|Medical Student Elective 93ZL710||Dr. Schneider|
|History of Medicine and Public Health||February 2013|
|Medical Library IB 307|
There are some changes in study questions for Alternative medicine, to reflect revisions in assigned readings, including Eisenberg, et al.'s original 1993 study, and the most recent survey of the NIH Center for Complementary and Alternative Medicine. (available in Oncourse)
There is a new document available in the "resources" section of Oncourse on "How to research a medical topic." It is aimed precisely at medical students doing research papers. Look in the folder, "A. Introduction" for the file titled "Duffin Ch 16." We will discuss this Thursday, when we next discuss research papers.
The link to the on-line Index Catalog of the Surgeon General, a digital version of references for medical atticles published between 1880-1961, is now available at: http://www.nlm.nih.gov/pubs/techbull/mj04/mj04_cat.html. There is also a link from the resources section below describing Pubmed.
These notes will be used for class announcements and reminders which you should check before each class to make sure of revisions. If there are any questions between classes, or if you find any problems with this or other web materials, contact the instructor at firstname.lastname@example.org.
The following syllabus was last corrected on Feb. 17, 2013.
It is subject to changes which will be announced in class.
The successful completion of this one-month seminar course in the history of medicine would enable the student to earn a level 3 competency in either Lifelong Learning or the Social and Community Contexts of Health Care.
Class meetings and times:
The course meets three times a week as indicated below. NOTE: most sessions will be held in Ruth Lilly library Medical History room 307, unless otherwise indicated.
Deborah Brunton, ed. Medicine Transformed: Health, Disease and Society in Europe, 1800-1930 (2004)
David J. Rothman, et al., eds., Medicine and Western Civilization (Rutgers University Press, 1995)
(sufficient pages assigned to warrant purchase; available at Cavanaugh Hall bookstore, but listed as recommended)
Thomas Neville Bonner. Becoming a Physician: Medical Education in Britain, France, Germany, and the United States, 1750-1945 (Johns Hopkins University Press, 2000)
Norman Gevitz, ed., Other Healers: Unorthodox Medicine in America (Baltimore: Johns Hopkins University Press, 1988)
Other Required Readings:
Other readings listed below are either available on the web, in journals of the IUPUI librarires (usually the Medical Library), or they are available in the "Resources" section of Oncourse site for this class. Log onto Oncourse and select the course H546 "History of medicine and Public health." Then click on the "Resources" link listed in the left-hand column. The readings noted below can be downloaded from the topic of the class.
Note: Some of the readings on the web require you to give your IUPUI userid and password.
Some History of Medicine Web resources
IUCAT (The Medical Library holdings are denoted by IM.)
OCLC The largest on-line catalog of all books with library holdings, primarily in the U.S.,requires your IUPUI userid and password.
PubMed: Access to Index Medicus, a bibliography of journal articles, including many on the History of Medicine, maintained by the NLM. A good source of articles since 1964, but not all inclusive. Click here to try the on-line version of Index Catalog of medical articles published before 1964 and as early as the late 19th century.
Journals on-line: for journals available through University Library click here; for the Medical Library click here. Both require your IUPUI userid and password.
National Library of Medicine: the on-line catalog of the most comprehensive medical library in the world and best database of medical books.
Excellent web sites with reference materials in the history of medicine are at the History of Medicine Division of the National Library of Medicine (see especially its image database), and MedHist: a guide to history of medicine resources on the Internet maintained by the Wellcome History of Medicine Library in London
History of Women and Science, Health, and Technology: a Bibliographic Guide to the Professions and the Disciplines
Historical Abstracts/American History and Life : The most complete databases of articles on history in general, requires your IUPUI userid and password.
Who Named It? a very comprehensive dictionary and encyclopedia about the origin of medical terms. Self described as " It is our ambition to present a complete survey of all medical phenomena named for a person, with a biography of that person."
ProQuest Historical Newspapers: The New York Times (1851-2001) The full text of the New York Times, searchable by key words, dates, etc. [Note: If link fails, go to the University Library home page. Then click on "Find articles" and select "e-journals." Type in New York Times and after giving your username and password, it will take you to the database.]
The London Times, 1785-1985 Full text and searchable online database of the London Times. [Note: If link fails, go to the University Library home page. Then click on "Find articles" and select "e-journals." Type in London Times and after giving your username and password, it will take you to the database.]]
Google Books: quickest search of books published in the U.S., including a number of older books which have been digitized by Google and are accessible online.
This class meets three times a week and will consist primarily of reading and discussion. Students must attend all twelve in-class seminar sessions and actively participate in the in-class discussions. If a student misses any session, they must turn in an additional 5-page, typed, report analyzing the reading assignments for the missed session. (Click here for more information about this report.) Each student is required to complete the two class assignments and the final project (see below).
The student will be able to receive Honors, High Pass, Pass and Fail grades based upon the following criteria [Note: Students taking History H546 will be graded according to the usual letter grading scale):
Assignment #1 (due Feb. 8) 15% Assignment #2 (due Feb. 18) 20% Class Participation 15%
Feb. 5 initial discussion of topics
Feb. 14 topic and initial bibliography
Feb. 21 progress and revised bibliography
Feb. 28 final project due (plus presentation)
Assignments are explained below. Click here for more about the Final project.
Click on the following for information about format of notes for papers.
Be sure you understand the school's policy on plagiarism (copying).
See IU Code of Student Rights, Responsibilities, and Conduct Part 3, Section
A Number 3 for further definition. Those guilty of it will
be dealt with in accordance with the regulations spelled out in
The time and relative weight of these assignments may be changed
during the term. If so, changes will be announced in advance during
To contact the instructors outside of class:
Dr. William Schneider
Cavanaugh Hall 406
Feb 1 Fri
|Introduction & the Emergence of Western Scientific Medicine|
Lederer, Susan, "Medical History in the Undergraduate Medical Curriculum", Academic Medicine, 1995, 70: 770 - 776 (Available in "Resources" section of Oncourse site for this class)
Brunton, "Preface," ix-xvii
Rothman, Medicine and Western Civilization, "Introduction," 1-10
Traditional healing in pre-modern cultures
"The Bible," 263-6,
Jordan of Turre, "The Symptoms of Lepers (1313-35)," 209-11
Ulrich von Hutten, "On the Beginning of the French Pox (1519)," 212-16
Leviticus, Chapters 13 and 14 "Laws concerning leprosy"
Boccaccio: The Decameron - Introduction and description of plague (1348)
Origins of Western Medicine
Rothman, Medicine and Western Civilization,
Hippocrates, "The Nature of Man," and "Sacred Disease," 43-47; 139-44
Hippocrates, "The Hippocratic Oath," 261-63 (See also, IU School of Medicine Hippocratic oath)
Galen, "The Hand," 17-22
Vesalius, Andreas, "The Fabric of the Human Body," 54-60
|Feb 4 Mon
|Medicine & Health in 1800|
Medicine & Health in 1800: diagnosis, treatment, training, practice, and research
Outline available on Medicine in 1800,
Skim for the main points and background:
Harvey, William, "An Anatomical study on the motion of the heart and the blood in animals," in Rothman, 68-75
James Lind: A Treatise of the Scurvy, 1753 (For original click here.)
Edward Jenner, "An Inquiry into the Causes of the Variolae Vaccinae, or Cow-pox, (1798)," in Rothman, 299-309
Lester King, "The Practice of Medicine in 1787" Illinois Medical Journal, 107(1955), 130-5 (Available in "Resources" section of Oncourse site for this class)
Benjamin Rush, "The Vices and Virtues of Physicians (1801)," in Rothman, 278-81
Thomas Jefferson on medicine:
letter to Edward Jenner, 1806 (orig.)
letter to William Green Munford, 1799 (orig.)
letter to Caspar Wistar , 1807 (orig.)
|Feb 5 Tues
| 19th Century Foundations of Scientific Medicinefrom bedside to laboratory
Anesthesia, Antisepsis and Surgery, 1800-1900
First discussion of Final Project topics
Note: Special guest: Dr. Richard Gunderman, M.D.
From Bedside to Laboratory
L. S. Jacyna, "The Localization of Disease," in Brunton, 1-14
N. D. Jewson, "The disappearance of the sick-man from medical cosmology, 1770-1870," International Journal of Epidemiology 2009;1-12 (orig. publ 1976) (Available in "Resources" section of Oncourse site for this class)
Anesthesia, Antisepsis and Surgery, 1800-1900
Outline available on 19th Century Surgery
Thomas Schlich, "The Emergence of Modern Surgery," in Brunton, 61-91
John Brown, "Rab and His Friends" (~1830) (Available in "Resources" section of Oncourse site for this class)
Frances Burney, "A Mastectomy: letter of September 30, 1811," reprinted in Rothman, et al., 383-89
Henry Jacob Bigelow, "Insensibility During Surgical Operations Produced By Inhalation" Boston Medical And Surgical Journal (1846), 309-17 (orig.)
Click here for background.
Rothman, Medicine and Western Civilization,
"Answer to the Religious Objections to the Use of Ether in Obstetrics and Surgery" by James Young Simpson (1849), Rothman, 398-401
Ignaz Philipp Semmelweis."The Etiology, Concept, and Prophylaxis of Childbed Fever (1861)," Rothman, 240-46
Joseph Lister (1827-1912), "On the Antiseptic Principle Of The Practice Of Surgery," 1867, Rothman, 247-52
Additional web resource: Relief of Pain and Suffering, exhibit at UCLA March 1998
Pain Alleviation and "Anesthesia" 19th Century and Earlier
The Anesthesia Revolution of the1800s Early Experiments with Surgical Anesthesia
|Feb 6 Wed
|19th Century Foundations of Scientific Medicine: research in physiology and anatomy; diagnosis with statistics and instruments|
Note: Special guest: Dr. Stephen Jay, M.D.
Outline available on 19th Century Diagnosis of Disease
L. S. Jacyna, "The Localization of Disease," in Brunton, 14-30
R. T. H. Laennec, A Treatise on the Diseases of the Chest, reprinted in Rothman, et al., 310-13
Bollet AJ , "Pierre Louis: the numerical method and the foundation of quantitative medicine," Am J Med Sci. 1973 Aug;266(2):92-101 (Available in "Resources" section of Oncourse site for this class)
Claude Bernard, "An Introduction to the Study of Experimental Medicine (1865)," reprinted in Rothman, 314-18
Wilhelm Conrad Röntgen (1845-1923), "On a New Kind of Rays," read before the Würzburg Physical and Medical Society, 1895. [Translated by Arthur Stanton, Nature 53, 274 (1896).] (orig.)
Additional web resource: The Visible Human Project at the National Library of Medicine
|Feb 8 Fri
|19th Century Foundations of Scientific Medicine: Impact of a medical discovery, Röntgen's X-rays|
Assignment #1 Due:
Impact of medical discovery: Röntgen's X-rays
Using scholarly (secondary) publications and primary sources (published at the time), describe the response to Roentgen's discovery during the months that followed in any one of the following countries: France, Germany, United States, and Great Britain.
The type-written paper should be 3-4 pages in length. Identify your sources, at least one of which must be a scientific article from that time. Another useful source is the ProQuest Historical Newspapers: The New York Times (1851-2001) and the London Times, which gives access to the full text of the newspapers, searchable by key words, dates, etc. [Note: requires login with student ID and Password].
To find sources for earlier scientific publications, click here for the on-line version of Index Catalog of medical articles published before 1964. Many of the earlier journals have been digitized and are available online, as well as the originals being available in the medical library.
In a separate bibliographic section comment on the utility of each source. You should have between 5 to 7 sources. Click on the following for information about format of notes for papers.
**Be prepared to discuss your findings in class.**
|Feb 11 Mon
|Germ Theory and tropical medicine|
NOTE: Class will meet in the evening at the
Indiana Medical History Museum
3045 W. Vermont Street
For directions from campus, click here; and for a map, vist the museum website.
Timeline of 20th Century History and Medicine
Germ Theory and tropical medicine
Deborah Brunton, "The Rise of Laboratory Medicine," 92-117
Florence Nightingale, "Notes on Hospitals (1859)," Rothman, Medicine and Western Civilization, 360-64 (reread)
Koch R , "The Aetiology of tuberculosis (1882)" Rothman, Medicine and Western Civilization, 319-29
Michael Worboys, "Colonial and Imperial Medicine," in Brunton, 211-38
Myron Echenburg, "Pestis Redux: The Intial Years of the Third Bubonic Plague Pandemic, 1891-1901," Journal of World History, 13 (2002), 429-49 (Available in "Resources" section of Oncourse site for this class; or available online at University Library, online periodicals.)
|Feb 12 Tues
|Hospitals and Modern Nursing|
Outline available on Nursing and Hospitals
Maxine Rhodes, "Women in Medicine: Doctors and Nurses, 1850-1920," in Brunton, 164-76
Rothman, Medicine and Western Civilization
Battista Piergilius, "The Life of Sister Chiara of Montefalco (1663)," 37-40"
Description of Sairy Gamp, nurse and midwife
from Charles Dickens, Martin Chuzzlewit (1844)
"Florence Nightingale: obituary in London Times, (orig.)
Richard H. Shryock, "Nursing Emerges as a Profession: The American Experience," in Sickness and Health in America, Judith Walzer Leavitt and Ronald L. Numbers, eds. (Madison: University of Wisconsin Press, 1978), 203-15. (Available in "Resources" section of Oncourse site for this class)
Hilary Marland, "The Changing Role of the Hospital, 1800-1900," in Brunton, 31-60
Rothman, Medicine and Western Civilization
Florence Nightingale, "Notes on Hospitals (1859)," 360-64
Massachusetts General Hospital, "By-Laws, Rules and Regulations (1861)," 365-67
William Bennett, "The Geneology of Mass General," American Heritage Magazine ( October/November 198)4 Volume 35, Issue 6 (Click here for article.)
Dora B. Weiner, The Citizen-Patient in Revolutionary and Imperial Paris, (Baltimore and London: JohnsHopkins University Press,1993), pp. 177-83 (Available in "Resources" section of Oncourse site for this class)
Michel Foucault, "The Birth of the Clinic (1963)," reprinted in Rothman, 376-82
Rosenberg, Care of Strangers (Available in "Resources" section of Oncourse site for this class)
|Feb 14 Thur
|Medical Education in the US|
"Work in progress" deadline for Final Project: Topic and bibliography due (hand in)
Special guest: Kevin Grau, currently writing a history of the Indiana University School of Medicine
Medical Education before Flexner
Brunton, "The Emergence of a Modern Profession?" 119-50
Maxine Rhodes, "Women in Medicine: Doctors and Nurses, 1850-1920," in Brunton, 151-64; 176-79
Bonner, 103-41; 158-230
Philippe Pinel, "The Clinical Training of Doctors, (1793)" Rothman, Medicine and Western Civilization, p. 343-51
Mary Putnam Jacobi, "Do women require mental and bodily rest during menstruation? (1876), Rothman, Medicine and Western Civilization, 97-102
Elizabeth Blackwell,"The Influences of Women in the Profession of Medicine (1890)," Rothman, Medicine and Western Civilization, 282 - 287
Arthur Conan Doyle, "The Doctors of Hoyland" (from The Physician in Literature Philadelphia; The Saunders Press, 1982. pp. 327-336) Click here.
Kenneth Ludmerer, Time to Heal (N.Y.: Basic Books, 1998), 3-25; 79-101 (Available in "Resources" section of Oncourse site for this class)
Flexner, Abraham, Medical Education in the United States and Canada (NY: Carnegie Foundation, 1910), pgs 20-27, 42-59, 141-146, 151-155, 179-181 (Available in "Resources" section of Oncourse site for this class)
Molly Cooke, et al., "American Medical Education 100 Years after the Flexner Report," New England Journal of Medicine, 355 (September 28, 2006), 1339-44 (Available in "Resources" section of Oncourse site for this class)
Additional study assignment: before class, visit the second floor landing above the Medical Library (on the right facing the entrance) and examine the class pictures from the IU School of Medicine since its beginning in 1903. What conclusions can you draw about medical education in the U.S. in the twentieth century?
Letters to Indiana University President William Loeb Bryan (1906-1934) (Available in "Resources" section of Oncourse site for this class)
Indiana State Board of Medical Registration and Examination (1906)
Burton D. Myers to Bryan (1909-1915)
Charles P. Emerson to Bryan (1920-1922)
Emerson to Bryan (1923-1934)
|Feb 18 Mon
|The Development of Alternative Health Care in the US|
Gevitz, 124-56; 192-214
Alvin Shapiro, "Alternative medicine: Alternative to what?" Bulletin Allegheny County Medical Society, 1998 (September, 26): 458-459 (Available in "Resources" section of Oncourse site for this class)
David Eisenberg, et al., "Unconventional Medicine in the United States," NEJM, 328 (Jan. 28, 1993), 246-52
David Eisenberg, "Advising patients who seek alternative medical therapies." Annals of Internal Medicine, 1997 (127): 61-69 (Available in "Resources" section of Oncourse site for this class)
James Goodwin, "Battling quackery: Attitudes about micronutrient supplements in American academic medicine." Archives , 1998 (158): 2187-2191 (original) (Available in "Resources" section of Oncourse site for this class)
JAMA editorial, "Alternative Medicine Meets Science," 280:1618-19 (Nov. 11,
1998) (click here for original in Ovid database.)
NIH, National Center for Complementary and Alternative Medicine, "The Use of Complementary and Alternative Medicine in the United States: Cost data" (2009) Click here (Also available in "Resources" section of Oncourse site for this class)
Assignment #2 due:
Write a brief (6 to 8 pages total) type-written on one of the following:
a biographical sketch on an important individual who figures in your research paper,
or on any two individuals from the list below, in which you:
-compare and contrast what influenced the individuals,
-the historically significant facts in their lives (ie. what they did), and
-the episodes, events, discoveries, acts, etc which make the individuals historically important.
Elizabeth Blackwell Rosalind Franklin Helen Taussig Margaret Sanger Virginia Apgar Dorothea Dix Anne Hutchinson Mary Breckinridge Mary Putnam Jacobi Mary Baker Eddy Julia Bell Marie Stopes
Use and identify your sources in a separate bibliographic section, commenting on their utility; you should have one primary source per individual, and a total of four to five per individual.
|Feb 19 Tues
|19th - 20th Century public health and eugenics|
Deborah Brunton, "Dealing With Disease in Populations: Public Health, 1830-1880," 180-210
Paul Weindling, "From Germ Theory to Social Medicine: Public Health, 1880-1930," in Brunton, 239-65
Edwin Chadwick , "Report on the Sanitary Conditions of the Labouring Population of Great Britain (1842)" Rothman, Medicine and Western Civilization, 217-39
Bill Bynum, "The McKeown thesis," The Lancet, Volume 371, Issue 9613, Pages 644 - 645, 23 February 2008 (Available online at University Library, Electronic Journal List; contact instructor if you have problems locating article; also available in "Resources" section of Oncourse site for this class)
Duffy, John. "Bacteriology Revolutionizes Public health," and "State Health Boards...," in The Sanitarians: A History of American Public Health (Urbana: University of Illinois Press, 1990), pp. 193-204; 221-38 (Available in "Resources" section of Oncourse site for this class)
Elmore JG, Feinstein AR., "Joseph Goldberger: an unsung hero of American clinical epidemiology," Ann Intern Med. 1994 Sep 1;121(5):372-5 (original)
James Moore, "The Fortune of Eugenics," in Brunton, 266-97
Pernick, Martin S. "Eugenics and public health in American history." American Journal of Public Health, 1997 (87): 1767-1772 (original)
Jason S. Lantzer and Alexandra Minna Stern, “Building A Fit Society: Indiana's Eugenics Crusaders” Traces of Indiana and Midwestern History, (Winter 2007): 4-11 (Available in "Resources" section of Oncourse site for this class)
Fit to Breed? The History and Legacy of Indiana Eugenics, 1907-2007: a virtual website based on an exhibit about the history of eugenics in Indiana that appeared at the Indiana State Library in 2007.
Additional web resource:
Water filtration and typhoid fever death rates
Recent statistics on world health and income (or view a lecture by Hans Rosling)
Image Archive on the American Eugenics Movement
Website for film, Tomorrow's Children" (1934) [Note: Wait for initial commercial to be played. Click here for alternate site]
|Feb 21 Thur
|Miracle Drugs; WWII: War and Medicine|
Note: "Work in progress" deadline for Final Project: Topic and bibliography due (hand in)
Three "miracle" drugs: insulin, penicillin, and streptomycin
Michael Bliss, "Resurrections in Toronto: The Emergence of Insulin," Hormone Research, 2005;64(suppl 2): 98-102
Ronald Bentley, "Different roads to discovery; Prontosil (hence sulfa drugs) and penicillin (hence b-lactams)," J Ind Microbiol Biotechnol (2009) 36:775786 NOTE: concentrate on pp. 775-79(Available in "Resources" section of Oncourse site for this class)
Bernhard Witkop, "Paul Ehrlich and His Magic Bullets - Revisited," Proceedings of the American Philosophical Society, vol. 143 (December 1999), 540-57(Click here)
Presentation speech for Nobel Prize in Physiology or Medicine, 1945, to Sir Alexander Fleming, Doctor Ernst B. Chain, and Sir Howard Florey
Presentation speech for Nobel Prize in Physiology or Medicine 1952 to Selman Waksman
WWII: War and Medicine
Roger Cooter, "Medicine in War," in Brunton, 331-63
John Keegan, "Introduction," A History of Military Medicine, Richard A. Gabriel and Karen S. Metz (1994), vol 1: xi-xiii (Available in "Resources" section of Oncourse site for this class)
Schneider, "Blood Transfusion in Peace and War, 1900-1918," Soc. Hist. Med., 1997, 10, 105-26 (Available in "Resources" section of Oncourse site for this class)
E.C. Andrus, "Foreward", and Chester S. Keefer, "Part 9: Penicillin: A Wartime Achievement," in Advances in Military Medicine, eds. E.C. Andrus et al. (Boston: Little, Brown, 1948), 1:xli-xlviii; 2: 717-22 (Available in "Resources" section of Oncourse site for this class)
Additional web resource:
World War I: The medical Front
U.S. Army Medical Department: Office of Medical History
Second deadline for Final Project: full outline and bibliography due; rough drafts encouraged
|Feb 25 Mon
|Trends after 1945 (1): End of the Golden Age and access to healthcare|
Trends after 1945: patients and medicine; The end of the "golden age;" access to healthcare, 1965 -1985
Burnham, John C. "American medicine's golden age: What happened to it?" Science, 215 (March 19, 1982), 1474-79 (available online at University Library, online periodicals, click here)
Allan M. Brandt and Martha Gardner, ""The Golden Age of Medicine?"in Medicine in the Twentieth Century,
Roger Cooter and John Pickstone eds., (Netherlands: Harwood Academic Publishing, 2000), pp.
21-37 (Available in "Resources" section of Oncourse site for this class)
James le Fanu, "The Fall of Medicine," Prospect Magazine, 43 (July 1999)
"The NHS's 50th Anniversary, BMJ Vol. 317 4 July 1998, 97-107(Available in "Resources" section of Oncourse site for this class)
-Michael Portillo, "Something to celebrate: The Bevan legacy"
-David Morrell, "As I recall"
-Charles Webster, "The BMA and the NH"
Ronald L. Numbers, “The Third Party: Health Insurance in America,” in Sickness and Health in America, ed. by Judith Walzer Leavitt and Ronald L. Numbers (3rd ed.; Madison, Wis., 1997), 269-83 (Available in "Resources" section of Oncourse site for this class)
Aaron Carroll, "Support for National Health Insurance among U.S. Physicians: 5 Years Later," Annals of Internal Medicine, 148 (2008), 566-7
Additional web resource:
"The Lifesaving Century" (Indianapolis Star, April 25, 1999)
Important dates in the history of health insurance
|Feb 26 Tues
|Trends after 1945 (2): Bioethics and race; medical education after Flexner|
Note: earlier time than usual; students are urged to plan to attend symposium on "The Professions" from 11 a.m. - 1:00 p.m. More details to follow
Trends after 1945: Bioethics and race
Pius XXII, "The prolongation of Life(1958)," 417-420
"A Definition of Irreversible Coma(1968)," 421-25
Brandt AM (1978) "Racism and Research: The case of the Tuskegee Syphilis Study," The Hastings Center 8:21-29 (Available in "Resources" section of Oncourse site for this class)
Trends after 1945: Medical education today in historical perspective
Note: Special guest: Dr. Richard Gunderman, M.D.
Kenneth Ludmerer, Time to Heal (N.Y.: Basic Books, 1998), 180-95 (Available in "Resources" section of Oncourse site for this class)
Carol Carraccio, et al, "Shifting Paradigms: From Flexner to Competencies," Academic Medicine 2002; 77:361-367 (available online at University Library, online periodicals, click here)
|Feb 28 Thur
|Final Project Due|
Note: Class will meet in Ruth Lilly library Room 302 on this date for lunch and presentation of final projects by students.