Psychiatric training in Argentina's two major cities

Argentina is the second largest country in Latin America. The country extends for about 2360 miles (3800 km) from north to south and is about 884 miles (1423 km) at its widest extension from east to west. Its population is around 35 million. Ninety-five per cent of the habitants are of European origin, more than 50% Italian, followed closely by Spanish and the rest Germans, Russians, Irish, English and other minorities from Eastern European and Arab countries.

Buenos Aires has a population of approximately 4 500 000 within its federal district, and 13 million in Greater Buenos Aires. The city has eight medical university colleges.

Córdoba City's population is estimated at 1.3 million. The metropolis is the second largest in Argentina. It has four university colleges and two medical schools; the National University, founded in 1613 by the Jesuits, is South America's second oldest university.

Psychiatric services

Psychiatric services in Argentina have developed since the opening of the Borda Hospital for the Mentally Ill, in Buenos Aires in 1876. Almost all Argentinian general hospitals have liaison psychiatric services, but few have in-patient units. Psychiatric state hospitals have community services but these are still being developed. They are organised in teams formed by psychiatrists, psychologists and social workers, but do not have community psychiatric nurses as mental health nursing training is very much in its infancy. The exception to this is the Instituto Austral de Salud Mental (IASM — Austral Institute of Mental Health) in Neuquen, Patagonia (south Argentina) directed by Dr José Lumerman, which has developed a cost-effective community mental health team that serves a vast territory. The Epidemiological Department of Columbia University is studying its excellent organisation and the IASM is partially funded by the British Council.

Private and trade union insurance share the care of psychiatric patients with the government. At both levels follow-up is poorly organised. Despite the fact that it is possible to ‘legally’ admit psychiatric patients against their will, Argentina does not have a formal mental health act system.

Psychiatric training in Buenos Aires

Psychiatric training is available in some private psychiatric hospitals and universities in the form of short- and medium-term postgraduate courses, but the major training centres are the University of Buenos Aires (UBA) and the City Council schemes.

The USA rotation created by J.I. 32 years ago is located at the Hospital Francés and at the Hospital Nacional de Clínicas and lasts for four years. This scheme recognised as the best in the country, is supported by the Department of Psychiatry of the UBA and the National Department of Health, and supervised by Professor Roberto Fahrer. Twenty-three junior doctors and two senior registrars work from 8 am to 5 pm, four consultants supervise the junior doctor's clinical work.

The rotation includes an out-patient department, an in-patient unit with 10 beds used mainly for acute cases and six beds for liaison psychiatry, a liaison psychiatry service, child and adolescence psychiatry and old age psychiatry. The hospital also runs a community psychiatry service, a centre for homeless and an eating disorder clinic.

The City Council's psychiatric scheme lasts four years and aims to train psychiatrists, clinical psychologists, social workers and occupational therapists. Their services are community-oriented offering general psychiatric out-patient care Monday to Friday from 8 am to 1 pm — only two of the 11 hospitals have in-patients units. The City Council rotation trains around 400 mental health professionals, half of them being doctors and the other half include psychologists, occupational therapists and social workers.

Psychiatric training in Córdoba

The National University of Córdoba, through its school of Postgraduate Medical Training, provides the only psychiatric training scheme of the province that is recognised by the Argentinian General Medical Council. The rotation began in 1982 and training takes place at the Hospital Nacional de Clínicas.

The intake is 12-15 doctors per year and the training lasts four years. In their first year the trainees work in internal medicine and neurology. Formal psychiatric training starts in the second year and includes teaching in several psychiatric specialities mainly based on psychoanalytical theory. Trainees attend lectures from 9 am to 1 pm and are on-call once a week.

At the end of their training period doctors submit a research project to the provincial General Medical Council and if it is successful the same body examines the candidate through a multiple choice paper and a clinical case. The pass rate is 90%.

Clinical and academic experience

Through working in busy out-patient clinics and accident and emergency departments and looking after patients with wide range of psychiatric disorders, Argentinian trainees acquire vast clinical experience. Nevertheless, with the exception of few centres, there is not enough supervision, trainees are poorly paid, and in many cases vocational, unpaid training is the cause of low morale and lack of incentive among doctors. Academic activities and lectureships are meagre, outdated and mainly based on psychoanalysis. However, in recent years, the influence of psychoanalysis has markedly declined. Doctors and psychologists are turning their interest to cognitive and behavioural therapies, psychobiological and genetic models of mental illnesses, but training is still based on the postulates of Freud, Lacan, Klein, Kohut and Winnicott.

What next?

Professor Roy McClelland visited Buenos Aires in 1993 and 1994 helping a working party headed by J.I. and Professor Fahrer to design a four-year psychiatric training programme based on the Royal College of Psychiatrists' model. The programme, which has been running since 1996, highlights the importance of supervising the clinical work of junior staff, ensures the organisation and continuation of teaching activities and promotes continuing postgraduate professional development.

In their first year of training junior doctors rotate six months in general medicine with six months in clinical neurology. In the following three years, they are expected to acquire basic theoretical knowledge and training in at least three different psychotherapy models. This new system also stresses the importance of physical treatments.

In an effort to standardise postgraduate medical training, the Argentinian Academy of Science founded the National Medical Certificate Council in 1991. This body issues medical speciality certificates, supervises medical training and organises exams. The psychiatric training committee is coordinated by J.I.

Argentina has produced five Noble Prize winners, three of them in medical-related sciences, Bernardo A. Houssay, Louis F. Leloir and Cesar Milstein and can boasthigh standards in areas of medicine like cardiovascular surgery, oncology and immunology. However, Argentinian psychiatry must improve in both theoretical and clinical areas and catch up with contemporary mental health policies.