Explaining the role of the Dean of a Medical School in Europe is a difficult task. This is because Europe is a large and varied continent with different academic and cultural traditions. However, as the Portuguese physician and writer Miguel Torga observed, "universal things are local things without walls". That is why I am going to speak about how I see the role of the medical school deans in Spain.

I believe that many of you will identify with the situation I am going to describe. To begin, let me use a cinematography metaphor. The Japanese film Rashomon is a movie version of a very old Japanese story. The interesting thing about this story is that the same event is told by five different participants. The version of each participant is different because it is influenced by their own experience, emotions and interests.

If we want to know what it is like to be the Dean of a Medical School, we must take the approach used by the director of Rashomon: How do students see the Dean? How do the directors of the University see the Dean? What do the University departments think of the Dean? How does the chief economic administrator of the University hospital see the Dean? And finally, How do we see ourselves?

None of these five different views is complete or entirely accurate, but they all contribute to a vision of the true role of the Dean.

From the medical student's point of view the Dean is responsible for everything in the medical school, from shortages of chalk for the blackboards to poor-quality practice. In addition, the Dean is the student's advocate in problems with departments, professors and courses. Finally, the Dean is a sort of student's ombudsman in their relations with the university and society.

To the directors of the University the Medical School Dean is a supplicant of specific solutions and special favors for a presumably higher caste within the university, whose problems always require special attention. The Dean is therefore considered a selfish, inflexible person who is incapable of understanding the University's problems as a whole.

Finally, the Dean is that irritating person who represents the interests of a particularly bothersome professional collective: the well-paid academic practising physician.

How do the departments see the Office of the Dean? As an official busybody and organ that supposedly limits the effects of measures and decisions that are sometimes not entirely appropriate. For many departments the Dean's office is also a permanent shock absorber they can use as an excuse for not facing their own problems and responsibilities, and for not admitting their own limitations. What about the executive director of financial management at the university hospital? For this person, the Dean does not figure in their concept of health care. For the executive director of financial management the best dean is the one who keeps his or her mouth shut the longest. However, the Dean can sometimes be a threat to their goals and to their absolute, incontestable authority especially over the budget.

And finally, how do we see ourselves? I believe our self-image is one of infinite goodness and altruism. We see our role as a kind, and beneficial one.

This somewhat ironic Rashomon of the Office of the Dean illustrates our work from five different points of view. Although I may have exaggerated a few things, I have emphasised some features to paint a more vivid picture - a caricature, perhaps - of the players in this film. Like in the anonymous Japanese tale, the true role of the Dean is an amalgam of all these visions.

I do not know exactly what kind of vision each of you will have. But the one I get is of an agent of power, exercised through mediation within an extensive hierarchy of human and professional relations. Medical school Deans have, in fact, much more power than we are usually aware of, and I mean power in a positive sense. Along with this, power of course, comes responsibility: the responsibility to ensure that the different elements that make up our schools of medicine work together productively and harmoniously.

This means that we must work to develop three specific skills: to represent and transmit a sense of identity of what Medicine should be within the University; the ability to inspire confidence; and finally the capacity to build a nexus between the highest levels of University and hospital administration and the individual departments. The office of the Dean should be a place where the Departments local problems are understood, but also where these problems are seen from a distance, so that they can be considered within the context of the whole university or health care system.

How to achieve all this? How can we develop these capacities? How to be a Dean in this complicated and demanding environment? Let us go back to our five players in our academic Rashomon. For the medical student, the Dean should be a model, a stimulus and a symbol of the noble office of the medical practitioner as a professional who embodies Medicine as an integrating activity and an intellectual passion.

For the directors of the University, the Dean should be an effective negotiator. For the Departments, a wise and experience co-ordinator; for the financial managers, the Dean should be able to guarantee that quality in education, training and research is not sacrificed to anti-academic economical imperatives.

I would suggest to you two more considerations to keep in mind that may help you to keep your balance in your efforts to play these five roles. Reach for utopia and keep your feet firmly on the ground. To paraphrase the writer and philosopher Miguel de Unamuno: without utopia and without pragmatism it will be difficult for the modern Dean of a modern Medical School to be successful in his or her true role as Rashomon.

I will try to generalise the experience of my colleagues from our country and of myself with some reflections on the normal situation abroad.

The dean of the Faculty of Medicine should be a many-sided personality due to the very wide spectrum of his duties. The extent of the dean's activities is nearly a full time engagement. Therefore it is very difficult, if not impossible, to combine the official duties of the dean with those of the head of a department and with clinical practice. This detail could easily explain an old habit at our university. Until the second World War, on nearly every occasion the clinical professor was elected dean, but he regularly resigned in benefit of a second candidate from the theoretical department. I would like to try to characterise the most important qualifications for a contemporary dean of the Czech faculty of Medicine:

1. The dean should be a highly educated, skilled and respected teacher - the degree of professor is required. The dean needs to lead the staff of the faculty as a respected authority. The dean is responsible for the quality of education of the faculty and for the possible improvement of it. The dean should direct the pedagogic policy of the faculty, having the final decision in all students' affairs beginning from the admission to studies and ending with the closure of individual studies as well. It is taken that the dean should be an initiator of all discussions directed to the modernisation and reformation of education. The dean should be responsible for the preparation and realisation of new curriculum as well.

2. The dean should be a highly educated, skilled and respected researcher - a scientific degree is conditio sine qua non for the deanship. The dean is obliged to direct the research activities at the faculty and to give the instructions for them. For this purpose the dean presides over the Scientific board of the faculty which is responsible for co-ordination and evaluation of research activities, as well as for staff innovation and for the conferring of academic degrees. The dean is responsible for the research work at the faculty, he is expected to find out ways and means of improving upon it, how to recruit fresh and prospective ideas, new research fellows and how to protect and enhance the high standard of research activities at the faculty.

3. The dean should be a good manager and organiser, being responsible for the economy of the faculty, for the co-ordination of all activities necessary for a good functioning of the faculty and for good relations with other faculties, research institutions and the Faculty hospital as well. The dean should provide the direction for the economy of the faculty, and find new sources for financing and support. In addition, the dean is responsible for the economic status of the faculty as well.

The priorities of all three basic qualifications for the deanship are unstable due to the dependence upon the development of the state financial or educational policy and all other conditions influencing the academic and economic status.

I am sure that this last qualification is the most important one, because, if the economy of the faculty is stable, all other activities could be protected much more easily than under the imperative pressure of financial difficulties.

There are two possible mechanisms for the creation of the post of dean:

a) appointment,

b) election.

Both of these have been used in our country during this century. They differ in their benefits and risks. However, both of them need suitable candidates willing to accept the office and to offer their time and qualities to the faculty.

From my experience, it is very difficult to find at any of the faculties of Czech Universities specific 3 year deanship candidates with an optimal combination of qualifications mentioned above. It is in the interest of the faculty to retain a good and strong dean for a period longer than two-three year periods in accordance with our regulations. The appointment of a standing dean could, in fact, bring more stability. However, it is in the interests of the faculty to change a dean who proves to be weak or unqualified - a shorter term could be more effective as well. Furthermore, an election would be more effective than an appointment. Nevertheless, the option between appointment and election is a challenge of political decision making reflecting both the traditions of the university and of the contemporary political status of the society.

Therefore, in my opinion, the stability of the administration of the faculty is more important than the modus of the dean's creation. The professional qualities of the secretary general of the faculty and other employees are crucial for the common status of the faculty and can bring stability and resistance to the other influences. The faculty should have a stable apparatus and then the dean could be changed. Unfortunately, this important condition is not ensured in our country where the deans prove to be more stable than the staff of the faculty administration.

In addition I would like to reflect upon one of the important qualifications of a good dean, which is seldom expressed in a straight forward manner: The dean is expected to represent the faculty in all respects. Therefore the dean should be a person with vision and a good orator due to his necessary presentations during different academic ceremonies, debates, negotiations, etc., where it is necessary to give an impression both personally and orally.

The job of a Dean is, to a great extent, shaped by the structure and atmosphere of the academic institute to which his faculty belongs. Indeed, the Bruce Rappaport Faculty of Medicine, one of the 4 faculties of medicine in Israel, is an outstanding faculty world-wide because it is one out of 23 Faculties of the Israeli Institute of Technology, a research-oriented Technological Institute that is world famous for its engineering and scientific faculties. It is by far the largest faculty in the Technion, having some 250 faculty members, which is more than three times the number of faculty members of the second largest faculty on campus. Each class of medical students has 72-75 students who follow a 6 year study program. In addition, there are some 200 graduate students working toward their M.Sc. and D.Sc. degrees. Being part of a technological and research institute, it is not surprising that the medical curriculum emphasises an expanded background in sciences, and that medical students are encouraged to conduct research at all levels of their medical education. About 10% of the students in each class are studying toward a "double degree" of both MD and D.Sc. degrees. The Dean, who is at the head of the academic pyramid at each of the Technion faculties, is elected by the faculty council by secret ballot. To be elected, he must win at least 2/3 of the votes. According to the bylaws of the Technion, the Dean is elected for 2 years and can be re-elected for a maximum of three terms, namely 6 years. Currently, I am starting my sixth and last year in office.

How then can one begin to describe the job of a Dean in such a unique institute? In order to avoid portraying an idealistic and unrealistic picture of a Dean's job, I have decided to take a different, more direct approach. Using the Dean's office diaries, I conducted a time budget analysis of the Dean's activities during 1994-5, which are my third and fourth years as Dean. In this analysis, each diary entry was categorised and then weighted by a time factor which provides the amounts of time invested in each activity. This procedure provides an accurate mapping of all of the Dean's activities during this two-year period, which is in fact a realistic description of a Dean's job. An analysis of the Dean's activities revealed that three activities accounted for more than 60% of the time: day-to-day administrative work at the faculty, academic activities associated with academic promotion of faculty members, and activities associated with the faculty performed outside Haifa. While the first two activities could be expected, the amount of time associated with travelling outside Haifa to represent the faculty on various national committees and international activities was by far much more than anticipated. In summing up the activities of this two-year period, it also became clear that the Dean has a large number of social obligations. During the two-year period, I spent 8% of my time on social events which included official dinners or lunches, 3% of the time was spent on entertaining faculty guests, and on the average twice a month, I delivered a welcome address to officially open a symposium or scientific meeting organised by faculty members or one of the affiliated hospitals. There are two aspects of these activities that gave me food for thought: first, how can one participate in all official dinners without gaining extra weight, and second, how can one open so many meetings and still say something original. At the same time, it was comforting to find out that, in spite of the heavy administrative load and the numerous obligations, I was still able to allocate 15% of my time to my own research, to my own students and to attend scientific seminars of my choice - not as a dignitary obliged to attend the meeting, but as a participant.

From the analysis of the above there is no doubt, however, that the two most demanding activities that consumed most of the Dean's time were direct involvement in the day-to-day activities of the faculty, and being responsible for all the academic promotions of faculty members. In order to further demonstrate the nature of the administrative activities that come with the job, I would like to describe a typical faculty project in which the Dean was personally involved in almost every step of the way.

One of the major faculty projects that started shortly after my election as Dean was changing the curriculum. Being a part of a Technological institute, medical students at our faculty were given an overwhelmingly large background in basic sciences which inevitably came at the expense of clinical studies. Thus, students spent 4 years in preclinical studies and only two years in clinical studies. This program was unique and different from any of the other Israeli faculties of medicine. Although the imbalance in the program was bitterly criticised by students and faculty alike for many years, it was not before we found out from the national comparative examinations in medicine, paediatrics, and surgery that our graduates were inferior in their clinical knowledge, that a firm decision to revise the curriculum was made. Anybody who ever been involved in changing a curriculum of a medical school knows that this is an "impossible" mission that may take years to accomplish. Moreover, since the Technion is a very centralist institute, and any change in the curriculum must be approved by a number of committees as well as the Technion Senate (an assembly of full professors), the project became much more complicated. To initiate the process, we organised (November 1993) a one-day retreat of almost all of the clinical faculty, representative of the preclinical faculty and the students. The task presented to the faculty was to reach a consensus concerning the essential core knowledge for a preclinical program which should be a prerequisite for the clinical studies. They were instructed to take into consideration the unique characteristics of the Faculty as part of a technological institute, the explosion in medical knowledge toward the end of the 20" century and the need to incorporate elements of behavioural sciences and ethics into the program that were completely missing from the existing program. The faculty was divided into small groups, and after a day-long intensive discussions and negotiations, representatives of each of the groups presented their group consensus to the faculty. Within 2 weeks, a committee formed from these representatives formalised the faculty recommendations that were handed to the Dean. The next step was a similar one-day retreat including all the preclinical faculty responsible for teaching preclinical studies to discuss the clinical faculty recommendations, and to propose an outline for a tentative core program. Here too, they were accompanied by students who were actively involved in each step of the way. This was done again by forming small group discussions, each dealing with a different segment of the existing curriculum. Each one of the existing courses was put under a magnifying glass and analysed and dissected in great detail. By the end of that day, an agreement was reached concerning the possible changes in the program and a joint preclinical/clinical committee was formed to formulate and present a comprehensive program to the Dean. Within one month of intensive work, such a program was ready. On 26 of January 1994, I presented the program to the Faculty council (this assembly includes all faculty members from the rank of senior lecturer and above). The discussion that followed the presentation raised several issues that were addressed by the curriculum committee in a second series of meetings and on February 2"', the council approved the program and instructed the Dean to make all efforts to change it during the following academic year. The decision was a daring one; instead of changing the curriculum gradually starting from the first year, it was recommended to change it for all three of the preclinical years at the same time. The meaning of that decision was a double load of teaching for some of the teachers and a double load of studies for some of the classes. There is no doubt that the support and encouragement of the student representatives at this stage were essential. Further to the Council's approval, we started negotiations in the Technion committees. First, the program was presented to the vice presidents for academic affairs and the vice president for undergraduate studies, and then to the Technion curriculum committee. After getting their blessing, we started the preparation for the finale, the presentation at the Technion senate. To prepare the ground for this critical presentation, together with the Vice Dean for teaching I had a large number of meetings with key members of the senate and Deans of other faculties who were judged to be influential in the senate, in order to convince them of the importance of the proposed changes. On May 2"' 1994, the program was introduced to the Technion senate and after a short discussion, was adopted as the new curriculum of the medical school by an overwhelming majority.

As planned, in November 1994 the program began simultaneously for all three of the first three years of preclinical studies. Many people should be credited for the success of this project, the vice dean for teaching, the head of the medical education unit, and the heads of the various teaching committees. If I try to analyse the Dean's job in this process, I believe his contribution was mostly to set the time tables and to make sure that they are adhered to without compromise, to delegate his authority to each one of the other important players mentioned above, to cast his vote whenever there was a deadlock in the discussions and negotiations (particularly concerning how many hours should be cut and from whom), to use his influence to win the support of the council, the other deans and the Technion senate. I remember that during one of the never ending committee meetings that continued late in the night I found myself thinking that in fact my job during the entire process was more of a salesman than an educator.

Was it all worth it?

I have no doubt about it. Based on enthusiastic responses from students and faculty alike, the new program (see box for details) has proved to be a great success. Naturally, there's room for improvements and accommodations but in comparison with the old program, the faculty made an immense step forward. Soon the fruits became evident by objective criteria as well: within three years, our graduates achieved excellent results in the comparative national exams.

In additional to the traditional preclinical studies (i.e., mathematics, physics, chemistry, anatomy, histology etc) new courses in behavioral sciences have been introduced (psychology, introduction to clinical psychology, medical anthropology and the life cycle). In addition, a new course, "exposure to medicine", has been added during the second semester of each of the first three years. The purpose of this course is to expose students to hospital life, to medical services in the community (jails, industrial medicine, shelters for battered wives, homes for the aged etc.), and finally in the third year, to expose them to ethical dilemmas in medicine. Throughout the three years, students' work in this course is organised in small groups accompanied by a tutor.

The highlight of the fourth year is a 23-week system oriented integrative course taught by both clinicians and preclinical faculty. A one-week problem-based learning unit is introduced during the middle of the course, which should be expanded to 3 units in a year or two. A unique form of examination to evaluate students' integrative ability was developed by the head of the medical education unit, Prof. Rosalie Ber, especially for this course. After the completion of this course students start the first clinical clerkship in internal medicine.

The change that was introduced during the clinical years allows students to select groups of clerkships rather than be obliged to pass every single clerkship.

In addition to the traditional paper and pencil multiple choice questions type of exams, students are also required to pass a comprehensive OSCE (simulated patients) test.

For nearly 300 years a man follows the way of recognition and managing nature. In social practice priority is given to material development over a non-material one and to economy over ecology. Is that for or against a man and the earth? After the atomic power station explosion 28% of Byelorussia territory is not fit to be inhabited. Ecological disasters appear suddenly but they may disturb life chronically.

Ecology is a relatively young branch of biology. In 1870 Ernst Haeckel, while studying interactions between life forms and their organic and inorganic environment, first used a term "ecology" which he derived from the Greek word oikos (habitation). Ecology was primarily an observational science and since the very beginning had a revolutionary element. At present it is a complex science with its own study models and terminology interconnected with numerous other research disciplines.

It is not clear whether human ecology simply constitutes a part of general ecology. Human ecology is based on regarding a man as a unique species: the only form of life on earth able to create a civilisation. This is why human ecology as a science contains not only biologic aspects but also sociological psychological and cultural ones.

The term "ecology" became well known not earlier than 25 years ago when it started to gain popularity parallel to environment protection movements. These movements often used at their early days a saying: "the earth did not come down to us from our fathers, we borrowed it from our children and grand-children". Technical activity of a human being alters the territories inhabited by him/her. Technology poses a threat for the environment as the industrial world in its run for maximum income accelerates further technical development. The transformation of homo sapiens into homo economicus is associated with an ecological and ethical crisis which causes secondary negative phenomena of social sanitary and cultural type.

The urban/industrial civilisation cult which has existed until several years ago underlined unlimited perspectives of the human mind and the perfection of' its fruits. Only in modern times it has been realised that civilisation deeply penetrated and transformed nature on a global scale, a process of dangerous consequences for life on earth. In the forties TBS. Elite asked: Where is life which we lost living? Where is wisdom which we lost in knowledge? Where is knowledge which we lost in the information?

Gafo in his book "El hombre ante la alternativa de la manipulacion de su propria biologia" presents his opinion that already on the threshold of XXI century, a man would be able to control his psychobiological development.

Majdanski writes that a man with amazingly developed technology destroys his natural environment and consequently himself. Creation of this progress meant as a process of self-creation causes orientation towards so called anti-life mentality.

Expansive human activity which deeply alters the environment induces certain harmfulness of biological chemical physical social and psychobiological character.

Outstanding achievements of modern medicine raise common interest and hope but at the same time many of them make common opinion uneasy. Bioethical problems are of major importance.

For many years improvements in health care systems have focused on effectiveness of health care providers which finally resulted in increasing number of physicians nurses hospital beds and pieces of modern equipment. The importance of sanitary prophylactics by means of improving life standard working hygiene nutritional status etc. has for a long time been neglected. It has become clear that medical care is only one of the factors influencing human health. When the incidence of chronic so called "civilisational" diseases began to rapidly increase the old attitude proved its ineffectiveness: widespread investments in highly specialised medical services failed to stop the outbreak of these diseases. Consequently, despite raising health care resources, the sanitary status of European societies remains far below the expectations - in fact in many countries an increase in mortality rates is being observed.

This is why a global review of sanitary status has been undertaken and the effectiveness of former organisational strategies has been evaluated. A profound reorientation of health care activities appeared to be necessary. Twenty years ago the World Health Assembly voted a "Health for all 2000" resolution known as "Health for all before the year 2000". Its aim was to "achieve before the year 2000 the health status of a global population which would allow to live a socially and economically effective life". Suggestions appeared at the end of the eighties to extend the WHO definition of health (health is a status of physical, psychic and social well-being, and not only the lack of disease or defect) by adding "as well as ecological well-being". In 1977 the WHO assembly held in Alma-Ata resolved that health should not be a privilege it should be a right for every individual.

"Health for all 2000" regards health as a positive value of economical importance and therefore as being one of the national economy resources. In this attitude health has two dimensions - medical and social. The medical one contains "negative" indicators concerning certain diseases and "positive" indicators concerning the functioning of an individual and his/her well-being.

Of fundamental importance in European health policy is a statement that human health is determined by multiple factors such as genetics environment health-destructive lifestyle factors (nicotinism, alcoholism, narcotics, drug abuse) suboptimal social status etc.

It is easily understandable that among these general guidelines of special importance is perinatal medicine, and generally speaking human procreation. Interestingly, several countries which drastically decreased neonatal mortality in the years 1960-1985, underwent at the same time a rapid industrial development. This happened in Hong Kong,Singapore and South Korea.

Of great political significance is that poor countries can achieve a health care standard comparable with that of developed countries resulting in the average life-time elongation. This challenges the opinion that poor countries cannot stand the additional investments into the health care and education at least not before their macroeconomic improvement.

Major changes take place in social life mainly caused by progress in science. This process is associated by alterations in human mentality hierarchy of values and life style.

There emerges a new direction in medicine namely observing and treating a patients in his/her biosocial surrounding. According to the famous polish professor Ruzyllo this change in attitude direction is equivalent to the XVIII century milestone contribution of H. Boerhaave, a Dutch physician regarded as a father of clinical medicine.

The human being is doomed to good and love, not only with respect to him/her but to nature as well. Another famous polish professor J. Aleksandrowicz says: "what is beneficial for man must not be harmful for nature". This is why a holistic attitude to the world and natural environment protection are necessary. And this is also why a medical education in ecology becomes necessary, considered not as a narrow subdiscipline of biology, but as a new vision of the world and man. Neil Everndorn called ecology a subversive science which forces a man to change his/her point of view from observation of the reality to its integral perception. A physician of today, as well as the one of tomorrow, must look at a man in all the complexity of a consumptive society and the dangers brought to him by so-called economic metabolism.

Due to all these aspects, ecological problems must be present in the medical education on both general and specialist levels of teaching, especially if according to WHO's suggestion our goal is to train "five stars doctors".

Information: ask details and registration forms to: AMEE Office - University of Dundee

Tay Park House - 484 Perth Road - Dundee DD2 1LR - UK

Tel: +44-1382.631967 Fax: +44-1382.645748 E-mail:p.m.lilley@dundee.ac.uk

Topics: Current issues in medical education: new technologies - curriculum development - academic audit and quality assurance - multiprofessional education - postgraduate education - continuing medical education - international medical education - staff development - etc.

Conference format: plenaries, short communications, posters, exhibitions, workshops, special interest groups.