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Asclepion of Epidaurus: the application of a historical perspective in medical education

Asclepion of Epidaurus: the application of a historical perspective in medical education Background: The Asclepion of Epidaurus is one of the first healing environments in the world. Descendants of Asclepius, specifically medical students, have been singularly deprived of any information concerning this legacy. This article illuminates the role of Asclepion of Epidaurus and examines the view of medical students upon the subject and the possible benefits of this knowledge in their medical education. Methods: The participants were 105 senior-year students from the Athens Medical School, who attended a multi- media assisted lecture related to the structure and the role of the Asclepion of Epidaurus. Afterwards, they answered anonymously a questionnaire of 12 pairs of opposite adjectives in order to describe their view regarding the meaning of Asclepion. The method used in the evaluation of their answers was that of semantic differential. Results: The attitude of the students towards the meaning of Asclepion was positive, showing interest and excite- ment about a powerful, though unfamiliar piece of knowledge. Conclusion: Today’s novice doctors have welcomed the concept of Asclepion as essential knowledge for the service they will be called to fulfill. The potential benefits of the Asclepian ideals in medical education and ethos are thor - oughly discussed. Keyword: Asclepion, Healing environment, Sacred space, Medical education, Medical ethics Background of whole-person focus, and first contact care for a wide Medical education nowadays calls for a reform due to range of situations and symptoms. Specialists, who are the increasing ageing population and the rapidly grow- necessary to provide condition-focused solutions, may ing number of patients with long term diseases and mul- also integrate some features of generalist practice, such as tiple comorbidities. Specialization and subspecialization the person-centred decision making [1]. which dominate in current models of medical train- Furthermore, increased health care needs and cultural ing do not adequately prepare physicians to respond to diversity in modern societies demand a more sophisti- patient and community needs anymore. Generalism cated medical education which can transform all medical and generalist training have been proposed as a potent students to well-rounded personalities with the potential solution to reforming the medical education in order to to play any one of the six key roles of the ideal doctor: respond to future population health needs. Generalism communicator, team member, leader, health care advo- includes uninterrupted and interpretative care, principles cate, professional and medical expert [2]. Potential contribution of the Asclepions in the modern *Correspondence: k.giannopoulou.14@hotmail.com 5 medical education Department of Neurology, Henry Dunant Hospital Center, Athens, Greece Ancient Greek medicine, as it was applied in the sacred Full list of author information is available at the end of the article spaces of Asclepions, may teach us about performing © The Author(s) 2022. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http:// creat iveco mmons. org/ licen ses/ by/4. 0/. The Creative Commons Public Domain Dedication waiver (http:// creat iveco mmons. org/ publi cdoma in/ zero/1. 0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Papageorgiou et al. Philosophy, Ethics, and Humanities in Medicine (2022) 17:7 Page 2 of 9 these key roles of the ideal modern doctor and general- In answer to the above, graduates of the Medi- ism as well. cal School of Athens were called to complete a ques- The Asclepions were sacred worshipping grounds οf tionnaire. The method used in the evaluation of their doctor and healing god Asclepius. In fact, they were answers was that of semantic differential [6 ], a very the first healing spaces, or rather building complexes, simple method developed by Charles Osgood, 67 years where medical services were rendered, not only on Greek ago [7]. The semantic differential is probably the most land but also throughout western civilization [3]. From successful empirical method invented for studying the ancient written accounts as well as excavated remains, nature of connotative meaning of any concept [8]. it is known today that the sacred spaces named “Ascle- The semantic differential scale is considered to be a pions” were equipped with mythological, ideological special version of a cumulative grading scale, which and philosophical perceptions of the well-being of our is used for measuring the importance of meanings. ancestors, offered holistic health care to their patients. A The purpose for creating this scale was for a quantita - person (patient and supplicant) was treated with solemn tive description of different ways (subjective) a person respect, as a complete entity with inseparable spiritual, interprets a specific concept. The main assumption mental, emotional, social, moral and natural characteris- of this method is that the interpretation of a concept tics. Illness was viewed as the outcome of complex, nega- is based on the attributes each person assigns to it tive interactions of environmental, social, psychological, through his personal experiences and not through what spiritual, emotional and natural factors, and health care is socially acceptable or objective [7]. seemed to aim at resolving these conflicts and restoring Establishing the semantic differential method is pro - balance among the above-mentioned by having as sup- cedurally plain: Concepts (e.g. settings, actions, behav- plementary aid medical intervention, either surgical or iors, techniques, objects) are presented to participants pharmaceutical [4]. who are asked to rate them on perhaps as many as Today it is known from proof of written sources and/ 10—50 scales [9]. Each scale is typically a seven point or archaeological findings the existence of approxi - scale based on opposing adjectives (e.g. good-bad, fair- mately 320 Asclepions buildings in ancient Greece. In unfair, etc.), with the central point being neutral. The the mainland of Epidaurus, an area with mild climate participants assess the concept under study by using and plentiful, therapeutic water springs is found perhaps these adjectives. Usually a number of 10–20 pairs of the most significant therapeutic center in all of Greece adjectives are considered satisfactory to examine all and Rome: the Asclepion of Epidaurus. Although it was aspects of the phenomenon. A greater number would the main sanctuary of a small, seaside town of the Argo- lead to participant fatigue [6]. lis region, its reputation and recognition quickly went Osgood studied fundamental dimensions that could beyond its geographical boundaries and was considered lead to a differentiation of perception that participants by the Greeks as the place where medicine was born. have of a concept. He submitted for analysis the answers More than 100 therapeutic spring centers in the entire of one group of participants with 50 bipolar pairs of east Mediterranean are considered its foundings. Today adjectives (e.g. fair-unfair, good-bad, strong–weak, fast- these monuments are not only recognized as worldwide slow). Factor analysis or principal components analysis wonders of ancient Greek art and architecture, but also was then used to determine the concealed dimensions as exceptional testaments to the practice of medicine or factors underlying these ratings [10]. in antiquity. These monuments reflect the evolution of The results of this study revealed three aspects which medical practice, starting from the time curing illness were confirmed after subsequent research of different was dependent wholly on a god to its transformation groups and societies [11]. The factors that resulted from into a science which involved the systematic recording this study are the following: of medical cases and the gradual gathering of knowledge and experience [5]. • Activity. It indicates the degree to which a concept is Nowadays, the Asclepion is considered to be the pri- described by motion and action and captures the extent mary form of holistic medical design and is studied in this concept is ‘active’ or ‘passive. This is r ’ epresented by depth by Greek and international centers as a sacred pro- adjectives such as active–passive, hot–cold, fast-slow. totype of incredible significance and is used as a guidance • Evaluation. This aspect indicates the degree to which for new medical design proposals [4, 5]. a concept is favorable to an individual. It almost However, the question arises of whether descendants always corresponds to whether the concept is ‘good’ of Asclepius, more specifically, medical students and or ‘bad’. It is represented by pairs of adjectives such new doctors, recognize the significance of this legacy and as valuable-useless, sacred-sacrilegious, good-bad, what their view is upon the subject. clean-dirty, pleasant-unpleasant. P apageorgiou et al. Philosophy, Ethics, and Humanities in Medicine (2022) 17:7 Page 3 of 9 • Potency. This aspect captures the extent the concept PLEASANT + 3 + 2 + 1 0 -1 -2 -3 UNPLEASANT is ‘strong’ or ‘weak’. It is represented by adjectives BIG + 3 + 2 + 1 0 -1 -2 -3 SMALL such as strong–weak, heavy-light, big-small. FAST + 3 + 2 + 1 0 -1 -2 -3 SLOW GOOD + 3 + 2 + 1 0 -1 -2 -3 BAD The technique of semantic differential is a useful STRONG + 3 + 2 + 1 0 -1 -2 -3 WEAK means to create scales for research purposes and mul- ALIVE + 3 + 2 + 1 0 -1 -2 -3 DEAD tiple applications. The scale is used broadly for the SWEET + 3 + 2 + 1 0 -1 -2 -3 SOUR measurement of the attitude one has towards persons, POSSIBLE + 3 + 2 + 1 0 -1 -2 -3 IMPOSSIBLE social groups, institutions, social phenomena, etc. as QUIET + 3 + 2 + 1 0 -1 -2 -3 NOISY well as the detection of differences in the way individu - USEFUL + 3 + 2 + 1 0 -1 -2 -3 USELESS als perceive particular concepts. The way in which a MEANINGFUL + 3 + 2 + 1 0 -1 -2 -3 SENSELESS participant evaluates a concept (e.g. valuable-useless, YOUNG + 3 + 2 + 1 0 -1 -2 -3 OLD strong–weak, good-bad etc.) expresses a more general attitude towards it [6, 7]. The questionnaire consisted of basic demographic infor - Although the semantic differential method is over sixty mation of the participants (age, sex) as well as 12 pairs years old, it has been found to be vigorous across cul- of adjectives: pleasant-unpleasant, big-small, good-bad, tures [11] and domains [12], probably because the three fast-slow, possible-impossible, strong–weak, alive-dead, dimensions of the semantic differential represent a sum - sweet–sour, noisy-quiet, useful-useless, meaningful- mary of the universal human perception, specifically the senseless, young-old. For selecting the most appropriate average sense of order, benefit and power associated with pairs of adjectives for our study, we used the semantic dif- a particular concept. ferential dictionary which was compiled during 2002/3 at Indiana University [13]. This dictionary consists of 1500 concepts grouped under four different headings: Behav - Methods iors (actions that a person can perform), Identities (differ - The participants were 105 senior-year students from the ent kinds of individual), Settings (places or times where Athens University Medical School (46 women and 47 interactions might take place) and Modifiers (emotions, men). Participation was voluntary. traits, and statuses). We chose the final 12 pairs of adjec - Within the context of the Psychiatry course, an intro- tives among them under the heading of Settings. Each pair duction was given through multi-media relating to the contained two poles of an attribute, among which were structure and the role of the Asclepion of Epidaurus. placed 7 values (-3, -2, –1, 0, + 1, + 2, + 3). All of the students were unaware of the existence of an The subjects of this research were called to describe Asclepion in the ancient region of Epidaurus and most their view regarding the meaning of “Asclepion” under of them had a vague idea of the role of the Asclepions as the scope of their subjective point of view and from healing spaces and their contribution in the evolution of the introduction that was conducted. Since they were medical practice. totally unaware of the meaning and the healing role of The scientific-rational and mystical -divine healing the Asclepion of Epidaurus and the Asclepions in gen- systems that coexisted in a dynamic balance in these eral, before the lecture, their knowledge and impres- healing spaces were analyzed in the introduction. The sions were totally new and vivid and it was almost students became aware of the healing method of Ascle- spontaneous for them to assign a number in the 7 point pions where besides relieving, a broader scope was scale for each bipolar pair corresponding to their per- required: one in which questions of meaning, purpose, sonal view about the characterization of Asclepions destiny and mortality could be more fully explored as a setting pleasant or unpleasant, big or small, good and individuals were strongly bound by frameworks of or bad, fast or slow, possible or impossible, strong or nature and community. It was also highlighted that ill- weak, alive or dead, sweet or sour, noisy or quiet, useful ness was considered within the context of spirituality or useless, meaningful or senseless, young or old and to instead of physical failing. Besides some attention to what extent. A score between -3 and -1 represents an the bodily frame, the power of the mind was unleashed attitude more proximal to the negative pole of the pair through images, stories, sensations, and "radical ritu- (for instance, for the pair unpleasant – pleasant, the als" designed to break down old assumptions. participant percepts this setting as unpleasant), a score After the introduction, the following questionnaire was of 0 represents a neutral response (neither unpleas- distributed and requested that the participants fill it out ant or pleasant), and a score + 1 to + 3 represents an anonymously: Papageorgiou et al. Philosophy, Ethics, and Humanities in Medicine (2022) 17:7 Page 4 of 9 Table 1 No significant differences between the sexes were attitude more proximal to the positive pole (more remarked by the Mann–Whitney U inferential statistics test pleasant than unpleasant). After the questionnaires were collected, the data was Mann–Whitney U test Rank Sum Rank Sum U p-value men women subsequently recorded on an Excel sheet followed by a factor analysis with the purpose of defining the dimen - Unpleasant—Pleasant 1804,500 1936,500 814,5000 0,346,354 sions of meaning under examination and the individual Small—Big 2081,500 2013,500 953,5000 0,648,111 properties. Finally, calculations were made on the over- Bad—Good 1853,000 1888,000 818,0000 0,368,536 all score of each participant by adding the numerical Slow – Fast 2211,000 1794,000 848,0000 0,248,690 answers to the adjectives that represent each dimension. Weak – Strong 1964,000 1952,000 883,0000 0,490,697 The seven-number scale was modified as -3, -2, -1, 0, 1, Dead—Alive 2122,000 1973,000 994,0000 0,897,166 2, 3. The negative scoring concerned greater proximity to Sour – Sweet 2232,500 1772,500 826,5000 0,183,499 the negative pole of each pair. Powerless—Powerfull 1866,500 2049,500 831,5000 0,258,021 Noisy – Quiet 2106,500 1809,500 906,5000 0,622,095 Results Useless—Useful 1922,000 2173,000 794,0000 0,081,024 Following the recording of the score each participant Superficial—Substantial 1880,000 2036,000 799,0000 0,164,247 assigned to every dimension, the numerical answers were Old—Young 2056,500 1948,500 928,5000 0,633,593 added and the mean value for each dimension by gender was calculated (Fig.  1). Overall there were no noticeable differences between the sexes (Table  1). Both women’s accounted for 20.89% of the total variance, the second and men’s answers were directed towards the negative (Evaluation) for 16.40% while the third (Potency) for pole only in three cases of bipolar pairs. The specific 13.94%. bipolars were: slow-fast, old-young, noisy-quiet. In the The first factor (Activity) had high loadings on the four remaining bipolar pairs the scores tended to lean towards bipolar pairs: fast-slow, powerful-powerless, useful-use- the positive side for both genders (Fig. 1). less, substantial-superficial. These results show that the Principal component analysis with varimax rotation students perceived the healing environment of Asclepion performed on the questionnaire data, revealed the pres- as a dynamic process with rapidity, vitality, strength, pos- ence of three factors. These factors explained the 51,24% itive influence and perpetual importance. of total variance. The first of the three factors (Activity) Fig. 1 Depiction of the average value for each dimension by gender: Following the recording of the score, each participant assigned to every dimension, the numerical answers were added and the average value for each dimension by gender was calculated P apageorgiou et al. Philosophy, Ethics, and Humanities in Medicine (2022) 17:7 Page 5 of 9 With respect to the second factor, high loadings were Overall, these results reveal that the majority of the noted on the six pairs of bipolar adjectives: pleasant- students perceived the meaning and the role of Asclepion unpleasant, good-bad, alive-dead, sweet–sour, noisy- as an active (Activity factor), valuable (Evaluation factor) quiet, young-old. The students’ answers described a and powerful (Potency factor) entity. The most popular rather modern meaning of the Asclepions, capable of positive characterizations of Asclepion among the stu- creating pleasure, positivity, hope, vibration and even dents, as they are depicted in Fig. 1 are: big, good, power- freshness. ful, useful and substantial. Finally, the third factor had high loadings on the four bipolar pairs: pleasant-unpleasant, big-small, strong– Discussion weak, powerful-powerless (Table  2). This group of In the present study and in the context of a theoretical answers seems to depict an innovative educational and Psychiatry course given at the Medical School of Ath- medical environment and it is a real surprise that in fact ens, graduating students studied the structure, role and depicts an ancient healing world. organization of the Asclepion in Epidaurus, as mentioned Table 2 From the factor analysis that was conducted from the questionnaires, three factors emerged which accounted for 51.24% of the total deviation Factor 1 (Activity) had high loadings in fast-slow, strong–weak, useful-useless, substantial-superficial and accounted for 20.89% of the total variance Factor 2 (Evaluation) had high loadings in pleasant-unpleasant, good-bad, alive-dead, sweet–sour, noisy-calm, young-old and accounted for 16.40% of the total variance Factor 3 (Potency) had high loadings in pleasant-unpleasant, big-small, strong–weak, powerful-powerless and accounted for 13.94% of the total variance The highest percentages are highlighted Papageorgiou et al. Philosophy, Ethics, and Humanities in Medicine (2022) 17:7 Page 6 of 9 before. Next, based on the introduction, their personal was set up there. The mild climate along with the calming knowledge and subjective views of the Asclepion, the green foliage would have supplied the ill and cheerless participants were called in to score in the form of a ques- pilgrims with recreation and tranquillity. Furthermore, tionnaire the information they received, approaching the the plentiful spring waters of the region were another concept of “Asclepion” through the method of semantic chief asset in the healing expectation [5, 14, 15]. differential. A well-organized list of active and passive rituals and From the analysis of the participants’ answers stem- healing activities was customized to the needs of every ming from the questionnaire, it appears that for the individual [16]. The various healing dimensions that were descendants (novice doctors) of Asclepius’s work, the offered were: importance of the monument and its vital role is new information. Most likely, the concept of “Asclepion” • The purification process: “Purity means to think might not be unprecedented. However, its connection to nothing but holy thoughts” [16] was the inscription the archaeological site of Epidaurus, as well as the wide- with which the pilgrims/patients were encountered spread impact it had for the times then, are what had at the entrance of the sacred space. Basins for hygiene been introduced for the first time. Today’s new doctors purposes and relaxation were the initial part of the have welcomed the above as essential and useful knowl- purification process which would be lengthened by edge. That effectively transferred knowledge has aroused sacrifices and accompanying rituals. their interest not only in the history and evolution of • Sacred healing rituals: After purification, the direc - Asclepion, but also in the service, they will be called to tive priests created a state of deep auto—sugges- fulfill. tion accompanied with religious exaltations in the Overall, the students showed a real interest and even patients-believers. The spiritual experience was fur - excitement about this unfamiliar but attractive piece of ther intensified by the healing aesthetic of sacred knowledge. They also expressed their surprise with many environments as well as the hymns chanted by the questions and comments about the specific methods Paianists (specialised singers) [16]. involved in this healing attitude, the results and the pub- • Therapeutic procedures: In separate(d) halls, the licity of the sacred space of Asclepion of Epidaurus. Dur- healing priests – ancient Greek physicians, also per- ing this survey, they had also the opportunity to confess formed and recorded a detailed history and physical that are no longer satisfied with the intensifying focus of examination of the patient and afterwards, they rec- scientific medicine as applied biology and technology and ommended dietary guidelines, gave instructions for many demand the inclusion of spirituality in health edu- the use of many kinds of medicinal herbs per os or cation and care. in the form of suppositories, ointments or eye drops and whenever it was necessary, they performed sur- gical operations [16, 17]. Overview of healing environment and methods • Physical exercise: It took place in the gymnasium [5]. of Asclepion • Communal bonding and encouragement: This The following piece of information helped them to involved viewing athletic events in the stadium [5]. complete their perception of the healing environment • Communal catharsis: It took place in the mag- and methods of Asclepion and to connect it with the nificent Epidaurus theatre with a seating capacity of humanism and spirituality that the modern medical care 14,000, where ancient drama was presented [5]. demands. • Communal meals: Formal banquets were included About 2,500 years ago, the Greeks realised the neces- in the healing process for selected worshippers sity of a healing space in order to mend their society’s which took place in Banqueting Hall- a mesmer- collective health and every citizen’s well-being since izing building that inspired pilgrims to trust each they had been at continual war for centuries. They other and share empathy and hope in their common selected Epidaurus as their building site for their heal- effort [18, 19]. ing sanctuary as they knew clearly what kind of resi- • Dream healing (“Enkoimesis”): It was the final stage dences and environments suited their needs. Indeed, of the healing process with its own sacred space, the location of Epidaurus incorporates the two most which was named “Abaton” or “Enkoimeterion”. well-established principles of current healthcare archi- According to the priests, when the testing of the soul tecture: the inclusion of sunlight and that of natural was complete, the believer was led to the sacred site scenery [5, 14, 15]. to spend the night alone. Already overcome with The pleasure every visitor derived from viewing the religious faith and anticipation, the patient excit- land of Epidaurus then extends to those experiencing its edly imagined the impending miracle of being cured. beautiful scenery today, and explains why the Asclepion P apageorgiou et al. Philosophy, Ethics, and Humanities in Medicine (2022) 17:7 Page 7 of 9 Moreover, concealed oil lamps which illuminated the It is suggested, that the study of the healing environ- premises, heightened even further the supernatural ment of the Asclepion in Epidaurus can offer a plethora experience he was about to undergo. After the with- of benefits to novice doctors since they are eager to gain drawal of the priest, the patient was abandoned in new ancient knowledge. the darkness to enter the phase of healing sleep. The The results of our study reveal that the majority of the following morning the patient would awake healthy students perceived the Asclepion as an active setting [5, 14, 20]. (Activity factor). This remark can become a motivation • Testimonials of gratitude: After the cure, the wor- for their educators to revive the most intriguing features shipping of the god Asclepius in the monuments fol- of the Asclepions integrating them in modern medical lowed [14]. education. The following suggestions can function as triggers for innovative educational methods based in the Contemporary psychologists and psychotherapists sug- humanistic and holistic ideals of Asclepions: gest that Asclepian purification and healing rituals when First of all, medical students can appreciate the heal- used shifted believers’ understanding of the self and the ing power of architecturally appealing and sun-filled sur - universe to the point where they could self-heal them- roundings that respect patients and the quality of their selves and hence function in a healthy manner [20, 21]. stay there. A specialized subject, such as medical archi- The multitude of sacred spaces and ritual opportunities tecture or architecture of healing environments could available at Epidaurus contributed to the ancient city’s be proved beneficial for medical students as well as their reputation as a place for healing among traumatized future patients. It is true that nowadays modern medical pilgrims. centers’ design has shifted to a focus on patient, upgrad- Overall, in ancient times the sanctuary of Asclepius ing their surroundings aesthetically to provide a pleasant was an organized medical healing center, which marked and relaxing experience for their patients and their fami- the transition from occult rituals for treatment to the use lies. However, the environment would not be defined as of actual medical science. That is, the therapy for any ail - one of healing as those of the wise ancient Greeks had ment would be executed based on diagnosis and appro- foreseen. Since their first impression of the Asclepion set - priate administering of medicine or surgical intervention, ting was that this space is active and powerful, the medi- but with divine guidance. It can be realized that medical cal students’ curriculum could be pleasantly enriched practice in Asclepion of Epidaurus was focused simulta- by a brief subject about the main architectural features neously on a holistic and individual approach for every of sacred spaces and the healing powers of light and the patient. At the same time, the issue of total harmony views of natural environment [5, 23]. Hence, novice doc- among the personal, social and natural environment was tors can request the improvement of medical facilities highlighted as a prioritized healing process within the in their working environment, where the model healing boundaries of that sacred space [22]. space of the Asclepion of Epidaurus would be followed. The reputation of the Asclepion for the time then Ideally, organized visits to the Asclepion of Epidaurus could be characterized as worldwide. With the Ascle- could enlighten the natural impact of the architecture pion of Epidaurus being the center for patient care, rev- and the surroundings on their mentality. After that, they erence for Asclepius was spread not only in Greece but would probably seek the reproduction of the harmony, also throughout the Mediterranean world; and at the simplicity and grandeur of this environment to their eve- same time, with the creation of more than 100 subsidi- ryday working space. Even more beneficial might be the ary Asclepions, medical science was spread through- educational workshops or small group congresses in this out Attica, in the Peloponnese, in western Greece, the space. Deprived from any modern equipment, just talk- Aegean Islands, Crete, from Asia Minor to the distant ing and walking under the olive trees in small groups, Cilicia, Rome and Cyrene in Africa. However, nowadays, accompanied by an experienced clinician who would the restoration and use of the ancient theater has led to provide them with facts and questions and totally con- the public’s mistaken perception of the archaeological centrated in the conversation, it is more than probable grounds [3]. that their appreciation for their role as therapists and for To our knowledge, there are no studies on the inter- the active and continuous learning for their patients’ sake est and views of doctors about the beginnings of medical would become an invaluable lifetime’s lesson. To sum up, practice in the Asclepions, especially about the Ascle- specialized subject, such as medical architecture or archi- pion of Epidaurus. This site is not known as a great-sized tecture of healing environments could be proved benefi - monument of worship and medical practice as it had cial for medical students as well as their future patients. been, but as a great architectural and aesthetic, theatrical Furthermore, the majority of the students, according to structure. our study’s results perceived the Asclepion as a valuable Papageorgiou et al. Philosophy, Ethics, and Humanities in Medicine (2022) 17:7 Page 8 of 9 setting (Evaluation factor). This aspect might be trans - Today, patients do not admire the focus of scientific lated into their need for discovering deeper values in medicine as applied technology on their bodies any more their profession, derived from the dawning of medicine and many demand ethos, “phronesis” and the inclusion in the healing spaces of the Asclepions. of spirituality in health care. Their request for meaning - For instance, modern medical educators inspired by ful answers to their eternal questions recurs: Why is this priest – physicians of Asclepions can teach new doc- suffering happening only to me and now? Am I going to tors – through vivid presentations or documentaries to live and for how long? What is the meaning of my short start thinking not only with guidelines, rules, manage- life? What will be my legacy? Current medical education ment systems, and frameworks, as they have already been has to expand its scope and address the issue of suffer - taught to do so, but also with phronesis. For Aristotle, ing. The model of Asclepian healing spaces and methods phronesis, which means ‘practical wisdom’, is one of the enlightens this approach and can guide the modern med- most important human virtues. It commands our skills, ical education in this area. thoughts, and courage, with the use of both knowledge The attitude of the students towards the new knowl - and judgment, guiding us to the most efficient actions. edge of Asclepion of Epidaurus was positive, showing Medical students and new doctors can emulate this kind a real interest and sometimes excitement about a use- of practical wisdom from the best practices of the ancient ful and alive, though still unfamiliar piece of knowledge. physicians, who worked in demanding and hostile envi- We cannot ignore this attitude that allows us to see that ronment, usually in times of warfare, without protocols our students are no longer satisfied with the intensifying or equipment, but always providing the best they could focus of scientific medicine as applied biology and tech - [24]. These priests – physicians had in mind that the real nology and many demand the inclusion of spirituality in world always presents us with situations that are more health education and care. complex than our experience and knowledge can predict We suggest that the modern curricula of medical stu- and that patients have varying priorities and demand dif- dents should be further potentiated by humanistic and ferent therapeutic approaches to their being healed. And social subjects, such as principles of philosophy, medi- to achieve positive results, they worked with phronesis cal ethics and medical leadership. Thus, novice doctors [25–27]. Modern educators, especially experienced clini- might be empowered to treat not only diseases but also cians in the emergencies or in remote areas without the patients. basic technological facilities can effectively teach ‘phro - nesis’ in medical students. The results of our study also indicated that medical Conclusions students perceived the Asclepion as a powerful setting We believe, as Socrates probably did, that it would be (Potency factor). Their estimation is probably in line with of great importance instead of focusing on our techno- that of Socrates [28]: cratic and selfish way of thinking to seek knowledge and The last words of the famous philosopher before his points of perspectives of the Asclepions, especially that death, undoubtedly express what Asclepius’ values meant of Epidaurus, which used the influence of environment to the former personally. and architecture and the principles of phronesis and ethos “Crito, we owe a cock to Asclepius—Pay it and do not as healing powers. The positive attitude of medical stu - neglect it” [29]. dents to the meaning of Asclepions as healing spaces is Socrates had called his students for an offering to a strong encouragement to further explore this source of Asclepius. He was sentenced to death for impiety, that is, medical experience and inspiration as an educational tool for not believing in the state’s gods but introducing new and environment. Future studies could evaluate the shift ones. Thus, the questions arises of why the philosopher’s of view that this knowledge can induce in physicians’ way last words were an expression of gratitude to a healing of thinking and practice of medical healing as well as the god. influence this shift can have on their patients’ satisfaction The most probable explanation may be he believed in and overall health status. the reviving and humanistic power of Asclepian ideals, Acknowledgements which was the only value that could keep his own spirit The authors thank the sixth-year medical students of Medical School at and ideas alive. Socrates summons us from the past to National and Kapodistrian University of Athens, (academic year: 2017-2018) who voluntarily participated in this study. apply eternal Asclepian medical practices to self, patients and community. He reminds us of our personal duty to Authors’ contributions st make our ethos a first priority, of our professional duty to CP (1 author), VL and KGY conceptualized the study, developed the proposal, th coordinated the project and wrote the report. GK and CP (4 completed initial alleviate suffering, and of our social duty to support the data entry and analysis, conducted the statistical analyses and assisted in vulnerable, sick, and deprived [30]. writing and editing the final report. KGY participated in overall supervision of P apageorgiou et al. Philosophy, Ethics, and Humanities in Medicine (2022) 17:7 Page 9 of 9 the project and revision of the report. All authors read and approved the final 14. Charitonidou A. Epidaurus: The Sanctuary of Asclepius and the Museum. manuscript. Clio Ed. 1978;13. 15. Λαμπρινουδάκης Β., Ένα μοναδικό ταξίδι στην ιστορία της υγείας , Funding Δήμος Επιδαύρου – Διάζωμα, Πάτρα 2016, σ.3-31 [Lambrinoudakis V. None. The sanctuary of Apollo Maleatas and Asclepius at Epidaurus: A unique travel in health’s history. Municipality of Epidaurus - Diazoma Association, Availability of data and materials Patras; 2016. p. 3–31]. The datasets used and analyzed during the current study are available from 16. Mironidou-Tzouveleki M, Tzitzis PM. Medical practice in the ancient Ascle- the corresponding author on reasonable request. peion in Kos island. Hell J Nucl Med. 2014;17(3):167–70. 17. Tsoucalas G, Kousoulis AA, Mariolis-Sapsakos T, Sgantzos M. Trepanation Practices in Asclepieia Systematizing a Neurosurgical Innovation. World Declarations Neurosurg. 2017;103:501–3. 18. Tomlinson RA. Epidauros. 1st ed. Austin, Texas: University of Texas; 1983. p. Ethics approval and consent to participate Written informed consent was received by the students who participated. The 19. Tick E. The Practice of Dream Healing: Bringing Ancient Greek Mysteries study analyzed de-identified data and the participation of the students was into Modern Medicine. 1st ed. Wheaton, Illinois: Quest Books; 2001. p. voluntary. We obtained the data use agreement as required with the Medical Education Unit, National and Kapodistrian University of Athens, School of 20. Whitehead CC. On the Asclepian spirit and the future of psychoanalysis. J Medicine. Ethics approval and consent to participate Ethics approval was Am Acad Psychoanal. 2002;30(1):53–69. obtained by the Committee on Health Research Ethics of National and Kapo- 21. Kleisiaris CF, Sfakianakis C, Papathanasiou IV. Health care practices in distrian University of Athens. ancient Greece: The Hippocratic ideal. J Med Ethics Hist Med. 2014;7:6. 22. Dominiczak MH. The temple and the plane tree: rationality and Consent for publication cult at the beginnings of western medicine. Clin Chem Lab Med. Not applicable. 2001;39(10):997–1000. 23. Thumiger C. A History of the Mind and Mental Health in Classical Greek Competing interests Medical Thought. Hist Psychiatry. 2018;29(4):456–69. The authors declare that they have no competing interests. 24. Misselbrook D. An A–Z of medical philosophy. Brit J Gen Pract. 2014;191. 25. Ashley EA. Medical education - beyond tomorrow? The new doctor - Author details Asclepiad or Logiatros? Med Educ. 2000;34(6):455–9. 1St Department of Psychiatry, School of Medicine, National and Kapodistrian 26. Tountas Y. The historical origins of the basic concepts of health promo- University of Athens, Athens, Greece. University Mental Health Research tion and education: the role of ancient Greek philosophy and medicine. Institute (UMHRI), Athens, Greece. Department of Classical Archaeology, Health Promot Int. 2009;24(2):185–92. 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Mean Aec ff tive Ratings of 1,500 Concepts by Indiana University Undergraduates in 2002–3 [Computer file]. 2006. Availa- At BMC, research is always in progress. ble: https:// www. india na. edu/ ~socpsy/ ACT/ inter act/ JavaI ntera ct. html\% 3E. Learn more biomedcentral.com/submissions http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png "Philosophy, Ethics, and Humanities in Medicine" Springer Journals

Asclepion of Epidaurus: the application of a historical perspective in medical education

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Abstract

Background: The Asclepion of Epidaurus is one of the first healing environments in the world. Descendants of Asclepius, specifically medical students, have been singularly deprived of any information concerning this legacy. This article illuminates the role of Asclepion of Epidaurus and examines the view of medical students upon the subject and the possible benefits of this knowledge in their medical education. Methods: The participants were 105 senior-year students from the Athens Medical School, who attended a multi- media assisted lecture related to the structure and the role of the Asclepion of Epidaurus. Afterwards, they answered anonymously a questionnaire of 12 pairs of opposite adjectives in order to describe their view regarding the meaning of Asclepion. The method used in the evaluation of their answers was that of semantic differential. Results: The attitude of the students towards the meaning of Asclepion was positive, showing interest and excite- ment about a powerful, though unfamiliar piece of knowledge. Conclusion: Today’s novice doctors have welcomed the concept of Asclepion as essential knowledge for the service they will be called to fulfill. The potential benefits of the Asclepian ideals in medical education and ethos are thor - oughly discussed. Keyword: Asclepion, Healing environment, Sacred space, Medical education, Medical ethics Background of whole-person focus, and first contact care for a wide Medical education nowadays calls for a reform due to range of situations and symptoms. Specialists, who are the increasing ageing population and the rapidly grow- necessary to provide condition-focused solutions, may ing number of patients with long term diseases and mul- also integrate some features of generalist practice, such as tiple comorbidities. Specialization and subspecialization the person-centred decision making [1]. which dominate in current models of medical train- Furthermore, increased health care needs and cultural ing do not adequately prepare physicians to respond to diversity in modern societies demand a more sophisti- patient and community needs anymore. Generalism cated medical education which can transform all medical and generalist training have been proposed as a potent students to well-rounded personalities with the potential solution to reforming the medical education in order to to play any one of the six key roles of the ideal doctor: respond to future population health needs. Generalism communicator, team member, leader, health care advo- includes uninterrupted and interpretative care, principles cate, professional and medical expert [2]. Potential contribution of the Asclepions in the modern *Correspondence: k.giannopoulou.14@hotmail.com 5 medical education Department of Neurology, Henry Dunant Hospital Center, Athens, Greece Ancient Greek medicine, as it was applied in the sacred Full list of author information is available at the end of the article spaces of Asclepions, may teach us about performing © The Author(s) 2022. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http:// creat iveco mmons. org/ licen ses/ by/4. 0/. The Creative Commons Public Domain Dedication waiver (http:// creat iveco mmons. org/ publi cdoma in/ zero/1. 0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Papageorgiou et al. Philosophy, Ethics, and Humanities in Medicine (2022) 17:7 Page 2 of 9 these key roles of the ideal modern doctor and general- In answer to the above, graduates of the Medi- ism as well. cal School of Athens were called to complete a ques- The Asclepions were sacred worshipping grounds οf tionnaire. The method used in the evaluation of their doctor and healing god Asclepius. In fact, they were answers was that of semantic differential [6 ], a very the first healing spaces, or rather building complexes, simple method developed by Charles Osgood, 67 years where medical services were rendered, not only on Greek ago [7]. The semantic differential is probably the most land but also throughout western civilization [3]. From successful empirical method invented for studying the ancient written accounts as well as excavated remains, nature of connotative meaning of any concept [8]. it is known today that the sacred spaces named “Ascle- The semantic differential scale is considered to be a pions” were equipped with mythological, ideological special version of a cumulative grading scale, which and philosophical perceptions of the well-being of our is used for measuring the importance of meanings. ancestors, offered holistic health care to their patients. A The purpose for creating this scale was for a quantita - person (patient and supplicant) was treated with solemn tive description of different ways (subjective) a person respect, as a complete entity with inseparable spiritual, interprets a specific concept. The main assumption mental, emotional, social, moral and natural characteris- of this method is that the interpretation of a concept tics. Illness was viewed as the outcome of complex, nega- is based on the attributes each person assigns to it tive interactions of environmental, social, psychological, through his personal experiences and not through what spiritual, emotional and natural factors, and health care is socially acceptable or objective [7]. seemed to aim at resolving these conflicts and restoring Establishing the semantic differential method is pro - balance among the above-mentioned by having as sup- cedurally plain: Concepts (e.g. settings, actions, behav- plementary aid medical intervention, either surgical or iors, techniques, objects) are presented to participants pharmaceutical [4]. who are asked to rate them on perhaps as many as Today it is known from proof of written sources and/ 10—50 scales [9]. Each scale is typically a seven point or archaeological findings the existence of approxi - scale based on opposing adjectives (e.g. good-bad, fair- mately 320 Asclepions buildings in ancient Greece. In unfair, etc.), with the central point being neutral. The the mainland of Epidaurus, an area with mild climate participants assess the concept under study by using and plentiful, therapeutic water springs is found perhaps these adjectives. Usually a number of 10–20 pairs of the most significant therapeutic center in all of Greece adjectives are considered satisfactory to examine all and Rome: the Asclepion of Epidaurus. Although it was aspects of the phenomenon. A greater number would the main sanctuary of a small, seaside town of the Argo- lead to participant fatigue [6]. lis region, its reputation and recognition quickly went Osgood studied fundamental dimensions that could beyond its geographical boundaries and was considered lead to a differentiation of perception that participants by the Greeks as the place where medicine was born. have of a concept. He submitted for analysis the answers More than 100 therapeutic spring centers in the entire of one group of participants with 50 bipolar pairs of east Mediterranean are considered its foundings. Today adjectives (e.g. fair-unfair, good-bad, strong–weak, fast- these monuments are not only recognized as worldwide slow). Factor analysis or principal components analysis wonders of ancient Greek art and architecture, but also was then used to determine the concealed dimensions as exceptional testaments to the practice of medicine or factors underlying these ratings [10]. in antiquity. These monuments reflect the evolution of The results of this study revealed three aspects which medical practice, starting from the time curing illness were confirmed after subsequent research of different was dependent wholly on a god to its transformation groups and societies [11]. The factors that resulted from into a science which involved the systematic recording this study are the following: of medical cases and the gradual gathering of knowledge and experience [5]. • Activity. It indicates the degree to which a concept is Nowadays, the Asclepion is considered to be the pri- described by motion and action and captures the extent mary form of holistic medical design and is studied in this concept is ‘active’ or ‘passive. This is r ’ epresented by depth by Greek and international centers as a sacred pro- adjectives such as active–passive, hot–cold, fast-slow. totype of incredible significance and is used as a guidance • Evaluation. This aspect indicates the degree to which for new medical design proposals [4, 5]. a concept is favorable to an individual. It almost However, the question arises of whether descendants always corresponds to whether the concept is ‘good’ of Asclepius, more specifically, medical students and or ‘bad’. It is represented by pairs of adjectives such new doctors, recognize the significance of this legacy and as valuable-useless, sacred-sacrilegious, good-bad, what their view is upon the subject. clean-dirty, pleasant-unpleasant. P apageorgiou et al. Philosophy, Ethics, and Humanities in Medicine (2022) 17:7 Page 3 of 9 • Potency. This aspect captures the extent the concept PLEASANT + 3 + 2 + 1 0 -1 -2 -3 UNPLEASANT is ‘strong’ or ‘weak’. It is represented by adjectives BIG + 3 + 2 + 1 0 -1 -2 -3 SMALL such as strong–weak, heavy-light, big-small. FAST + 3 + 2 + 1 0 -1 -2 -3 SLOW GOOD + 3 + 2 + 1 0 -1 -2 -3 BAD The technique of semantic differential is a useful STRONG + 3 + 2 + 1 0 -1 -2 -3 WEAK means to create scales for research purposes and mul- ALIVE + 3 + 2 + 1 0 -1 -2 -3 DEAD tiple applications. The scale is used broadly for the SWEET + 3 + 2 + 1 0 -1 -2 -3 SOUR measurement of the attitude one has towards persons, POSSIBLE + 3 + 2 + 1 0 -1 -2 -3 IMPOSSIBLE social groups, institutions, social phenomena, etc. as QUIET + 3 + 2 + 1 0 -1 -2 -3 NOISY well as the detection of differences in the way individu - USEFUL + 3 + 2 + 1 0 -1 -2 -3 USELESS als perceive particular concepts. The way in which a MEANINGFUL + 3 + 2 + 1 0 -1 -2 -3 SENSELESS participant evaluates a concept (e.g. valuable-useless, YOUNG + 3 + 2 + 1 0 -1 -2 -3 OLD strong–weak, good-bad etc.) expresses a more general attitude towards it [6, 7]. The questionnaire consisted of basic demographic infor - Although the semantic differential method is over sixty mation of the participants (age, sex) as well as 12 pairs years old, it has been found to be vigorous across cul- of adjectives: pleasant-unpleasant, big-small, good-bad, tures [11] and domains [12], probably because the three fast-slow, possible-impossible, strong–weak, alive-dead, dimensions of the semantic differential represent a sum - sweet–sour, noisy-quiet, useful-useless, meaningful- mary of the universal human perception, specifically the senseless, young-old. For selecting the most appropriate average sense of order, benefit and power associated with pairs of adjectives for our study, we used the semantic dif- a particular concept. ferential dictionary which was compiled during 2002/3 at Indiana University [13]. This dictionary consists of 1500 concepts grouped under four different headings: Behav - Methods iors (actions that a person can perform), Identities (differ - The participants were 105 senior-year students from the ent kinds of individual), Settings (places or times where Athens University Medical School (46 women and 47 interactions might take place) and Modifiers (emotions, men). Participation was voluntary. traits, and statuses). We chose the final 12 pairs of adjec - Within the context of the Psychiatry course, an intro- tives among them under the heading of Settings. Each pair duction was given through multi-media relating to the contained two poles of an attribute, among which were structure and the role of the Asclepion of Epidaurus. placed 7 values (-3, -2, –1, 0, + 1, + 2, + 3). All of the students were unaware of the existence of an The subjects of this research were called to describe Asclepion in the ancient region of Epidaurus and most their view regarding the meaning of “Asclepion” under of them had a vague idea of the role of the Asclepions as the scope of their subjective point of view and from healing spaces and their contribution in the evolution of the introduction that was conducted. Since they were medical practice. totally unaware of the meaning and the healing role of The scientific-rational and mystical -divine healing the Asclepion of Epidaurus and the Asclepions in gen- systems that coexisted in a dynamic balance in these eral, before the lecture, their knowledge and impres- healing spaces were analyzed in the introduction. The sions were totally new and vivid and it was almost students became aware of the healing method of Ascle- spontaneous for them to assign a number in the 7 point pions where besides relieving, a broader scope was scale for each bipolar pair corresponding to their per- required: one in which questions of meaning, purpose, sonal view about the characterization of Asclepions destiny and mortality could be more fully explored as a setting pleasant or unpleasant, big or small, good and individuals were strongly bound by frameworks of or bad, fast or slow, possible or impossible, strong or nature and community. It was also highlighted that ill- weak, alive or dead, sweet or sour, noisy or quiet, useful ness was considered within the context of spirituality or useless, meaningful or senseless, young or old and to instead of physical failing. Besides some attention to what extent. A score between -3 and -1 represents an the bodily frame, the power of the mind was unleashed attitude more proximal to the negative pole of the pair through images, stories, sensations, and "radical ritu- (for instance, for the pair unpleasant – pleasant, the als" designed to break down old assumptions. participant percepts this setting as unpleasant), a score After the introduction, the following questionnaire was of 0 represents a neutral response (neither unpleas- distributed and requested that the participants fill it out ant or pleasant), and a score + 1 to + 3 represents an anonymously: Papageorgiou et al. Philosophy, Ethics, and Humanities in Medicine (2022) 17:7 Page 4 of 9 Table 1 No significant differences between the sexes were attitude more proximal to the positive pole (more remarked by the Mann–Whitney U inferential statistics test pleasant than unpleasant). After the questionnaires were collected, the data was Mann–Whitney U test Rank Sum Rank Sum U p-value men women subsequently recorded on an Excel sheet followed by a factor analysis with the purpose of defining the dimen - Unpleasant—Pleasant 1804,500 1936,500 814,5000 0,346,354 sions of meaning under examination and the individual Small—Big 2081,500 2013,500 953,5000 0,648,111 properties. Finally, calculations were made on the over- Bad—Good 1853,000 1888,000 818,0000 0,368,536 all score of each participant by adding the numerical Slow – Fast 2211,000 1794,000 848,0000 0,248,690 answers to the adjectives that represent each dimension. Weak – Strong 1964,000 1952,000 883,0000 0,490,697 The seven-number scale was modified as -3, -2, -1, 0, 1, Dead—Alive 2122,000 1973,000 994,0000 0,897,166 2, 3. The negative scoring concerned greater proximity to Sour – Sweet 2232,500 1772,500 826,5000 0,183,499 the negative pole of each pair. Powerless—Powerfull 1866,500 2049,500 831,5000 0,258,021 Noisy – Quiet 2106,500 1809,500 906,5000 0,622,095 Results Useless—Useful 1922,000 2173,000 794,0000 0,081,024 Following the recording of the score each participant Superficial—Substantial 1880,000 2036,000 799,0000 0,164,247 assigned to every dimension, the numerical answers were Old—Young 2056,500 1948,500 928,5000 0,633,593 added and the mean value for each dimension by gender was calculated (Fig.  1). Overall there were no noticeable differences between the sexes (Table  1). Both women’s accounted for 20.89% of the total variance, the second and men’s answers were directed towards the negative (Evaluation) for 16.40% while the third (Potency) for pole only in three cases of bipolar pairs. The specific 13.94%. bipolars were: slow-fast, old-young, noisy-quiet. In the The first factor (Activity) had high loadings on the four remaining bipolar pairs the scores tended to lean towards bipolar pairs: fast-slow, powerful-powerless, useful-use- the positive side for both genders (Fig. 1). less, substantial-superficial. These results show that the Principal component analysis with varimax rotation students perceived the healing environment of Asclepion performed on the questionnaire data, revealed the pres- as a dynamic process with rapidity, vitality, strength, pos- ence of three factors. These factors explained the 51,24% itive influence and perpetual importance. of total variance. The first of the three factors (Activity) Fig. 1 Depiction of the average value for each dimension by gender: Following the recording of the score, each participant assigned to every dimension, the numerical answers were added and the average value for each dimension by gender was calculated P apageorgiou et al. Philosophy, Ethics, and Humanities in Medicine (2022) 17:7 Page 5 of 9 With respect to the second factor, high loadings were Overall, these results reveal that the majority of the noted on the six pairs of bipolar adjectives: pleasant- students perceived the meaning and the role of Asclepion unpleasant, good-bad, alive-dead, sweet–sour, noisy- as an active (Activity factor), valuable (Evaluation factor) quiet, young-old. The students’ answers described a and powerful (Potency factor) entity. The most popular rather modern meaning of the Asclepions, capable of positive characterizations of Asclepion among the stu- creating pleasure, positivity, hope, vibration and even dents, as they are depicted in Fig. 1 are: big, good, power- freshness. ful, useful and substantial. Finally, the third factor had high loadings on the four bipolar pairs: pleasant-unpleasant, big-small, strong– Discussion weak, powerful-powerless (Table  2). This group of In the present study and in the context of a theoretical answers seems to depict an innovative educational and Psychiatry course given at the Medical School of Ath- medical environment and it is a real surprise that in fact ens, graduating students studied the structure, role and depicts an ancient healing world. organization of the Asclepion in Epidaurus, as mentioned Table 2 From the factor analysis that was conducted from the questionnaires, three factors emerged which accounted for 51.24% of the total deviation Factor 1 (Activity) had high loadings in fast-slow, strong–weak, useful-useless, substantial-superficial and accounted for 20.89% of the total variance Factor 2 (Evaluation) had high loadings in pleasant-unpleasant, good-bad, alive-dead, sweet–sour, noisy-calm, young-old and accounted for 16.40% of the total variance Factor 3 (Potency) had high loadings in pleasant-unpleasant, big-small, strong–weak, powerful-powerless and accounted for 13.94% of the total variance The highest percentages are highlighted Papageorgiou et al. Philosophy, Ethics, and Humanities in Medicine (2022) 17:7 Page 6 of 9 before. Next, based on the introduction, their personal was set up there. The mild climate along with the calming knowledge and subjective views of the Asclepion, the green foliage would have supplied the ill and cheerless participants were called in to score in the form of a ques- pilgrims with recreation and tranquillity. Furthermore, tionnaire the information they received, approaching the the plentiful spring waters of the region were another concept of “Asclepion” through the method of semantic chief asset in the healing expectation [5, 14, 15]. differential. A well-organized list of active and passive rituals and From the analysis of the participants’ answers stem- healing activities was customized to the needs of every ming from the questionnaire, it appears that for the individual [16]. The various healing dimensions that were descendants (novice doctors) of Asclepius’s work, the offered were: importance of the monument and its vital role is new information. Most likely, the concept of “Asclepion” • The purification process: “Purity means to think might not be unprecedented. However, its connection to nothing but holy thoughts” [16] was the inscription the archaeological site of Epidaurus, as well as the wide- with which the pilgrims/patients were encountered spread impact it had for the times then, are what had at the entrance of the sacred space. Basins for hygiene been introduced for the first time. Today’s new doctors purposes and relaxation were the initial part of the have welcomed the above as essential and useful knowl- purification process which would be lengthened by edge. That effectively transferred knowledge has aroused sacrifices and accompanying rituals. their interest not only in the history and evolution of • Sacred healing rituals: After purification, the direc - Asclepion, but also in the service, they will be called to tive priests created a state of deep auto—sugges- fulfill. tion accompanied with religious exaltations in the Overall, the students showed a real interest and even patients-believers. The spiritual experience was fur - excitement about this unfamiliar but attractive piece of ther intensified by the healing aesthetic of sacred knowledge. They also expressed their surprise with many environments as well as the hymns chanted by the questions and comments about the specific methods Paianists (specialised singers) [16]. involved in this healing attitude, the results and the pub- • Therapeutic procedures: In separate(d) halls, the licity of the sacred space of Asclepion of Epidaurus. Dur- healing priests – ancient Greek physicians, also per- ing this survey, they had also the opportunity to confess formed and recorded a detailed history and physical that are no longer satisfied with the intensifying focus of examination of the patient and afterwards, they rec- scientific medicine as applied biology and technology and ommended dietary guidelines, gave instructions for many demand the inclusion of spirituality in health edu- the use of many kinds of medicinal herbs per os or cation and care. in the form of suppositories, ointments or eye drops and whenever it was necessary, they performed sur- gical operations [16, 17]. Overview of healing environment and methods • Physical exercise: It took place in the gymnasium [5]. of Asclepion • Communal bonding and encouragement: This The following piece of information helped them to involved viewing athletic events in the stadium [5]. complete their perception of the healing environment • Communal catharsis: It took place in the mag- and methods of Asclepion and to connect it with the nificent Epidaurus theatre with a seating capacity of humanism and spirituality that the modern medical care 14,000, where ancient drama was presented [5]. demands. • Communal meals: Formal banquets were included About 2,500 years ago, the Greeks realised the neces- in the healing process for selected worshippers sity of a healing space in order to mend their society’s which took place in Banqueting Hall- a mesmer- collective health and every citizen’s well-being since izing building that inspired pilgrims to trust each they had been at continual war for centuries. They other and share empathy and hope in their common selected Epidaurus as their building site for their heal- effort [18, 19]. ing sanctuary as they knew clearly what kind of resi- • Dream healing (“Enkoimesis”): It was the final stage dences and environments suited their needs. Indeed, of the healing process with its own sacred space, the location of Epidaurus incorporates the two most which was named “Abaton” or “Enkoimeterion”. well-established principles of current healthcare archi- According to the priests, when the testing of the soul tecture: the inclusion of sunlight and that of natural was complete, the believer was led to the sacred site scenery [5, 14, 15]. to spend the night alone. Already overcome with The pleasure every visitor derived from viewing the religious faith and anticipation, the patient excit- land of Epidaurus then extends to those experiencing its edly imagined the impending miracle of being cured. beautiful scenery today, and explains why the Asclepion P apageorgiou et al. Philosophy, Ethics, and Humanities in Medicine (2022) 17:7 Page 7 of 9 Moreover, concealed oil lamps which illuminated the It is suggested, that the study of the healing environ- premises, heightened even further the supernatural ment of the Asclepion in Epidaurus can offer a plethora experience he was about to undergo. After the with- of benefits to novice doctors since they are eager to gain drawal of the priest, the patient was abandoned in new ancient knowledge. the darkness to enter the phase of healing sleep. The The results of our study reveal that the majority of the following morning the patient would awake healthy students perceived the Asclepion as an active setting [5, 14, 20]. (Activity factor). This remark can become a motivation • Testimonials of gratitude: After the cure, the wor- for their educators to revive the most intriguing features shipping of the god Asclepius in the monuments fol- of the Asclepions integrating them in modern medical lowed [14]. education. The following suggestions can function as triggers for innovative educational methods based in the Contemporary psychologists and psychotherapists sug- humanistic and holistic ideals of Asclepions: gest that Asclepian purification and healing rituals when First of all, medical students can appreciate the heal- used shifted believers’ understanding of the self and the ing power of architecturally appealing and sun-filled sur - universe to the point where they could self-heal them- roundings that respect patients and the quality of their selves and hence function in a healthy manner [20, 21]. stay there. A specialized subject, such as medical archi- The multitude of sacred spaces and ritual opportunities tecture or architecture of healing environments could available at Epidaurus contributed to the ancient city’s be proved beneficial for medical students as well as their reputation as a place for healing among traumatized future patients. It is true that nowadays modern medical pilgrims. centers’ design has shifted to a focus on patient, upgrad- Overall, in ancient times the sanctuary of Asclepius ing their surroundings aesthetically to provide a pleasant was an organized medical healing center, which marked and relaxing experience for their patients and their fami- the transition from occult rituals for treatment to the use lies. However, the environment would not be defined as of actual medical science. That is, the therapy for any ail - one of healing as those of the wise ancient Greeks had ment would be executed based on diagnosis and appro- foreseen. Since their first impression of the Asclepion set - priate administering of medicine or surgical intervention, ting was that this space is active and powerful, the medi- but with divine guidance. It can be realized that medical cal students’ curriculum could be pleasantly enriched practice in Asclepion of Epidaurus was focused simulta- by a brief subject about the main architectural features neously on a holistic and individual approach for every of sacred spaces and the healing powers of light and the patient. At the same time, the issue of total harmony views of natural environment [5, 23]. Hence, novice doc- among the personal, social and natural environment was tors can request the improvement of medical facilities highlighted as a prioritized healing process within the in their working environment, where the model healing boundaries of that sacred space [22]. space of the Asclepion of Epidaurus would be followed. The reputation of the Asclepion for the time then Ideally, organized visits to the Asclepion of Epidaurus could be characterized as worldwide. With the Ascle- could enlighten the natural impact of the architecture pion of Epidaurus being the center for patient care, rev- and the surroundings on their mentality. After that, they erence for Asclepius was spread not only in Greece but would probably seek the reproduction of the harmony, also throughout the Mediterranean world; and at the simplicity and grandeur of this environment to their eve- same time, with the creation of more than 100 subsidi- ryday working space. Even more beneficial might be the ary Asclepions, medical science was spread through- educational workshops or small group congresses in this out Attica, in the Peloponnese, in western Greece, the space. Deprived from any modern equipment, just talk- Aegean Islands, Crete, from Asia Minor to the distant ing and walking under the olive trees in small groups, Cilicia, Rome and Cyrene in Africa. However, nowadays, accompanied by an experienced clinician who would the restoration and use of the ancient theater has led to provide them with facts and questions and totally con- the public’s mistaken perception of the archaeological centrated in the conversation, it is more than probable grounds [3]. that their appreciation for their role as therapists and for To our knowledge, there are no studies on the inter- the active and continuous learning for their patients’ sake est and views of doctors about the beginnings of medical would become an invaluable lifetime’s lesson. To sum up, practice in the Asclepions, especially about the Ascle- specialized subject, such as medical architecture or archi- pion of Epidaurus. This site is not known as a great-sized tecture of healing environments could be proved benefi - monument of worship and medical practice as it had cial for medical students as well as their future patients. been, but as a great architectural and aesthetic, theatrical Furthermore, the majority of the students, according to structure. our study’s results perceived the Asclepion as a valuable Papageorgiou et al. Philosophy, Ethics, and Humanities in Medicine (2022) 17:7 Page 8 of 9 setting (Evaluation factor). This aspect might be trans - Today, patients do not admire the focus of scientific lated into their need for discovering deeper values in medicine as applied technology on their bodies any more their profession, derived from the dawning of medicine and many demand ethos, “phronesis” and the inclusion in the healing spaces of the Asclepions. of spirituality in health care. Their request for meaning - For instance, modern medical educators inspired by ful answers to their eternal questions recurs: Why is this priest – physicians of Asclepions can teach new doc- suffering happening only to me and now? Am I going to tors – through vivid presentations or documentaries to live and for how long? What is the meaning of my short start thinking not only with guidelines, rules, manage- life? What will be my legacy? Current medical education ment systems, and frameworks, as they have already been has to expand its scope and address the issue of suffer - taught to do so, but also with phronesis. For Aristotle, ing. The model of Asclepian healing spaces and methods phronesis, which means ‘practical wisdom’, is one of the enlightens this approach and can guide the modern med- most important human virtues. It commands our skills, ical education in this area. thoughts, and courage, with the use of both knowledge The attitude of the students towards the new knowl - and judgment, guiding us to the most efficient actions. edge of Asclepion of Epidaurus was positive, showing Medical students and new doctors can emulate this kind a real interest and sometimes excitement about a use- of practical wisdom from the best practices of the ancient ful and alive, though still unfamiliar piece of knowledge. physicians, who worked in demanding and hostile envi- We cannot ignore this attitude that allows us to see that ronment, usually in times of warfare, without protocols our students are no longer satisfied with the intensifying or equipment, but always providing the best they could focus of scientific medicine as applied biology and tech - [24]. These priests – physicians had in mind that the real nology and many demand the inclusion of spirituality in world always presents us with situations that are more health education and care. complex than our experience and knowledge can predict We suggest that the modern curricula of medical stu- and that patients have varying priorities and demand dif- dents should be further potentiated by humanistic and ferent therapeutic approaches to their being healed. And social subjects, such as principles of philosophy, medi- to achieve positive results, they worked with phronesis cal ethics and medical leadership. Thus, novice doctors [25–27]. Modern educators, especially experienced clini- might be empowered to treat not only diseases but also cians in the emergencies or in remote areas without the patients. basic technological facilities can effectively teach ‘phro - nesis’ in medical students. The results of our study also indicated that medical Conclusions students perceived the Asclepion as a powerful setting We believe, as Socrates probably did, that it would be (Potency factor). Their estimation is probably in line with of great importance instead of focusing on our techno- that of Socrates [28]: cratic and selfish way of thinking to seek knowledge and The last words of the famous philosopher before his points of perspectives of the Asclepions, especially that death, undoubtedly express what Asclepius’ values meant of Epidaurus, which used the influence of environment to the former personally. and architecture and the principles of phronesis and ethos “Crito, we owe a cock to Asclepius—Pay it and do not as healing powers. The positive attitude of medical stu - neglect it” [29]. dents to the meaning of Asclepions as healing spaces is Socrates had called his students for an offering to a strong encouragement to further explore this source of Asclepius. He was sentenced to death for impiety, that is, medical experience and inspiration as an educational tool for not believing in the state’s gods but introducing new and environment. Future studies could evaluate the shift ones. Thus, the questions arises of why the philosopher’s of view that this knowledge can induce in physicians’ way last words were an expression of gratitude to a healing of thinking and practice of medical healing as well as the god. influence this shift can have on their patients’ satisfaction The most probable explanation may be he believed in and overall health status. the reviving and humanistic power of Asclepian ideals, Acknowledgements which was the only value that could keep his own spirit The authors thank the sixth-year medical students of Medical School at and ideas alive. Socrates summons us from the past to National and Kapodistrian University of Athens, (academic year: 2017-2018) who voluntarily participated in this study. apply eternal Asclepian medical practices to self, patients and community. He reminds us of our personal duty to Authors’ contributions st make our ethos a first priority, of our professional duty to CP (1 author), VL and KGY conceptualized the study, developed the proposal, th coordinated the project and wrote the report. GK and CP (4 completed initial alleviate suffering, and of our social duty to support the data entry and analysis, conducted the statistical analyses and assisted in vulnerable, sick, and deprived [30]. writing and editing the final report. KGY participated in overall supervision of P apageorgiou et al. Philosophy, Ethics, and Humanities in Medicine (2022) 17:7 Page 9 of 9 the project and revision of the report. All authors read and approved the final 14. Charitonidou A. 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Journal

"Philosophy, Ethics, and Humanities in Medicine" – Springer Journals

Published: Apr 20, 2022

Keywords: Asclepion; Healing environment; Sacred space; Medical education; Medical ethics

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