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ISLAMIC MEDICAL EDUCATION RESOURCES 04

0009-MOTIVATION, EDUCATION, and DEVELOPMENT (PART II)

Lecture to 4th year students on 30th September 2000 by Professor Omar Hasan Kasule Sr.

2.0 MEDICAL EDUCATION (I’IDAAD AL TABIIB)

A. MEDICAL EDUCATION: CONTENT and ISSUES

IMPORTANCE OF THE STUDY OF MEDICINE

Fardh kifayat

 

BASIC TRAINING, LICENSING, PROFESSIONAL CONTROL, AND CONTINOUS EDUCATION

Basic training: sites:  masjid, school, university, hospital, community

Methods: observation, reading, discussion, practice, hifdh.

Curriculum:

basic sciences (research base), clinical apprenticeship (practical skills), basics & essentials of islam (ma’lum fi bi dharurat), ahkam fiqhiyyat relating to medicine, teaching skills, knowledge of social basis of disease and treatment

Licencing (ijazat). practicing medicine without qualification

Physician liability:  (accidental mistake, wrong medicine, operating with no patient consent)

 

ISSUES IN MEDICAL EDUCATION

The section identifies 6 conceptual issues in medical education and presents Islamic approaches to them (a) The purpose of medicine, which defines the system of medical education,  is to maintain or improve the quality of life and not to prevent or postpone death because that is in the hands of the Creator (b) integration of the curriculum, deriving from the the tauhidi  paradigm, implies practice and teaching of medicine as a total holistic approach to the human in the social, psychological, material, & spiritual dimensions and not exclusively dealing with particular diseases or organs (c) The selection of medical students, their training, and evaluation should emphasize that medicine is a human service within the context of Islamic mutual social support, takaful ijtimae (d) The physician must provide leadership as a social activist  who identifies and resolves underlying social causes of ill-health; as a respected opinion leader whose moral values & attitudes are a model for others; and as an advisor on medical, legal, and ethical  issues associated with modern medical technology (e) The future physician must be prepared to undertake research, a type of ijtihad, to extend the frontiers of medical knowledge and apply available knowledge to improve the quality of life. Time allocated to  basic research methodological tools should be increased at the expense of accumulating biomedical scientific information that is either forgotten or becomes obsolete by the time of graduation (f) The education and development of the physician before, during, and after medical school should inculcate the motivation  to excel in commitment, ikhlas, and care delivery following the model of the early Muslim scientists and physicians

 

ISSUES IN MEDICAL EDUCATION: AN INTERNATIONAL VIEW:

The European medical education system is dominant having been adopted or adapted by most countries. This makes the problems of medical education similar in different medical schools in different countries. Dr Fulop, Director of the Division of Health Manpower in the World Health Organization gave what amounts to a laundry list of problems in medical education: isolation of the medical school from the health care system, lack of integration, lack of active student participation, curricula irrelevant to the actual needs of society, curricula not community-oriented, outdated teaching methods, non-experiential learning, and outmoded methods of student evaluation (14).

 

The results of the last 4 world conferences on medical education have shown rapid changes in issues affecting medical education. The first world conference on medical education held in 1953 affirmed that the western medical model was satisfactory and  multidisciplinary skills were needed for advances in biomedical research (16). The second world conference on medical education held in 1959 noted new trends and innovations such as coordination of the curriculum in the basic sciences, interdisciplinary approaches, problem-centered education, introduction to clinical experience in the 1st and 2nd years, family and community medicine, learning and not teaching. It also noted that medicine was a humanistic, holistic discipline (17). The third world conference on medical education held in 1966 observed that medical education was dynamic and was affected by both social change and developments in science. Technological changes necessitate revision of the curriculum. Progress of medical education must also consider socio-cultural aspects (18). The fourth conference on medical education held in 1972 noted the emphasis of modern medicine on a technological approach to disease and called for a redefinition of the goals of medical education. It noted that the undergraduate curriculum could not provide detailed specialized knowledge and that it can only produce a person capable of learning. Medical needs and patterns of professional conduct were found to influence medical education. The need to redefine medical curricula continuously and dynamically was underlined (19).

 

A WHO-sponsored workshop at the University of New South Wales discussed the following issues in medical education: community-based learning, integrated curricula experiences, problem-based learning, behavioral sciences in medicine, early clinical exposure, skills learning, field assignments (Bandara 1987).

 

MEDICAL EDUCATION ISSUES IN MALAYSIA:

The leading issues in medical education in Malaysia have not changed dramatically over the past 30 years. In 1988 an experienced Malaysian medical educator identified the following problems of medical education: overcrowded curriculum, new medical advances that make today’s teachings obsolete, unsatisfactory assessment of students, over-emphasis on hospital medicine, fragmentation, dehumanizing emphasis on technology, curricula irrelevant to local problems, emphasis on quantity and not quality in the quest to satisfy manpower requirements (7). A conference on medical education held in conjunction with the official opening of the Faculty of Medicine at the university of Malaya in 1965 dealt with health needs of Malaysia as they relate to medical education, identifying objectives of medical education, trends in medical education, organization of medical education, quality vs quantity, and movement of practical training out of the medical school (10). A workshop at the University of Malaya in 1978 discussed the  sort of doctor needed to be produced to serve the needs of Malaysia, how to decide what to cut out of the curriculum and what to teach, integration/correlation of the curriculum, attitudes and ethics (11-12). The Penang workshop of 1981 addressed what should students learn, what teaching technics should be used, evaluation of medical education, curriculum planning, and alternative formulations of the medical curriculum (student vs teacher-centered, problem vs information-centered, integrated vs speciality, uniform vs elective, planned vs apprecenticeship)  (6).

 

MEDICAL EDUCATION ISSUES IN OTHER COUNTRIES:

The following reports of issues in medical education in Great Britain and Australia are representative of many other countries. This is not surprising since many medical schools in the world follow the same European tradition of medical education.The 1965-68 Royal Commission Commission in UK on medical education (the Todd Commission) was the first comprehensive review of medical education in UK since 1942-44. It made recommendation about the length of the medical course and the need for integration between pre-clinical and clinical courses (41-42). The Committee on Medical Schools in Australia in 1973 identified the following problems: lack of innovation, emphasis on medical science and not clinical practice or community care, lack of departments of general practice in medical schools, selection of students based only on academic criteria without considering aptitude or motivation with the result that those ‘academically’ oriented students go into research and not practice (58 ).

 

B. THE ISSUES PURPOSE, INTEGRATION, and BALANCE

THE PURPOSE OF MEDICINE:

Two questions must be posed and answered before proceeding. There is no unanimity of answers to these 2 questions. The first question is: what is the aim of medicine and medical treatment ? The second question is: what is the aim of medical education? What do medical schools try to achieve?. These questions generate further disagreement. On one hand the answer to the second questions depends on the answer to the first question. On the other hand, it could be argued equally logically that in practice medical schools and systems of medical education do not reflect the medical care delivery system. Muslims have several disagreements with some basic paradigms that define the objectives of European medicine. From the Muslim’s point of view, European medicine suffers from the following deficiencies: (a) it is disease-oriented and not health-oriented (b) it is very arrogant and claiming ability to cure any disease with no recognition of Allah’s involvement (c) It does not have sufficient humility to accept its failures and they are many (d) it sets itself the unrealistic goal of preventing or postponing death regardless of the quality of life that is lived. Since health is the original state and illness is the exception, medicine must be health and not disease oriented. The main responsibility of the physician is to maintain health; cure of disease should be the exception rather than the rule. The ancient Chinese were nearer to our view of medicine and the role of the physician. They paid their physician as long as they were in good health. Payments would be suspended on falling sick. They would resume when the illness was cured. The disease model predominates in European medicine. The disease model involving a biological or physical insult to the tissues is the main causal mechanism recognized and other contributors to the final causal pathway are not emphasized. The bias to the disease model explains European medicine being more curative than preventive. Illness to a Muslim has its positive aspects and can be a blessing and a reason for expiation of sins 104-106). The trial of illness is a source of much good for a believer (107). An incident case of illness should not be looked at in isolation. When viewed in a larger context, illness or disease need not always be seen as bad. The Qur’an teaches that a human may like something that is bad for him or may hate something that is good for him (108-109). Falling ill may save a person from going where he would be hurt or where he could commit a sin. Pathophysiologically the symptoms of ill-health are useful even if people complain about them. Pain directs us to tissue injury so that corrective measures may be taken before the injury becomes more extensive. Exhaustion and collapsing may be the body’s way of forcing us to take a rest when we are over-stressed or overworked without adequate rest. Much of what manifests as disease are the body’s attempts to return to the natural or normal state. the ultimate cure of illness is from Allah (110-112). The attending physician must realise that his efforts will succeed only if divine will intervenes and should therefore not be to arrogant. He should be aware that his efforts may fail or succeed. Physician arrogance and overuse of biomedical and technological interventions has sometimes led to the excesses of modern medicine in the form of side-effects (short and long-term) or iatrogenic diseases that are on the increase today. Claims of European medicine to have reduced morbidity and mortality can be questioned. Mortality due to infectious diseases like tuberculosis and malaria fell dramatically in developed countries. Some infectious diseases like smallpox have been completely eradicated. However new types of morbidity have appeared. Sexually-transmitted diseases are on the increase. There is a lot of chronic fatigue and stress in industrialized society. Psychiatric morbidity (including depression, suicide, para-suicide, and substance abuse) is on the increase. Fetal wastage has actually increase with the rise in legal and illegal abortions and some forms of contraception. European medicine has had a marginal contribution to the falling mortality and morbidity over the past 2 centuries. Non-medical general improvements in nutrition, environmental sanitation, and personal hygiene have been responsible for the major changes. Mortality from diseases like tuberculosis was falling many decades before discovery of effective anti-infective agents. The prevalence of debilitating infectious diseases in the third world is more related to their low socio-economic development than to lack of scientific medicine. European medicine has reached or will soon reach a plateau in improving physical health at least in developed countries where infectious diseases that have plagued mankind for millenia are nearly being controlled. Any further improvements in health will not require biomedical interventions but changes in human behavior (nutrition, exercise, stress, psychological balance, substance abuse, violence). The most effective interventions will be non-medical. Changes of human behavior require will-power to choose and stick to healthy lifestyles while avoiding unhealthy ones as well as self-care. The medical profession may have to change its whole orientation to support and enhance the will and ability of the people to take care of maintaining their health (14) and lead healthy life-styles. The medical profession will have to know when to stop biomedical intervention and give room to non-medical interventions (14). Good results will be obtained only when an equilibrium is established between the two. It is a paradox that medicine will remain busy in the next few decades trying to reverse iatrogenic problems it has caused this decade. Medical exposure to irradiation and steroids 20-30 years ago are responsible for cancers of today. Tonsillectomy, once a popular procedure is now thought to be the cause of Hodgkin’s disease. Oral contraceptives cause coagulation disorders. Other similar examples abound in medicine. Health problems due to environmental pollution will increase in the following decades. It is our contention that an Islamic paradigm emphasizing an integrated and balanced approach would have foreseen and prevented some of these problems. From an Islamic point of view, the aim of medicine is to maintain or improve the quality of remaining life. Medicine does not have as an aim the prevention of death or prolongation of life; the ajal is in the hands of the Almighty(113-114). Life on earth has a fixed and limited span and no one has the power to extend it even for a brief moment (115). Importance of quality of life is recognized by some physicians trained in the European tradition but lacking an integrating tauhidi paradigm, they fail to define this quality in a holistic way. Fliender and Biefang (14) felt that reduction of mortality was not the real need of society and not the only goal to be set in training physicians. Islam can provide them with paradigms that enable them to pull everything together. The Islamic Quality of Life Index (IQLI) arises from the tauhidi integrative paradigm and is a comprehensive measure involving social, psychological, physical, spiritual, and environmental parameters. The quality of life is closely related to man’s understanding of the purpose of creation and the mission of humans on earth. Life becomes degraded, hayatan dhankan (116), in the absence of this understanding. The quality of life is also closely related to lifestyle. A good healthy lifestyle is associated with a higher quality of life. A bad unhealthy lifestyle is associated with a low quality of life. Lifestyle is directly related to the risk of physical and mental illness as well as the response or adjustment to that illness. A healthy lifestyle is characterized by: piety, generosity, charity, chastity, humility, trust, balance, moderation, patience, endurance, honor and dignity, integrity, moral courage, and wisdom. An unhealthy lifestyle is mainly a manifestation of one of the following diseases of the heart: shirk, kufr, takabbur, ujb, hiqd, hasad, ghadhab, ghurur, hypocrisy, miserliness, and suu al dhann. These diseases sooner or later lead to either physical or psychological transgression, dhulm, against self or others. Most human diseases can be traced to this transgression. Epidemiological studies if interpreted in an objective way provide sufficient data to relate ill-health to lifestyle and to quality of life.

 

PURPOSE OF MEDICAL EDUCATION:

 There is no general agreement on the purpose of medical education. A recent BMJ article reviewed the issue indicating that the matter is still on the agenda of medical thinkers (117). The following 4 examples illustrate a practical approach to stating the purpose of medical education in a pragmatic way without dealing with the underlying paradigms. (a) The 1953 commission of Enquiry into medical education in the Colony of Singapore, the Federation of Malaya, and the territory of Borneo identified three objectives of medical education: producing enough doctors to serve the needs of society and training some of the graduates as specialists and researchers to resolve medical problems (9). Such a conclusion is understandable since physician shortage is always a chronic problem (27) (b) At the 1965 conference on medical education in Kuala Lumpur, the objectives of medical education were identified as: diagnosis and treatment, prevention of disease, research and community leadership at (10 ).(c) The first Thai National Conference on Medical Education in 1956 defined the goals of a medical school in order of descending priority: teaching, patient care, and research (28). The second Thai National Conference on Medical Education mentioned morality, civility, and medical etiquette as additional objectives of medical education (29) (d) The University of Malaya philosophy states that the objective of the undergraduate program is to produce an undifferentiated doctor who will be capable, with further training, of developing full competence in any branch of medicine (27) (e) The UKM philosophy is similar to that of UM with an added rural emphasis (27). A proper fit is needed between the manpower producer, the medical school, and the manpower consumer, the health care delivery system. The process of medical education must be relevant to the needs of the society since health is a subset of the social system (49). In the ideal state, the type of medical education given should be a reflection of the aim of medical treatment in a particular society. This has however not been true in practice. The western model of medical education has widely been accepted as satisfactory and has been taught without regard to local circumstances. A lot of the tensions experienced in faculties of medicine arises out of this disassociation between the local medical needs and the system of medical education. It is clear that the normal undergraduate curriculum is not sufficient for practice of medicine without further education and training. The best that the undergraduate curriculum can do is to produce an educable basic doctor. It should aim at producing a physician capable of independent thought and should therefore include only those facts that are of enduring relevance (71). The Islamic paradigmatic approach to defining the purpose of medical education can be derived from the paradigm of tauhid and the general theory of the purposes of the Law,  maqasid al sharia. The majority of scholars concur that the following 5 purposes are protected by the law: (a) religion, diin (b)  life, nafs (c) procreation, nasl (d) intellect, aql (e) wealth, maal.  Medical practice is intimately involved with all 5 of them but most so with nafs, nasl, and aql. Once the puposes of medical intervention are established, the aim of medical education should be to produce physicians who in their practice of medicine will fulfil that purpose or maqsad within a holistic context to ensure harmony and equilibrium. Thus the medical education system should aim at producing a physician who will be health and not disease oriented, who will have the humility to know that he will exert his best and trust in Allah to cure the disease. He will not have the arrogance to feel that he can prevent death but will strive to improve the quality of life for people knowing that the Islamic index of the quality of life is derived from the wholistc tauhidi view: physical, spiritual, social, psychological aspects and proper balance between them. The physician should in addition have the following practical and conceptual skills: understanding of the society, epidemiological understanding of health problems, scientific capability, clinical expertise, and leadership (49). These qualities must be in a context of iman, tauhid and fulfillment of the general purposes of the sharia. Moosa (173) called for an Islamic ambience for medical education when he argued that ‘ the purpose of Islamic Medical Education is to produce men and women imbued with the Islamic spirit, who will serve mankind to improve and maintain the health and welfare of all peoples, undertake research and excel in whatsoever they do’

 

THE ISSUE OF FRAGMENTATION:

European medicine is characterized by narrow specialization and fragmentation. Physicians know more and more about less and less. The trend toward specialization in medical practice has strongly influenced medical educators to diminish the practical content of the crowded undergraduate program and transfer some of it to post-graduate or vocational training. A new graduate from medical school is therefore unable to treat a patient on his own until he becomes a specialist. Specialty practice however has the great disadvantage of fragmenting patient care among several specialists such that there is no one doctor to care for the whole patient (7). The fragmentation of medicine is reflected in the balkanization of administration (by department), stages of education (pre-medical, pre-clinical, and clinical) and by discipline or specialty. Separate curricular tracks for research and practice have even been suggested (10). In many cases each department teaches independently of others. Specialist physicians find it difficult to teach students who are just being introduced to medicine (118,71).

 

The following attempts have been suggested to overcome the problem of fragmentation: interdepartmental or inter-disciplinary programs, integration of clinical and basic sciences, generalist and not specialist medical practice, vertical integration (linking early with later years in the same discipline), horizontal integration (linkage between different disciplines), teaching by organ systems, and using the problem-centered approach (119,120-124).

The concept of integration has been well accepted and propagated but not understood well when it came to practical application (43). Attempts at integration are a response to a felt problem and are certainly a step in the right direction however they have not solved all the problems; they even succeeded in creating a few new ones. Unco-ordinated integration has succeeded in producing a hypertrophic curriculum (71,54). There is pressure from each discipline to ‘integrate’ its material into the curriculum (125-131). New disciplines such as genetics, statistics, epidemiology, demography, anthropology, and sociology are at the door claiming their share of the undergraduate curriculum. New disciplines have been created to ‘integrate’ or bridge the gap between pre-clinical and clinical disciplines eg clinical biochemistry, clinical pathology, clinical epidemiology (132). Interdisciplinary teams have been used as a tool of ‘integration’ in community medicine (133).

 

The Experiment at Case western Reserve that started in 1952 had a big impact on many other medical schools in the US and abroad. It was essentially an interdisciplinary approach to teaching (134). Training of generalists has become a vogue (135-138). No sooner are they trained than they claim recognition for their ‘generalist’ specialty. General practice or family medicine are now accepted in the US and UK as ‘specialties’. Some ideas of integration are at best laughable. The finding that 33% of medical students abused alcohol led to a suggestion to ‘integrate’ teaching about alcohol in the medical curriculum (139). If each of these demands and approaches to integration were to be fulfilled, the undergraduate medical curriculum will require a life-time to complete!. There are, however, defenders of a crowded undergraduate curriculum. They argue that students should be exposed to all disciplines to enable them informed choices about their future specialties (119). This reminds us of the story of an ’accomplished’ lawyer who knew a bit about every subject including law. The process of continuous additions to and pruning from  the curriculum is going on and has been dramatically described as integration, re-integration, and disintegration (10).

 

Fragmentation is a reflection of an underlying European world-view and did not come about in medical education by accident. This world-view started with the renaissance when religion was separated from public life and science. This set in motion centripetal forces that continually separate, fragment and subdivide. The body was separated from the soul. The mind was separated from the body. Science was separated from art in medical practice. Each disease or organ was isolated and was dealt with in isolation. It must however be recognized that specialization has been responsible for much of the progress in scientific medicine because of the concentration of the researcher’s energy on a narrow focused issue. It is not surprising that in a context of increasing fragmentation , the concepts of ‘total health’, ‘total disease’ are not easily accepted. It is not the ‘total human’ who gets sick but his organs or tissues. It is however very surprising that Claude Bernard’s concept of a harmonious ‘milieu interieur’ and the appreciation of the biochemical unity of all life did not motivate practice of ‘total medicine’. Many physicians in the west have recognized that fragmentation is a major problem and have set about attempting to achieve integration in medical treatment and medical education. Some of these attempts were described above.  Their limited success is due to lack of a guiding vision.

Integration is not just putting two or more disciplines together. It is a fundamental philosophical attitude based on a vision and a guiding paradigm. Only Islam can provide this paradigm. Criticism of the fragmented medical curriculum is actually criticism of the underlying European non-tauhid world-view. The fundamental reason for failure of integration efforts is that the European world-view is atomistic, it is good at analysis and not synthesis. It is incapable of synthesis because it lacks an integrating paradigm like tauhid.

 

THE ISSUE OF LACK OF BALANCE:

Lack of equilibrium is a secondary manifestation of lack of integration. A lot of human illness is due to lack of balance and equilibrium; for example excessive intake of some foods leads to disease just as inadequate intake leads to ill-health. The Qur’an calls for observing the equilibrium, al wastiyyat (143). Violating the rule of the golden middle is associated with many problems. Lack of balance is condemned as: taraf (141-142), israaf (143-145).

 

Ancient Muslim, Indian, Chinese, Greek medical systems understood the concept of equilibrium. Modern European medicine lacks the concept of equilibrium or balance. It  is replete with examples of overdoing a good thing beyond the equilibrium point and creating even bigger problems. Some therapies are worse than the disease they are supposed to cure. The quality of life of terminal cancer patients is made worse by chemotherapy and radiotherapy than the original disease perhaps they could have been left to die in dignity. Pesticides were used to eradicate malaria but they led to human disease. The best treatments of yesterday are known causes of malignancies today. The problem of balance like that of integration is acknowledged by some physicians trained in the European tradition but there is no solution because of lack of an underlying paradigm.

A European symposium called for balance between technological development and social change within an integrated system, education and skill acquisition, general and specialized training, science and behavioral disciplines (22). The conference did not however have a comprehensive solution or paradigm.

 

THE TAUHIDI PARADIGM, INTEGRATION AND BALANCE:

Tauhidi is the main paradigm in Islamic civilization that forms a backbone of all intellectual discussion of medical education. Tauhid al rububiyyat motivates the appreciation that there is only one creator and that thee is unity, harmony and useful interconnections among different forms of life and the physical environment. Tauhid al uluhiyyat motivates the appreciation that the creator has definite purposes from creation and that human life must fulfill those purposes which implies that there are certain laws that lead to a fulfilling life. Obeying those laws is associated with a healthy high-quality life-style. The tauhidi paradigm implies integration and harmony of matter and soul, body and mind, parts and the whole.

 

The physician should be trained to practise medicine as a total holistic approach to the human in the social, psychological, material, & spiritual dimensions and not an attack on particular diseases or organs. The example of the early Muslim physicians is worth emulating. They were well-rounded in their education and their practice of medicine. They were also integrated in the sense that their medical practice fitted in well with other social activities. Al Qadhi Abd al Razaaq used to teach medicine and mathematics in the mosque in Bukhara until his death. Muwaffaq al Ddiin Abd al Latiif al Baghdadi taught medicine in the Azhar mosque during his stay in Egypt (146) . Thus the context and the environment in which the teaching was carried out was integrative. It integrated medicine with the mosque and worship.

 

Al Faruqi (147) described tauhid as the source of truth, cosmic and social order. It ensures unity of truth and therefore prevents contradictions between different disciplines of knowledge. Tauhid is a world-wide view that can guide not only medical education but also all endeavors of building a civilization. The Islamic social order is totalistic and Islam is relevant to every aspect of human endeavor (  ). The tauhidi approach to integration is putting medical knowledge, teaching and practice in a larger context to making sure it is in harmony  and is well coordinated with other related medical or non-medical phenomena. It is therefore possible to envision a very ‘integrated’  doctor who at the same time is very specialized. Such a doctor will approach the patient as a whole human  and not just as organs or tissues. The ideas on integration above are known to some physicians trained in the European tradition as scattered facts that are not joined together by a paradigm. Simpson (71) described an integrated physician who will go beyond the physical manifestations of ill health to deal with cognitive, affective, and psyco-somatic issues without a paradigmatic context.

 

C. THE ISSUE OF SERVICE

SPIRIT OF SERVICE

A Malaysian medical educator did, as far back as 1965, pose a question that is very pertinent even today: ‘Should medicine repair damaged health or try to change the social environmental circumstances that led to ill-health?’(10). The challenge is still before medical educators. Changing the social circumstances requires working on the front-line in rural or poor urban areas. So far medical schools have not been heroes of social medicine although there are projects here and there that are successful and are laudable. In order to medical schools to face the challenge they will have to train medical students in such a way that they internalize the values of social service. The Islamic paradigm of service requires that the physician should be trained to understand medicine as a social service. The human dimension should dominate over the biomedical one. The selection of medical students, their training, and evaluation should emphasize human service and not material gain for the physician. The medical school can not be expected to effectively teach the spirit of serving others. The values and attitudes of self-less service for others are are taught by the family and the community and are already well set by the time the student enters medical school. The school can only build on and enhance basic values that students bring with them from their homes and communities. In such circumstances, the medical school will do well to select those students who already have the vocation to serve. A medical education or health care delivery system developed within an Islamic society will have no alternative but to be service-oriented. This is because of the emphasis on mutual social support, takaful ijtimae

 

 

ALLEVIATION OF  POVERTY:

Material deprivation causes social and psychological stress in addition to the physical impact of inadequate nutrition, housing and sanitation. Socially conscious physicians must be involved in programs to eradicate poverty and assure a reasonable standard of living. Muslim authors have written numerous books on practical methods of poverty eradication ( 148-154    ) . The Qur’an calls upon society to look after the weak and less privileged: the widows (155), the poor (156) , the wayfarer (157). A Muslim must love for others what he loves for himself 158). The concept of sadaqat includes all good things (159). Doing good is encouraged (160-161). The distinction between a faqir and a maskin is very significant (162). The former is poor and is known to be poor so that aid can be extended. The latter is not known and he does not actively seek help. The social services must have the ability to seek out those in need even if they do not come to them seeking aid. Islam is a very practical religion. It has a culture of action and many of its teachings are action-oriented (al Faruqi). Islam does not only enjoin followers to serve others but has practical measures to ensure this ocucurs. Zakat is an obligatory payment to the poor and the needy (163). The obligatory fasting of Ramadhan is training and inspiration for the rich to remenber the poor because they voluntarly taste hunger and fully understand the plight of the deprived. Many breaches of the law are expiated by kaffarat, normally feeding the poor.

 

COMMUNITY-BASED EDUCATION:the materially deprived:

There is an increasing emphasis on community and preventive medicine in many medical schools (6) as an introduction to service in less privileged areas. Traditionally, the service vocation in medicine called for training the student to serve in a poor or rural area or slums of the big cities (135). Involvement of the student in community-based education should be real and not cosmetic or sensational if it will have a major impact on him. The student must actually deliver useful service and should live among the poor for a reasonable amount of time as a fully-fledged professional. The normal prototype of community-based education is setting up a project in a defined community. For example the department of social and preventive medicine, established at the University of Malaya medical school in 1964, set up its field teaching facility at Kuala Langat in Selangor (7). The vision of such efforts was to break the traditional mould of the medical school as an ivory tower with no community responsibility and no outreach to the socially deprived groups. It was also expected that social responsibility will be taught to students. Such community facilities sometimes actually deliver services or are just an appendage on on-going services. Sometimes the educational may not agree with service priorities. Medical schools have not been very successful in inculcating the spirit of self-less service in depressed rural or urban areas. There is a reluctance among physicians to serve in rural areas. A study revealed that 83% of UM and 68% of UKM clinical students preferred to practice in urban areas. The respective figures for pre-clinical students were 60% and 45% indicating that idealism goes down the longer students stay in the medical school (4).

 

The specific goals of community-based education are: (a) understand lifestyles, health behaviors, health beliefs (b) know morbidity and mortality patterns by direct experience (c) acquire problem-solving skills (12). Community-based education is thought to help the student address social needs and responsibility to society (43).  It is argued that community-based learning will make the student more sensitive to society’s problems. This makes sense since the majority of those who manage to make to medical schools are often from middle-class urban homes and have no contact with the less privileged who live in rural areas or the urban slums. While these approaches are in the right direction, they have a misplaced conceptual basis. Community tends to mean the less privileged and the poor. It is a palliative approach for a student, normally of middle-class urban background, to ‘feel’ the problems of the poor. A few weeks spent such communities are not enough to change attitudes held by the student’s social class let alone sensitivity. We need evidence that such brief exposure changes the fundamental outlook like producing a zeal in him or her to leave the comforts of an urban middle-class life for serving in rural areas or the urban slums. It is possible that a short period of working in a less privileged environment only enhances the image the students have that community medicine is second class medicine for the less privileged members of society.

 

COMMUNITY-BASED EDUCATION: the materially well-off:

The disease profile and hence the pattern of medical care in Malaysia is changing with the rapid socio-economic development. The old diseases of poverty (parasitic infections, under-nutrition, poor sanitation) are disappearing. New diseases due to an unhealthy lifestyle of the now richer population are appearing. Over-nutrition, lack of exercise, substance abuse, stress, psychiatric morbidity are on the increase. The old social and psychological safety nets provided by the family are disappearing leaving many people lonely and vulnerable. Medical students of today will have to be trained to deal with the new patterns of morbidity. Medical schools will have to set up education projects in wealthy communities of urban areas that were not traditionally involved in community-based programs.

 

PRIMARY HEALTH CARE:

Medicine is passing through a period of innovative approaches to health care delivery. One of the most recent of these is the concept of primary health care (PHC) which essentially refers to the first point of contact of a patient with the health care system. PHC can be simple in a rural area or quite sophisticated. It does not have the connotation of second-class medicine. The PHC strategy requires training a physicians who will be able to do the following: respond to health needs and expressed demands of the community; work with the community so as to stimulate healthy life style and self-care; educate the community as well as the co-workers; solve, and stimulate the resolve, of both individual and community health problems; orient their own as well as community efforts to health promotion and to the prevention of diseases, unnecessary sufferings, disability and death; work in, and with, health teams, and if necessary provide leadership to such teams; continue learning lifelong so as to keep their competence up-to-date and even improve it as much as possible (164). We can envisage medical education in the future taking place in primary care settings in both its simple and sophisticated modes.

 

C. THE ISSUE OF LEADERSHIP

LEADERSHIP IN SOCIETY:

A physician is a leader. Islam teaches that everybody is a leader in one way or another (165 ). The physician has grave responsibilities for the health and welfare of individuals and their families. This is a trust, amanat, that must be fulfilled (166-168). The medical school curriculum and experience should be a lesson in social responsibility and leadership. The medical school takes the blame for not producing ethical leaders who have the guts to change and improve society. The physician gets the reward, thawab, for any initiative that leads to introduction of something good in the community (169) be it medical or non-medical. The best physician should be a social activist who goes into society and gives leadership in  solving underlying social causes of ill-health. The medical profession must be in the forefront of social change and reform. The physician must play the role of leader in the community (Relook). He can lead when in the community and not the hospital. Inside the four walls of the hospital the physician acts as a technician and not a leader. The traditional medical school curriculum does not equip the future physician with leadership skills in the form of courses or actual field experience.

 

PHYSICIAN AS A MORAL MODEL:

The physician is a respected opinion leader because of intimate contact with the patients therefore his or her moral values, attitudes, akhlaq, and thoughts must be a model for others. Ashour (170) presented 11 features of an ideal Muslim physician among which were: upright character, devotion to duty, honesty, compassion for the poor and the weak. Hathout (171) argued for an integrated approach to produce a Muslim missionary physician who will call others to be morally upright. Moosa (173) suggested that 4 requirements must be available to produce a physician imbued with the Islamic spirit: (a) an appropriate environment for the practice of Islam (b) courses on Islamic history, jurisprudence, ethics, Qur’an, and hadith studies (c) teachers imbued with the Islamic spirit who are at the same time experts in their respective fields (d) an atmosphere that will encourage freedom of thought, deductive reasoning, logical thinking, critical analysis, and tafakkur. He concluded that textbooks must be rewritten.

 

LEADERSHIP ON MEDICO-LEGAL AND ETHICAL ISSUES:

There is an increasing interest among Muslim physicians and fuqaha in legal and ethical issues that arise due to recent advances in medical technology (174-178). The physician is expected to give leadership to patients on ethical issues that arise out of modern biotechnology. Examples are: forced tube-feeding of the elderly (179), forced treatment (180), patients’ wish for death (181), birth control, artificial insemination, organ transplantation (176). He must be prepared not as a mufti who gives legal rulings but as a professional who understands the medical, legal, and ethical issue involved and can explain them to the patients and their families so that they can form an informed decision. In order to play this role well, the future physician must have sufficient grounding in Islamic law and other Islamic sciences

 

Muslim physicians, contemporary and ancient, did not write a lot about professional ethics in medicine because they assume that a Muslim society is ethical and is a protection against ethical transgressions. However recent experiences in Europe and America have shown that there are so many unethical conduct and that special corrective measures are needed (182-186). Unfortunately medical curricula do not prepare the future physician to be a leader in ethics. They give information about ethics but cannnot make him an ethical person (178). Ethics can not be taught as an academic discipline. They have to be internalized so that they may inspire and guide. Teaching ethics in a plural society is not easy (188). The initial ethical values of a student are important (186). A course in ethics may add very little.

 

D. RESEARCH and EXPANDING THE FRONTIERS OF KNOWLEDGE

WIDE SCOPE FOR RESEARCH:

The hadith of the Prophet that for every disease there is a cure (189-191) opens a wide door to research. The Qur’an presents a wide scope of knowledge (192-192). It calls upon humans to explore the signs of Allah in themselves (196) and the universe around them 197-201). The Qur’anic condemnation of blind following and taqlid is a motivation for research. The Qur’an calls for use of evidence-based knowledge (202-205). Research is a type of ijtihad. Research by understanding the signs of Allah leads to even more iman as we learn from the story of Ibrahim (baqara). A story  reported about Abu al Hasan al Anbari al hakiim when he was studying engineering shapes and he said he was reading the verse of  Allah’ didn’t they look at the sky how we built it?’ (146). The human researcher learns to appreciate the majesty of Allah by finding that human knowledge is limited. There is always more to be discovered about Allah’s signs. The field of research is ghaib nisbi. Ghaib mutlaq is in Allah’s knowledge only.

 

PARADIGM SHIFT FROM ‘CONSUMPTION’ TO ‘PRODUCTION’ OF KNOWLEDGE:

The physician of the future will have to change easily between three inter-related roles: research, teaching, and care delivery. The research called for is not a full-time occupation and will normally be carried out as a multi-disciplinary effort. The need for a research ability is motivated by the fact that the undergraduate curriculum can not provide all the knowledge that a physician will need. There is thus a need to acquire new knowledge on a continuous basis by reading and research. Medical graduates are not prepared to be researchers. A committee of the Royal College of Physicians noted that the average medical graduate tends to lack curiosity and initiative, his powers of observation are relatively underdeveloped, his ability to arrange and interpret facts is poor, and he lacks precision in the use of words (71).

 

The medical curriculum should aim at preparing the student to be a researcher, mujtahid, who will extend the frontiers of medical knowledge. The paradigm shift involved here is to change the student and future physician from a consumer to a producer of knowledge. The physician must be trained to be a life-long learner. Research is the best way to learn and stay on the frontiers of knowledge because it is learning by doing and being the midwife of new knowledge. In practical terms, preparation for research means increasing time devoted to subjects on basic research methodological tools and decreasing the amount of biomedical scientific information that is either forgotten or becomes obsolete by the time of graduation. Student research projects are a good introduction to life-long curiosity in science and discovery

 

RESEARCH, MEDICAL CARE, AND TEACHING:

physician actively involved in research will be more dynamic and innovative in caring for his patients. Research combined with patient care fulfils the Prophetic guidance to look for useful knowledge, ilm nafei, because the practitioner does not have the luxury to research into esoteric problems and leave challenges that face him daily in the clinic or hospital.  Applied research is needed to find out how available bio-medical knowledge can be used. Knowledge alone is sometimes not enough for a good health outcome. Physicians who know the dangers of alcohol are sometimes the worst abusers. The most challenging topic for research as far a Muslim physician is concerned is to understand what constitutes quality of life since this is the main aim of medicine. A researcher who is a teacher will always have something new and interesting to share with the students. His teaching will be exciting and students will look forward to it. Research has been proposed as a measure of excellence of a medical school (Roddie). A question of balance arises. The teacher will have to find the right balance in time allocation between research and teaching. The practising physician will have to strike the right balance between research and patient care.

 

E. REFORM OF MEDICAL EDUCATION

ISLAMIZATION OF SOCIETY:

This paper has raised and discussed several issues in medical education. It seems that the medical school by itself has few solutions to most of them. This is because they arise out of fundamental visions of the world and paradigms of life. Any serious solution must start at the level of paradigms. Islam can provide the paradigms that can lead to correct solutions. This however can not be done in the isolation of the medical school. It must involve overall reform of the society so that positive values are imbued in all aspects of its life.  An Islamized society will  facilitate good teaching and eventually practice of good medicine. Before establishment of an Islamized society, interim measures to resolve outstanding problems of medical education cam be undertaken. These include review of the admission process, overhaul of the medical curriculum, and an Islamic ambience in which for the practice and teaching of medicine.

 

SELECTION OF STUDENTS INTO THE MEDICAL SCHOOL:

Many of the qualities of leadership needed in a future physician are not identifiable from the academic record. It is risky to admit students without the required personal and ethical qualities in the hope that they will be taught by the medical school. The medical school can not teach all these qualities; they have to be taught by society before entry into medical school. The medical schools will have no choice but to select candidates with acceptable academic and non-academic qualifications, quite a small pool. Research is needed on whether there is a definable personality profile for those attracted or admitted to medical schools. Anecdotal observation indicate that physicians in several countries and practice settings share some characteristics among which are: bad handwriting, a big ego, mastery and self-control, hard-work and activity. It could be possible to define a new personality profile including some of the good qualities and excluding the bad ones and submitting it to experimental verification over a period of 10-15 years. The process of selection need to be reviewed to identify those students who have the required qualities. Medical schools will have to draw up criteria, both academic and non-academic, suitable for their community and use them in selecting physicians. The future behavior of the graduates should be used as an evaluation tool of how good the criteria were.

 

Students admitted, in addition to academic competence, should possess the following qualities: a comprehensive holistic approach based on tauhid, a service vocation, ethical and community leadership, and motivation to get knowledge.  A heavy weighting may have to be given to the non-academic qualities such that some students may be admitted with lower academic standards if they have the ethical and personality traits need in a good physician. The Thai experience of admitting rural students with lower marks seems to be a good model here (recent develop). Entry into Malaysian medical schools is basically dependent on academic credentials (4). There is no clear-cut evidence that good grades are related to being a good and successful physician. In Malaysia and  other countries intrinsic motivation, personality, attitudes, values are not usually considered 71). In the Malaysian situation, the freedom to select those with the acceptable ethical and moral values is further constrained by the need to redress ethnic imbalances in graduates and the inadequate number of science graduates who qualify for the study of medicine (7).

 

CURRICULUM REFORM:

The curriculum of the medical school will have to be reformed along 2 fronts: (a) increase of methodological subjects and decrease of biomedical information and (b) early involvement of students in health care delivery not as bystanders but as actual providers. What is suggested is a medical curriculum that provides the future physician with basic methodological tools that he can use for life-long learning. Such a curriculum will be limited to the essentials that remain relevant for a long time. It will not be burdened with bio-medical information that is either  made obsolete at the time of teaching or soon after by the rapid scientific progress or is forgotten by the student even before graduation and should not have been taught in the first place. Such a curriculum can aptly be referred to as usul al tibb. The relation between usul al fiqh and fiqh is a very good model for reforming medical education. Usul al fiqh is a methodological subject that provides tools that can be applied to various situations n order to derive a legal ruling, hukm shari. Fiqh is the law derived by use of usul al fiqh (3). It is almost impossible for one alim to study all what is available in fiqh and to know the legal ruling in any situation that comes to him. Some of the legal ases that the alim is called upon to decide are novel and have no precedents. He is however not afraid to deal with any case because his training in usul al fiqh gives him methodological tools that can be applied to old and new situations.

 

It is suggested that the student should spend 30-40% of his time at medical school involved in direct health care delivery. This direct contact will provide the student with practical skills, attitudes, and motivation needed in a physician by an apprenticeship process. The laws of medical practice may have to be revised to accommodate the apprenticeship system. Apprenticepship as a method of medical education needs to be revived. Ancient Muslim medical schools in Egypt, Syria, and Iraq taught most by apprenticeship. Teachers were practising physicians who did most of their teaching at the bedside (Puschmann 1891). Another dimension of leadership in medical education is the mentor role of the senior physicians who are supposed to be a model especially in the domain of physician-patient relationship. Besides facts and skills, medical education imparts attitudes and assumptions. These are part of the non-factual learning that students acquire by watching their teachers. Students are wont to follow what their teachers do and not what they say (44). For apprenticeship to produce the physician with the desired qualities, the ambience in the hospital or primary health care setting must reflect the Islamic teachings and should be set up in such a way that there are many formal and informal learning opportunities. A system under control of the medical school should ensure systematic continuing medical education; the exact form and nature of this education can be worked out. Knowledge either becomes obsolete or is irrelevant to the particular circumstances in which the physician is practicing. Whatever useful knowledge the graduate may retain is the real education that he/she got since education can be alternatively defined as ‘what you know minus what you leaned at school’. At the opening of the UM faculty of medicine in 1965, the then dean, Dr Sreenivasan said: ‘ I tell my students that 50 percent of what I teach them today in clinical medicine will be proved wrong in 20 years’ time but I do not know which 50 percent it is; if I did I would not teach it to them (10).

 

CHARACTER OF THE IDEAL MUSLIM PHYSICIAN

Characteristics of a muslim physician: physical ability. professional competence. dignified appearance. moral character. akhlaq. the ignorant/negligent physician

 

3.0 SPIRITUAL DEVELOPMENT

QUR’AN RECITATION

QUR’AN TAFSIR

HADITH STUDY

THE MA’THURAT

 

4.0 INTELLECTUAL DEVELOPMENT

HISTORY STUDY

PRESENT STATUS STUDY

SOCIETY STUDY

ISLAMIC THOUGHT

 

5.0 SKILL DEVELOPMENT

LEADERSHIP

MANAGEMENT

Professor Omar Hasan Kasule Sr. September 2000