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Lecture to the freshmen at the Faculties of Medicine and Dentistry, National University of Malaysia by Professor Dr Omar Hasan Kasule, Sr. MB ChB (MUK), MPH (Harvard) and DrPH (Harvard) Deputy Dean Faculty of Medicine UIA Kuantan
OUTLINE
1.0 CHARACTER and VALUES
- Principled and purposive life
- Integrity
- Courage
- Wisdom, hikmat
- Patience, sabr
- Humility
- Self-restraint
- Modesty
- Equilibrium and moderation
2.0 MOTIVATION
- Motivation
- Idealism
3.0 ETIQUETTE
· Teacher’s etiquette
· Student etiquette
· Team etiquette
4. HOLISTIC ATTITUDE
5. LEADERSHIP
6. SELF-IMPROVEMENT
7.0 SELF-DEVELOPMENT (SOCIAL and PROFESSIONAL)
· Social development
· Economic empowerment
- Social action
- Good company
- Professional development
8.0 PROFESSIONAL ETHICS
- Basis for ethics
- Informed consent
- Disclosure and truthfulness
- Privacy and confidentiality
- Fidelity
9.0 PROFESSIONAL MISCONDUCT
- Abuse of professional privileges
- Fraudulent procurement
- Financial fraud
- False documentation
- Criminal action
- Private derogatory mis-conduct
- Abuse of position
- Other forms of misconduct
- Public professional mis-conduct
SUMMARY
This paper is a leap forward looking at the attributes of the future physician and then working backwards to see how those attributes can be acquired during undergraduate education and training. The medical school curriculum building on values, knowledge, and skills acquired in the pre-university period should aim at producing physicians with the following attributes: character and values (principled life, integrity, courage, wisdom, patience, humility, self-restraint, modesty, equilibrium & moderation), motivation, etiquette, holistic attitude, leadership, self improvement, self-development (social and professional), professional ethics, and no professional misconduct. These attributes are not acquired automatically on graduation. They are acquired over a long period of education, training, and apprenticeship and by a process of pro-active and consistent cooperation between students and teachers. The newly graduated physician must play a role in facing the challenges of inadequate number of practitioners, low research productivity, and poor quality of care.
1.0 CHARACTER and VALUES
Principled and purposive life: Physicians must live a principled life guided by high moral principles and not by expediency. They must be consistent and constant in pursuing well defined goals. The highest goal is achieving the pleasure of the Creator. This is followed by achieving professional and personal goals (long and short term) that must be reasonable, imaginative, specific, actionable, attainable, and challenging. The goals should stay permanent for a reasonable period of time. Frequent shifting of goal posts is a cause of failure.
Integrity is when actions conformity to values. Good values are universal and are found in all religions and belief systems. Innate knowledge of what is good and what is bad is reinforced by religious or moral teachings. Integrity in essence means successfully carrying and discharging responsibility, amanat. Integrity also means truthfulness, fulfilling promises and respecting commitments.
Courage: Moral courage is to stand up to evil with the full realization that such a stand may invite unpleasant consequences. Moral courage is needed to know your-self, self-criticize, and decide to improve. Social courage is needed to stick to morally right choices in one’s life even though the society around may behave differently.
Wisdom, hikmat, is a sign of maturity and is a great favor that brings a lot of good[1]. There is a difference between ‘ilm and hikmat. ‘Ilm is knowledge. Hikmat is a higher level of understanding and using knowledge taking into consideration previous experiences and high moral guiding principles. You are better off with less ‘ilm and more hikmat. A lot of ‘ilm with no hikmat is positively dangerous.
Patience, sabr, is needed to face life’s problems with inner strength, endurance, perseverance, and hope. Lack of patience is associated with wrong choices and moves.
Humility is the beginning of wisdom and is part of faith[2]. Know that you have limitations. Do not deceive yourself that you are superior to everybody else. Always remember that there are others who may be your equals or actually better than you.
Self-restraint is needed to control inner passions and evil promptings that can lead to evil action. It is also needed to counter temptations in the external social environment that can lead to evil. Sex is the most powerful drive in humans that can lead to evil. Chastity and sexual discipline are necessary for individual and societal well being.
Modesty is to set limits beyond which there is immorality and sin. It is a protecting barrier against evil. It is always good and can never be negative[3]. Part of modesty is to live a simple life. A simple uncomplicated lifestyle leads to personal strength because of relative independence from the physical environment. Too much luxury is pursuit of illusionary happiness and often ends in despair. Material possessions should be used as a means to fulfill your mission on earth and should not become an end to strive for.
Equilibrium and moderation: Moderation is the best approach. Be balanced in your attitudes and actions. Avoid extreme positions. Taking a middle path gives you a chance to change positions and follow what is right and what is best. Be moderate in expenditure; not wasteful and not miserly. Be calm and controlled in moments of emotional arousal whether pleasant or unpleasant.
2.0 MOTIVATION
Motivation can be intrinsic (self motivation), extrinsic (motivation by external rewards), or reactionary (temporary response to events). It can be positive motivation or can be negative motivation. High job satisfaction is directly related to high motivation. Motivated physicians know that work is worship and that the Creator observes all they do so they strive for excellence and quality. The salary meets the physical needs of the physicians so that they can devote time and energy to medical practice. Salaries and benefits can never be a just return for the sacrifices that physicians make in taking care of patients. The physician’s work is far more worth than the highest material compensation. Medicine is a form of worship that can be rewarded only by the Creator. A physician who is motivated by material gain alone will never be happy because material needs never end. A physician motivated by service will always be happy and contented whatever the level of material compensation.
Idealism: Students are idealistic on entry into medical school and talk about serving the community. On graduation many students think about material benefits and social status. Some practicing physicians have no idealism left and are in crass pursuit of material self-gratification. A physician in a materialistic society is torn between contradictory forces of greed and service. The medical curriculum should inculcate service. Although service should have the higher priority, the material rights and privileges of the physician should not be forgotten because he also wants to live a happy and honorable life.
3.0 ETIQUETTE
Teacher’s etiquette: Medicine is both an art and a science. It is learned by apprenticeship and also by direct instruction. Teachers must be humble. They must make the learning process easy and interesting. Teachers have to be careful in their behavior because their actions, attitudes, and words can be emulated. They should have appropriate emotional expression, encourage student questions, repeat to ensure understanding, and not hide knowledge.
Student etiquette: Medical students must have the right attitude towards their teachers who are their mentors. The student should respect the teachers for the knowledge they have. They should listen quietly and respectfully, teach one another, ask questions to clarify, and take notes for understanding and retention. They should stay around their teachers all the time to maximize learning opportunities.
Team etiquette: Students must have the right attitude to operate successfully in the medical care team in which most medical teaching occurs. Each member of the team carries personal responsibility with leaders carrying more responsibility. Leaders must be obeyed except in illegal acts, corruption, or oppression. The human touch is unfortunately being forgotten in modern medicine as the balance is increasingly tilted in favor of technology. Basic duties of brotherhood and best of manners must be observed. Encouraged are positive behaviors (mutual love, empathy, caring for one another; leniency, generosity, patience, modesty, a cheerful disposition, calling others by their favorite names, recognizing the rights of the older members, and self control in anger). Discouraged are negative attributes (harshness in speech, rumor mongering, excessive praise, mutual jealousy, turning away from other for more than 3 days, and spying on the privacy of others). Gender-specific identity should be maintained in dress, walking, and speaking. Free mixing of the genders is forbidden but professional contact within the limits of necessity is allowed. Patients of the opposite are examined in the presence of a chaperone. The gaze should be lowered. Modest and covering must be observed. Display of adornments that enhance natural beauty must be minimized.
4. HOLISTIC ATTITUDE
The purpose of medicine should be to restore, maintain or improve the quality of life within a holistic integrated context. Ideal physicians are health-oriented and not disease oriented. They are focused on quality and not quantity of life. European secular-oriented medicine is fragmented by organ, disease process, and is not holistic. It is atomistic, analytic, and not synthetic. In the absence of an integrating paradigm, European medicine lacks balance and equilibrium in its therapeutic approach. We must look into our own local traditions for a conceptual basis for holistic medicine that will assure equilibrium, balance, and moderation.
5. LEADERSHIP
The medical school curriculum and experience should be a lesson in social responsibility and leadership. The best physicians should be social activists who go into society and gives leadership in solving underlying social causes of ill-health. Physicians as respected opinion leaders with close contact with the patients must be a model of leadership for others in moral values, attitudes, akhlaq, and thoughts. They must give leadership in preventing or solving ethical issues arising out of modern biotechnology. They should also provide leadership in advocating for the less privileged: the poor, the weak, and the deprived.
6. SELF-IMPROVEMENT
Both the medical student and the new physician should constantly think of self-improvement. The beginning of failure is to think of oneself as perfect. Self-improvement requires commitment, effort and action to achieve goals, taking responsibility, learning from previous experiences (positive and negative), interdependence, pursing real needs and not mere wants, a positive attitude, a futuristic outlook, and self control The following are ingredients of self control: self-confidence, self-esteem, self-reliance, and self-discipline. Self-confidence is to know yourself, your strengths and weaknesses, to be comfortable with what you are, and to be psychologically secure. Psychological security raises self-esteem. Self-reliance in essence taking charge of your life, relying on yourself in solving problems, and taking the initiative to improve. Self discipline is needed for success and consists of control of whims and emotions, sticking to goals, acting according to long-term and not short-term interests, avoiding impulsive acts, following the head and not the emotions, and trusting your instincts.
7.0 SELF-DEVELOPMENT (SOCIAL and PROFESSIONAL)
Social development starts with selection of a spouse and starting a family. It involves learning to develop social networks and taking social responsibilities in the community.
Economic empowerment should have the objective of eventual financial independence. A long-term development plan must be made. Putting side some of the monthly earnings for asset accumulation and investment ensures financial security.
Social action: Good acts and words wipe away or neutralize evil. You should hasten to do good. While always engaged in doing good, there is little room for evil. Never injure anyone with your tongue. Say good or keep quiet. Learn to work with others in doing good and forbidding evil. Sharing and helping others helps you become even a better human being. It gives you a sense of mission beyond your physical needs. Give charity continuously; it cleanses both your wealth and your soul. Putting interests of others in front of yours helps you discover your humanity and conquers your egoistic tendencies. Altruism, iithaar, involves doing good for others at the expense of some inconvenience to yourself with no expectation of any reward.
Good company: Look for and stay in the company of wise people. You will learn the good from them. Their company will reinforce the good in you. Time spent in such good company is time taken away from possible bad company or bad influences. Do not trust or deal with bad people except in trying to correct and lead them to the right. Ignore stupid and immoral company. They will have a negative impact on you.
Professional development and success are based on a good basic education, postgraduate training, apprenticeship to a good mentor, setting goals and a time frame to achieve them, adopting a growth strategy, delivering quality results in the work and not seeking cheap publicity. Professional networking involves identification of strategic partners for mutual benefit and not manipulation or exploitation. Nurturing contacts is very important otherwise they get lost.
8.0 PROFESSIONAL ETHICS
Basis for ethics: The ethical theory is based on the 5 purposes of the Law, maqasid al shari’at. The five purposes are preservation of morality, life, progeny, intellect, and wealth. Any medical action must fulfill one of the above purposes if it is to be considered ethical. The basic ethical principles relevant to medical practice are good intention, certainty before action, and preventing harm.
Informed consent: No medical procedures can be carried out without informed consent by the patient. Informed consent requires disclosure by the physician, understanding by the patient, legal competence of the patient, recommendation of the physician on the best course of action, decision by the patient, and voluntary authorization by the patient to carry out the procedures.
Disclosure and truthfulness: As part of the professional contract between the physician and the patient, the physician must tell the whole truth. Patients have the right to know the risks and benefits of medical procedure in order for them to make an autonomous informed consent. Disclosure to the family and other professionals is allowed if it is necessary for treatment purposes.
Privacy and confidentiality: The patient voluntarily allows the physician access to private information in the trust that it will not be disclosed to others. This confidentiality must be maintained within the confines of the Law even after death of the patient. The physician cannot disclose confidential information to a third party without the consent of the patient.
Fidelity: The principle of fidelity requires that physicians be faithful to their patients. It includes: acting in faith, fulfilling agreements, maintaining relations, trust and confidence. Abandoning the patient at any stage of treatment without alternative arrangements is a violation of fidelity.
9.0 PROFESSIONAL MISCONDUCT
Abuse of professional privileges: Abuse of treatment privileges consists of unnecessary treatment, causing iatrogenic infection, and abetting an unlicensed practitioner.
Abuse of prescription privileges is supplying a controlled drug without a license, prescription of controlled drugs not following procedures, diverting or giving away controlled substances, dispensing harmful drugs, sale of poisons, and writing prescriptions using secret formulas.
Fraudulent procurement of a medical license, sale of medical licenses, and covering an unqualified practitioner are serious crimes.
Financial fraud may be pharmacy fraud (billing for medicine not supplied), billing fraud (billing for services not performed), or equipment fraud (using equipment that is really not needed or using equipment of poorer quality).
Kick-backs are unethical and illegal. It is also illegal to get financial advantage from prescriptions to be filled by pharmacies owned by the physician. Entering into a compact with pharmacists or laboratories involving fee splitting and unnecessary referrals is not moral.
False or inaccurate documentation is a breach of the law and includes issuing a false medical certificate of illness, false death certification, and false injury reports.
Criminal action could be brought against a physician for euthanasia (active and passive), induced non-therapeutic abortion, abusive therapy involving torture, intimate therapy; rape and child molestation; and sexual advances to patients or any other form of sexual involvement with patients.
Private mis-conduct derogatory to reputation, kharq al muru’at: A physician must be a respected and trusted member of the community so any misbehavior even in private has serious consequences because it puts the profession in disrepute. Sexual misbehavior such as zina and liwaat are severely condemned.
Abuse of position is by abuse of trust (eg harmful or inappropriate personal and sexual relations with patients and their families), abuse of confidence (eg disclosure of secrets), abuse of power/influence (eg undue influence on patients for personal gain), and conflict of interest (when the physician puts personal selfish interests before the interests of the patient).
Other forms of misconduct are in-humane behavior such as participation in torture or cruel punishment, abuse of alcohol and drugs, behavior unbecoming, indecent behavior, violence, and conviction for a felony.
Public professional mis-conduct: Physicians in private practice must adopt good business practices. Halal transactions are praised[4]. An honest businessman is held in high regard[5]. Leniency in transactions is encouraged[6]. Full disclosure is needed in any transaction[7]. Measures and scales must be fulfilled[8]. Bad business practices are condemned. There is no blessing in immoral earnings[9]. Unfair competition is condemned[10].
THE CHALLENGE
Our situation today was described correctly by Imaam al Shafe’e more than a thousand years ago as quoted by Jalaluddin al Suyuti in his book al Tibb al Nabawi. Imaam al Shafe’e said ‘After the science which distinguishes between what is halal and what is haram, I know of no science which is nobler than that of medicine.... Truly the people of the Book have overcome us and overtaken us in this supreme art”.
We face a challenge of quantity. At the moment there are not enough physicians to satisfy the medical needs of the nation.
We face a challenge of being consumers and not producers of medical knowledge. We need both intellectual and practical stimulation to work hard in medical research and medical services delivery in order to become leaders and not followers in medicine.
We face the challenge of quality. We must deliver quality, holistic, and humane care.
[1] (Qur’an 2:269)
[2] (Tirmidhi K25 B80)
[3] (Muslim K1 H60)
[4] (Zaid H539)
[5] (Tirmidhi K12 B4)
[6] (Bukhari K34 B16)
[7] (Ibn Majah K12 B45)
[8] (Muwatta K31 H99)
[9] (Darimi K20 B60)
[10] (Bukhari K34 B58)