The provision of better health care to the community has been one of the greatest challenges in all societies. Accordingly, there have been several changes over the centuries in medical education according to new knowledge inherent to scientific advancement and the concern of trainers in preparing health professionals able to respond to various challenges in health care.
Before the foundation of universities, both in Portugal and in Europe, in which the Christian religion was professed, the teaching of various sciences, arts and medicine (which was still presented in a very superficial way) operated in monasteries’ and cathedrals’ schools.
The most important of these schools was the Santa Cruz Monastery in Coimbra, founded in 1131 and belonging to the Order of Saint Augustine. Initially, in the 12th and 13th centuries, the teaching of medicine was exercised and directed only to monks, while in the 14th and 15th centuries it included clerics and lay people, supported by classical medical texts of Greek-Roman and Arabic origin.
In Portugal, the first medical studies are attributed to canons who followed the doctrine of St. Augustine, with King Sancho I (1154-1211) encouraging their previous training abroad. Still, we are aware of a small number of renowned figures in Portuguese medicine at that time, namely Friar Gil de Santarém (1185-1265) and Pedro Hispano (1216-1276), later Pope John XXI, who studied in Paris and Vasco de Taranta, who attended the university in Montpellier.
By decision of King D. Dinis, the first university in Portugal was founded around 1289 under the name of Estudos Gerais (General Studies). Portugal followed the educational system in place in Europe at that time.
In the Middle Ages, studies conducted at the University were dedicated to the study of universal sciences: the seven "liberal arts" (grammar, rhetoric, dialectics, geometry, arithmetic, music, and astronomy), two types of law (canonic and laws), medicine and theology.
The medical degree was considered for centuries to be inferior compared to other degrees, such as canonic law and general law, which had great prestige. Until 1493, there was only one medical chair, and only in the reign of D. João II (1455-1495) did it change to two, Prima and Vespera.
Also the differences in earnings between the teachers of the various degrees were quite big. Thus, "in 1323 the annual income of a medical lecturer (£200) was three times lower than that of a lecturer of Canon law."
Due to these factors and over the years, the teaching of medicine deteriorated until the Marquis of Pombal’s major reform in 1772.
At that time, anyone who obtained a university degree, whether a bachelor or a doctorate, was considered to be very import. However, these degrees were limited to noblemen, clerics and descendants of wealthy bourgeois. In 1473, in the Lisbon Study, “…41 young men, sons of nobles and court officials,… studied most likely Canon or General Law”.
Around 1504, as a result of the education reform that took place during the reign of King Manuel I (1469-1521), to obtain a bachelor degree in medicine it was necessary to study it for five years and it was also necessary to have a Bachelor of Arts (having studied logic and natural philosophy courses). Those who intended to obtain a degree “were questioned by the faculty's professors, in theses published two days before and freely chosen by the candidates. The exam was done in the Cathedral, behind closed doors, and started just before sunset”.
In 1537, a few years after the university studies moved from Lisbon to Coimbra (and vice versa several times), university education settled permanently in this city, with several changes taking place in the medical degree. Although medical education continued to be based on classic works such as Galen's, the 1559 statutes referred to the inclusion of the human anatomy subject, with practical teaching supported by the dissection of cadavers from the hospital, which very rarely happened.
There were several actions carried out during the reign of King João III (1502 –1557) with the purpose of changing both university education and medical education. Examples include the invitation made to Erasmus of Rotterdam to teach in Portugal; the creation of 50 scholarships as an opportunity for national students to attend the University of Paris; establishment of the Jesuits in Portugal and the banning of several books by the Holy Office; the foundation, in 1553, of Colégio de Santo Antão, in Lisbon, by the Jesuits, who became the “organic intellectuals of Catholicism during the Ancien Régime”.
Despite the changes that occurred with the transfer of the University to Coimbra, the number of students enrolled in medicine continued to be very low, as it had been since the 13th century. In 1537, there were a dozen medical students out of a total of 642 enrolled, the preference and even increase in law degrees prevailing at the expense of medicine.
At the time of the regency of Cardinal D. Henrique, around 1568, there was a clinical practice subject in which medical education was carried out “at the bedside of hospitalized patients”.
Despite the university reform of King João III in 1537 and later of the Marquis of Pombal in 1772, the teaching of surgery, unlike medicine, continued to be carried out outside the universities, in some hospitals, mainly in the Hospital Real de Todos os Santos. It was independent of clinical medicine until very late, at least until the creation of the medical-surgical schools in Lisbon and Porto, in 1836.
Doctors were seen by the people as idiots for not mastering Latin. There were about 2000 in the 16th century, and they were considered the only ones capable of practicing medicine. Still, the Chief Physicist and the Master Surgeon “abused their privilege and granted licenses to skilled people to practice the art of healing in places where there were no offers for such care”.
By the 18th century, there was a great distinction between doctors and surgeons. While the latter barely knew how to read and write, and learned the trade in the hospital, doctors, in order to graduate in medicine, required "thirteen years of study, with three or more exams” at a time when, “the diagnosis of the patient (the “knowledge of the pulse”) was a medical act par excellence”.
During the reign of King. João V (1689-1750), several actions were carried out in the reform of medical education in Portugal, such as the development of anatomy and surgery, the invitation, albeit refused, to Boerhhave, the great master of Leiden, to work in Portugal and the Portuguese doctor who lived and ended his days in London, Jacobo de Castro Sarmento.
However, it was only in the reign of King José I (1714-1777) that Portugal experienced a significant reform of university education, namely in the teaching of medicine as part of the country's modernization effort. There was the introduction of the teaching of Natural Sciences, Experimental Physics, Chemistry and the creation of the first laboratories, and of the first teaching hospital.
During Pombal’s reform in university education and medicine, there were two huge influencers in the evolution of medical education: Luis A. Verney (1713-1791), author of the True Method of Study to be Useful to the Republic and the Church (Verdadeiro Método de Estudar para ser Útil á Republica e á Egreja) and the famous 12th letter addressed to the medical art; Antonio Ribeiro Sanches (1699-1782), author of the Method of Learning and Studying Medicine (Methodo de Aprender e Estudar Medicina); and Martinho de Mendonça, author of Notes for the education of a noble boy (Apontamentos para a educação de hum menino nobre).
António Verney, a staunch defender of Enlightenment ideals, generally argued for a new study system, for progress, for Newtonian-based experimentalism, condemning the cultural isolation of the kingdom and the Jesuit-scholastic education system. In medicine, “the scholastic training of medical students, ignorance of basic sciences such as physics, mechanics and natural history, the extreme decadence that the study of human anatomy had reached among us was criticized. In fact, although there was an anatomy chair, only two dissections were practiced a year... and on sheep, which was "an inexcusable step back from the 1559 statutes, as these already provided for anatomy on bodies provided by the hospital”.
Verney proposed that the syllabus be reformulated, giving priority to anatomical practice, the study of different “medical institutions” and clinical hospital practice. After performing the acts, students would be able to practice medicine.
However, he defended that the teaching of surgery should remain separate from medicine, outside the university and be carried out in the hospital (namely at the Hospital Real de Todos os Santos, in Lisbon), and that it should last from five to six years.
António Ribeiro Sanches did a doctorate in medicine at the University of Salamanca in 1725 and was one of the preferred disciples of Boherhaave, in Leiden. He held important positions both in the court and in the Russian imperial armies. He authored several works and was considered an authentic encyclopaedist. Thirty years after António Verney, he advocated a profound reform of teaching in Portugal, with “the introduction of new subjects, definition of new academic rules and the secularization of teaching staff” that led to the work, at the request of the Government, “Method of Learning and Studying Medicine” (Methodo de Aprender e Estudar Medicina”).
Ribeiro Sanches explained that it was necessary for the medical degree to include new knowledge, and proposed the foundation of a college for the teaching of medical sciences, the creation of a teaching hospital with an anatomy theatre, a botanical garden, a laboratory and a pharmacy. The teaching of medicine, which until then was based on classic works by Hippocrates, Galen and Arab books, had to be replaced by those of Boherhaave.
The Marquis of Pombal took on many of Verney's ideas, but mainly of Ribeiro Sanches’. Between 1759 and 1772, there were several actions, from the expulsion of the Jesuits to the foundation of the Real Colégio dos Nobres or the Real Mesa Censória, which proposed “a law aiming at the creation of a public and secularized basic education system”.
After studying the causes of the university's decay and proposing its reform by the Junta de Providência Literária, in 1772 the Statutes of the University of Coimbra became known under the supervision of King José I.
In this reform of medical education, great importance was given to clinical practice and experimentation. In addition to having created other institutions, apart from those mentioned above, the library was restructured. The importance of knowledge of French and English was acknowledged. Teaching itself was reorganised, including the use of timetables, texts to be made available or attendance control. The requirement to attend preparatory studies for three years before starting the actual degree (five years) was introduced, and the minimum age of 18 years was established. Those who were not university graduates were expressly prohibited from practicing medicine.
Five years after the implementation of this reform, medical education continued to be little chosen. At that time, the “socioeconomic status of university students was measured according to the number of servants and horses (or mules) at their service (hence the meaning of the proverb "Doctor of the mule")”. Students studied new topics and new authors. Also, the salary of medical professors was adjusted to that of theose who taught Canon Law and General Law, considered quite high for the time.
In the last years of the 18th century and early 19th century, many Portuguese scholarship holders went to England to study. This later enabled them to hold teaching positions in future medical-surgical schools and made up for the deficient teaching of surgery.
In the mid-19th century, there was still a rivalry between the doctor-surgeon professions. Despite the significant advance in the teaching of medicine due to Pombal’s reform and the development of science, medical education was still very deficient, often relying on ancient authors such as Hippocrates.
In 1825, King João VI (1767-1826), under the influence of the main surgeon of the kingdom, Teodoro de ,Aguiar, created the Royal Schools of Surgery in Lisbon and Porto.
Later, in 1836, with the foundation of the Medical-Surgical Schools in Lisbon and Porto (surgery became part of university education), medical education reached a stage of modernization. In the second half of the 19th century, some names of distinctive doctors in Portuguese medicine such as Câmara Pestana, Miguel Bombarda, Ricardo Jorge or Sousa Martins stood out. Only thirty years later, in 1866, the distinction between surgeons and doctors came to an end.
Until 1910, medical education was provided at the Medical-Surgical Schools. It was only after the proclamation of the Republic in 1911 that they were they replaced by the Faculties of Medicine of Lisbon and Porto. That year, the legal status of the teaching hospital was created by decree, and the one at the Faculty of Medicine of Lisbon was set up in Santa Marta Hospital. “The reform of higher education, which included the reform of medical education, was considered by the regime implemented on 5 October 1910 as a priority and a national asset”.
The Faculties of Medicine had the purpose of structurally modernizing the teaching and training of physicians. It consisted of basic subjects such as physics, teaching in hospitals and the writing of a thesis. It trained physicians to play complex but effective roles for the conservation and resolution of individual, public and social health, “and also regulations of the faculties, reorganization of studies, medical training and institutionalization of other health establishments”.
At that time, “a group of doctors and medical professors formed part of a scientific, cultural and political elite: Miguel Bombarda, Eduardo Mota, May Figueira, Ricardo Jorge, Oliveira Feijão. Silva Amado, Curry Cabral, Ferraz de Macedo, Augusto Celestino da Costa, Egas Moniz, Henrique de Vilhena, Francisco Gentil, Júlio de Mattos, and Bettencourt Raposo”.
In the 30s of the 20th century, there were new reforms in medical education, namely in terms of access to the medical degree. From that time on, all students in year 7 of the science group (excluding those in the literature group, as had happened until then) had the possibility of entering the medical degree, which from that point onwards lasted six years.
From that time onwards and for several years (1948, 1955, 1975, 1981, 1986/1987), there were several reforms in the medical degree. Between 1988 and 1994/1995, several groups and committees were created with the objective of studying and presenting proposals and projects for necessary reforms to be incorporated in the medical degree. In the 1995/96 academic year, “the new syllabus for year 1 of the medical degree started”.
With the implementation of the Bologna Process, the last reform of clinical education took place in 2006/2007.
Since the first decade of the 21st century, there have been several gaps in the syllabus structure and it is necessary to respond positively to students’ needs. A thorough analysis of clinical education was carried out and after the conclusions were presented, the final proposal for the clinical education reform was presented at the end of 2018. The new reform was planned to be implemented in the 2020/2021 academic year, but due to the Covid-19 pandemic, it was decided that its implementation should be carried out in the following academic year, in 2021/2022.
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