years of clinical sciences, and one internship year. This structure is common to all schools, although there are variations in the way these programs are delivered. The Association of Medical Schools of Argentina has established that a medical student's education in medical school must consist of a minimum of 3,600 hours and a maximum of 3,900 hours. Fifty percent of their time must be spent in practical activities. Students must devote at least 1,600 hours to their internship year (the sixth year), with a minimum of 80% of the time of hands-on work. During the internship year, students spend their time as active members of the patient-care team in internal medicine, pediatrics, obstetrics–gynecology, and surgery, and often in primary care (either rural or urban) and emergency medicine. They are entitled to an elective time, and some students engage in small research projects to gain experience in this area. The requirement to participate in the internship year is successful completion of all clinical clerkships. The final objective of this internship year is to provide full-time experience with patients in different settings to complement the instruction given during the required clerkships. As is true in many other countries, there is a strong interest in increasing learning in ambulatory settings, in fostering early contact with patients during the education process, and in including community teaching and primary care.
Only one school has fully embraced problem-based learning, although many use different combinations of problem-based learning as a teaching strategy. Two schools are oriented mostly toward rural and primary care service. However, most medical schools still invest much time teaching secondary and tertiary health care, with a special emphasis on subspecialties and complex diseases. As stated before, there is a strong movement directed towards promoting the study of those most prevalent diseases and toward recognizing the generalist physician as the desired final outcome. Although most educators agree with this objective, it has not been achieved yet.
There are 110,000 physicians in our country (a ratio of 29 physicians to every 10,000 inhabitants), with a marked unequal distribution among the different provinces and between the rural and the urban areas. The ratio of physicians to nurses is 5:1; the WHO standard is 1:4. The coordination between the Ministry of Education (whose work focuses on universities and medical schools) and the Ministry of Health (whose work focuses on health care delivery and is important to physicians and most residencies) is still poor. This means that there is insufficient coordination between medical school education and Argentina's health care system.
Since 2000, medical schools in Argentina have been required to be accredited by a national agency, the National Commission of University Evaluation and Accreditation (CONEAU). CONEAU is a government agency under the Ministry of Education, whose final accrediting decisions are taken by a board whose members include legislators and representatives of universities. It accredits medical schools as well as schools of other professions. Concerning the accreditation of medical schools, CONEAU identifies peers from the academic medical community to conduct site visits, prepare evaluations, and produce recommendations based on previously set accreditation standards approved by a consensus of medical school deans. The accreditation process started in 2000 and is conducted every 6 years. If deficiencies are found, schools can be reevaluated after 3 years. After the first and only accreditation round so far, most schools received accreditation after the first visit or after introducing some suggested changes in subsequent visits. The accreditation process is a thorough one, and it has made a positive, qualitative difference at most of the medical schools. Medical education has benefited because the accreditation system has set standards for medical education and introduced a culture of institutional evaluation. Although the accreditation process is still new, there have been improvements in the quality of medical education in Argentina already, as evidenced by the increased attention to complying with higher standards at the medical schools. This accreditation process evaluates four areas: the institution, the faculty and students, the programs, and facilities and financial aspects. Research has been one of the weaknesses most commonly found, and the accreditation process has fostered the development of new research activities.
Offices of medical education
Eighteen of the 29 schools have some institutional office of medical education in charge of educational issues. The level of responsibility and influence of these offices varies from school to school. The success of these offices depends mainly on four factors:
1. Strong institutional support.
2. Engaging in long-term projects, such as reforming the curriculum or enlarging the role of the educator so that he or she will no longer be exclusively an “information provider” but also will be a “scholar,” carrying out mentoring, research, and the evaluation of his or her work.
3. Promoting the academic development of the staff and faculty involved in curriculum change and in offices of medical education.
4. Giving high visibility to educational activities and encouraging participation in these activities at every level in the institution, to change the culture of the institution to one where education is valued by the institution's leadership and by individuals in the school.
The success and impact of these offices of education are still insufficient, and it will take time, strong leadership, and commitment from the members of these offices to show the results of their influence.
As is the case in medical education worldwide, educators bring their own cultures, beliefs, disciplinary focus, and standards to the medical school world. An implicit role of these offices of education is to overcome these differences and to help educators work together to eliminate the barriers between them. These offices also try to promote the sense of a common educational mission to replace the department-focused missions that are common in many schools.
In Argentina, approximately 20% of medical faculty (at any academic level, from full professor to instructor) work full time, and another 20% dedicate more than 20 h/wk to teaching at the university, spending the rest of their time working either clinically or in research in non–university-related positions. The remaining 60% of the faculty teach part time, and the low salaries they receive for teaching makes it necessary for them to hold other jobs to maintain a reasonable standard of living.
Most of the faculty who hold full-time jobs at the medical school are basic science researchers with an appointment at the national Council of Science and Technology Research (CONICET) or another national funding agency run by the government. They are simultaneously appointed at CONICET and at the medical schools, so there is a mutual benefit for the agency, the institution, and the faculty member.
Frequently, a faculty member has an appointment at more than one medical school and, in some cases, more than two. This results in competing interests between the various institutions for faculty members' time. In addition to full-time faculty, there are a great number (as high as 41% at one school) who teach without compensation and who may not receive any formal academic recognition for doing so. Despite this situation, which reflects the low status of the teaching profession in medical schools, being a faculty member of a medical school is a sought-after position.
The appointment system, the need for faculty members to maintain more than one position (sometimes at different institutions), and the low level of recognition and support for teaching all present obstacles to achieving high-quality medical education good institution–faculty–student interactions. The medical education system in Argentina, as in many other countries in the world, rewards clinical service above research and both clinical service and research above teaching, both explicitly and implicitly.
The widespread but insufficient amount of faculty-development activity that does exist is directed toward medical school teaching. There are no faculty-development programs in CME or residency teaching. Initially, the largest school, at the University of Buenos Aires, required all of its faculty to complete a faculty-development course to qualify for an academic promotion. This program included pedagogy and topics such as evaluation, skills, group dynamics, educational planning, history of medicine and social sciences related to health, and research methods. Because this program was a requirement, the genuine motivation for physicians to participate in it and their commitment to it were low. It was, however, very important, because many faculty were formally introduced to the educational arena with this course, where they found a venue to discuss medical education topics. This was the real contribution of the program. In the last decade, parts of this program have been replicated at different schools simply because it was the only model of a faculty-development program in Argentina's medical schools, although there are no published reports of its efficacy.
Although there is not enough faculty development, it is remarkable that 25 of the 29 medical schools offer some form of faculty-development program. These programs differ in duration, methods used, and topics addressed, and institutional support (one of the keys to success) is variable. The individual strengths of each program, and the fact that so many schools have engaged in faculty-development activities, present an excellent opportunity on which to build new programs for the future.
The Medical Students
At all but six of the medical schools in Argentina, a predetermined number of medical students is accepted to each class, and the only requirements for admission are the successful completion of an introductory course and, sometimes, an interview. The introductory course is different for each school; it usually focuses on the basics of biology, mathematics, chemistry, and physics. Some introductory courses include some form of introductory social or humanistic studies. However, the introductory courses are often much less rigorous than the medical schools' curricula, which helps explain why many students who successfully complete the course do not survive the academic demands of medical school.
Data from the Ministry of Education show that there are 12,000 medical students admitted each year into the 26 medical schools and that 5,000 students graduate during the same period of time.4 The graduation rates vary considerably among schools, depending on the institution's objectives, projects, and standards. Also, for Argentina's public medical schools, there is a mandate to provide education to all students who can meet admission requirements. Public medical schools in Argentina are free, and the government finances the education of all of its students in the public system. There is a long, strong tradition to offer free university education; this tradition originated in the government's commitment to promote higher education to all potential students. The smaller schools can be more selective in their admissions because they accept fewer students and, therefore, have higher graduation rates, but the large schools must be more inclusive because they accept more students. As a result, there are often students who encounter academic difficulties and do not graduate. The acceptance of large numbers of students leads to extremely large classes—there are two schools with more than 2,000 students in the first year, and another three have more than 500 first-year students—with consequent difficulties for the teaching and learning process. The high number of students leads to a high level of student attrition during medical school, sometimes as much as 75%. This system is an ineffective one because creates frustration for students (who abandon their education) as well as faculty (who have to deal with classes that cannot be handled) and because it wastes the institutions' resources.
Another reason that some students fail is that they are admitted to medical school right out of high school, usually at the age of 18, and have difficulty adapting to university studies in medical school; many do not perform well academically during the initial years. There are numerous efforts and strategies in place to aid students in this passage from high school to university, with the goal to improve students' academic performance in the initial years of their medical education; however, to date, results have been poor. The large student bodies, the high attrition rate, the relative immaturity of the students, and their resulting poor performance in medical school mean that faculty members' attention is focused on counseling and managing students in addition to focusing on the best techniques to teach them. All of these issues suggest the need for more faculty-development programs to help teachers cope with these problems.
Graduate Medical Education
Residency programs admit only 50% of each year's graduates after a rigorous selection process.5 The remaining 50% try to find different opportunities for further education—mainly subspecialty courses at scientific societies, or postgraduate programs in medical school, or informal, sometimes unrewarded positions at health care centers—and often fail to do so. Graduates who cannot enter a residency program are, nevertheless, legally authorized to practice medicine, because the only requirement for licensure and clinical practice is graduation from medical school.
The selection process for a residency position includes a multiple-choice examination and, at some institutions, a personal interview. Medical school grades are taken into account in the decision process. Each residency, either governmental or private, has its own admission system. Because of this lack of a single admission procedure, many candidates sit for many different exams. There is no matching of residents such as occurs in other countries, including the United States, because of this variety of admission systems. Most programs are 4 years long, and they are carried in teaching hospitals, although many of them have begun to incorporate ambulatory care into their programs. The number of duty hours is still excessive, and many program directors are beginning to consider the possibility of limiting the amount of residents' working time. The tension between education and work is often apparent.
Although data from residency programs are lacking or are not reliable, it is safe to say that there were roughly 9,000 residents at the beginning of this decade. Of these, 68% were in the basic specialties, and the remaining 32% were in subspecialties.5 These statistics probably have not changed greatly.
Residency programs depend on different systems. The biggest ones (69%) are state based and depend on the nation, the provinces, or a municipal government. Only 6% are university-dependent residencies. The remaining residencies are offered by the private sector. Residents carry out clinical care in hospitals, clinics, or in the community, and programs also include formal classes. The accreditation of residencies is not mandatory, although it is desirable. Accreditation depends on the scientific specialty societies. As stated earlier, completion of a residency program is not necessary to obtain professional certification.
Although I have emphasized many problematic aspects of medical education in Argentina, despite these deficiencies, the movement to improve the education of physicians and other health care workers is growing. There are actions that must be taken at different levels (national or local, governmental or private), but I want to mention two that are usually neglected but are important.
First, medical education should be reformed so that it is free from political influence.6,7 It is necessary to identify the real needs of health care in our country and to plan for long-term solutions to them, with the participation of all stakeholders, including academicians and policy makers.
Second, cooperation and interaction must be fostered between programs and institutions as a way to improve medical education. Such interaction is particularly necessary in settings where resources are scarce. The capability of setting common objectives and agendas among institutions, and sharing resources, including faculty, is a necessity given Argentina's circumstances, and I do not doubt that this is a necessity in many other countries as well.