Hernán Claudio Doval received his medical degree from Universidad Nacional de Buenos Aires, completed his residency in Internal Medicine at CEMIC (Centro de Educación Médica e Investigaciones Clínicas Norberto Quirno) and at the end of the 1960s was summoned by Raúl Oliveri together with Oscar Bazzino to set up the Coronary Care Unit at Hospital Italiano de Buenos Aires. Carlos Bertolasi had created the first Coronary Unit in Latin America at Hospital Argerich, specially oriented to acute ischemic heart disease. A new stage of Cardiology began, a cycle of assistance at the bedside of the intensive care unit patient with ceremonial rounds associating staff physicians and residents, a practice that continued with Doval until the day of his stroke a few months ago. Except for a few years in which he was head of Cardiology at Sanatorio Otamendi, his institutional work was fully concentrated at Hospital Italiano. The physiopathological thinking governed the conducts, and the availability of multiple resources of blood gas measurements together with the Swan Ganz catheter, allowed a thorough individual hemodynamic exploration. At that time he carried out researches on the hemodynamics of infarction, oxygenation evaluated through the divergence between ventilation and perfusion and anatomical shunt, and he invented a nomogram for the management of the acid-base status, and a peculiar device that allowed the measurement of oxygen consumption through a carbon dioxide filter and a parachute. His greatest achievement at that moment was the creation of the “Doval catheter”, a modification of the K31 catheter, that with an electrode placed near its end allowed guiding its placement by electrocardiography without requiring expensive monitors to measure pulmonary pressure. He never patented this catheter, which was widely used in low complexity intensive care units in our country and in many others. Already in the 70s the Hospital Italiano was consolidated as a school of cardiology that has maintained its excellence to this day, with Doval as one of its central protagonists.
The 80s, with the Oxford manifesto that led to the ISIS studies in Great Britain and collaterally to the GISSI study, brought about a historical change in medicine, with cardiology as its leading specialty in the evaluation of "simple questions with large studies". On the basis of scientific evidence that proved beyond any doubt, for example, that aspirin reduced mortality in acute myocardial infarction, a new paradigmatic concept emerged and was adopted as hegemonic in contemporary medicine: the "evidence-based" practice, better translated as practice based on scientific evidence with clinical benefit on relevant events. This new reality, which implied generating information that could be taken up by the community to improve the population health on an irrefutable basis, was Doval's passion. Since the first Council of Emergencies in Cardiology, Doval felt encouraged to design studies to evaluate thrombolytics and surveys of different pathologies. He formed and led the GESICA Group that carried out the multicenter study of amiodarone, which showed for the first time that a drug could improve survival in patients with advanced heart failure. This finding, which was based on the hypothesis of the antiarrhythmic effect of the drug, and which was surprising because it also reduced death due to advanced heart failure, provided a rational basis for the convenience of reducing heart rate in this condition, later supported by studies with beta-blockers. Not only was it published in The Lancet with the generous collaboration of Peter Sleight (leader of the group of young people such as Salim Yusuf in Oxford) and the JACC but it also involved multiple international presentations, conferences and dialogues with the acknowledgement of the leaders in this field.
The late 80s and 90s were thus a time of explosion of national and international multicenter projects, in Argentina ECLA, GEMICA, and ENAI from the Argentine Society of Cardiology (SAC). Doval preferred to maintain GESICA as an independent group with the intention of exploring his own ideas and not being part of the canned studies that were later multiplied as a routine form of exploration of new molecules by the pharmaceutical industry.
With the desire to promote independent national research, he formed the GEDIC group, and since the late 90s he began to teach a training course for clinical researchers, at a time when these concepts were little known in our setting, hosting more than 1000 health professionals for more than 25 years. He taught his last class three days before his stroke. From this course came the idea of a conference on Evidences in Cardiology that brought together a select group of young scholars and resulted in the risky attempt of a self-financed book on the subject in a small format in the year 2000, a few months before the launching of Salim Yusuf's immense book. Evidencias en Cardiología (Evidences in Cardiology) under Doval's leadership was adopted as a kind of textbook for the practice of cardiology by young physicians and residents, and grew slowly from four volumes to reach its tenth edition in 2023, with the addition of national and international contributions.
The GESICA group was consolidated as an example of national independent research, with the virtues and limitations that this implies: remaining independent of the pharmaceutical industry except for minor collaborations, and with national research agencies that have completely ignored clinical research until very recently. It carried out projects such as DIAL, a telephone intervention through nursing that proved to reduce the rate of hospitalizations in heart failure in a practical and economical way, and later studies on Omega 3 in atrial fibrillation. In recent years, there was also an exploration of risk factors in slum areas, which showed a doubling of the concentration of these factors with respect to the national survey that omits this sector of the population. The research led to the training of population agents in the same environment for prevention and early treatment interventions.
In the 2000s, the SAC decided to change the editorial policy of the Journal and summoned Raúl Oliveri, who was succeeded by Doval as editor. Based on his thorough knowledge of the leading journals, of which he had always been a daily reader in the library of Hospital Italiano, he proposed not only an aesthetic change, but also multiple modifications and the tradition of writing editorials on various topics of contemporary medicine. In these editorials, some of them compiled in a first book, he unfolded the approach to health in all its cultural and socioeconomic dimensions, the ethics of medical practice, and made inroads into all the advances of contemporary science, from genetics to regenerative medicine. Concerning concepts on health-disease his guide was Canguilhem, who participated in the French resistance to Nazism and later published The Normal and the Pathological, the cornerstone of the functional-valuative criterion as opposed to the naturalistic-objective-biologistic one. This dimension leads to a medicine more attentive to subjective and psychosocial aspects, which makes its ethical dimension. This stage of the journal marked not only an improvement of its contents, which unfortunately was not enough for its indexation, but it also became a sort of weekly "debate club" on the most diverse topics of medicine and contemporary society. He also occupied the role of director of the Ethics Committee of the SAC for many years.
At Hospital Italiano, together with Dr. Enrique Beveraggi, he created the Family and Preventive Medicine Unit, which gave conceptual basis to the successful Health Plan. Despite being a cardiologist (or not, because he never obtained or claimed that formal title) he maintained a strong commitment to general and family medicine. An in-depth expert on the history of Social medicine since Bismarck, he collaboratively wrote the book Salud. Crisis del sistema. Propuestas desde la medicina social. (Health Crisis of the system. Proposals from Social Medicine). The "causes of causes" approach, as Salim Yusuf called the socioeconomic and cultural factors underlying risk factors, was applied by Doval to each of the topics he addressed.
His training as a great reader of the philosophy of science and his scientific culture in general, allowed him to transmit in the training courses for researchers very creative concepts of the emergence and maturation of ideas. Thus Galileo, Newton, Poincaré, Popper, Bradford Hill, Bateson converged in an epistemological thinking applicable to clinical research.
Throughout his life, he maintained a very committed ideology with the claim for the need for a socio-economic change as a contribution to a more egalitarian society, an essential part of his medical thinking and many of his projects.
In these brief lines I tried to summarize the dimensions of his professional career, his scientific production, his teaching in research, cardiological publications, his contributions to medical ideas, Argentine society and the ethical dimension. Personally, I did my residency at Hospital Italiano from 1977 to 1981, and I collaborated with Doval in the Emergency Council, in the Argentine Journal of Cardiology and in GEDIC, that is, many hours of joint work that only increased my admiration for his gigantic human and professional dimension, which makes him an undisputable Master of Argentine Medicine. Thus, I witnessed the controversial development of many of his projects, the emergence from nothing to their maturation in unthinkable concretions, the passionate (and stubborn) defense of his ideas, and the only tears I saw him shed when we shared a presentation on death in cardiology, from an evocative account of his first experiences. And from a distance, I believe that the hundreds of young physicians who have passed through the cardiology residency program at Hospital Italiano or his courses bear the imprint of an intellectual, very human clinical perspective and an ethical dimension, perhaps one of his greatest legacies embodied in the practice of his disciples.
Finally, I would like to share this poem that Doval found at a book fair on a poster in the Chinese pavilion, attributed to Bertold Brecht, although he was never able to verify it even with the help of ChatGPT.
I used to read it in the methodology course when the topic of observation and emergence of research ideas was addressed.
To observe you must learn to compare.
To compare you need to have observed.
Observation generates knowledge and knowledge is necessary to observe.
Observes wrongly he who cannot do anything with what is observed.
For the apple tree the farmer has a sharper eye than the stroller, but man is not exactly seen by who is not aware that man is man's destiny
