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Lecture to 4th year medical students at the Faculty of Medicine King Fahad Medical City Riyadh by Professor Omar Hasan Kasule Sr 13th March 2011
1.0 PHYSICIAN DUTY TO HIMSELF
1.1 PHYSICIANS DUTY TO HIMSELF: BASIC CHARACTER
1.1.1 Iman
Three aspects of iman bear directly on medical practice: tauhid, qadar, and tafakkur. The integrating paradigm of tauhid enables the physician to practice integrated and balanced medical. Such care combines Islamic values and Islamic law with the best available in advanced medical technology. Belief in qadar guides the physician in his work to know and understand that life, health, illness, and cure are in the hands of Allah. He will understand that he is a tool and not the reason for the cure. He will realize that the physician has limited knowledge and limited ability and should not be arrogant. After doing all what is humanly possible for his patients, the believing physician trusts in Allah's help and support. A believing physician will know that he cannot change the time of death, ajal, since that is under Allah’s direct control. He will concentrate on improving quality of remaining life for his patients. As the believing physician goes about his daily chores, he undertakes contemplation, tafakkur, about all what he sees. Medical knowledge and actual clinical experiences increase iman because the physician realizes the power and majesty of Allah who created the complex human organism and who cures it from the most severe diseases.
1.1.2 Taqwat
A believing physician is conscious that Allah is watching and is ever-present. He knows that other humans observe his actions. He will do well in public and private. He will strive to know the permitted, halal, and do it. He will even more intensely strive to know what is prohibited, haram, and avoid it. He will avoid being involved in prohibited medical procedures that result in destruction of life such as abortion, euthanasia, and assisted suicide. He will keep away from fraud, false evidence, lying and misrepresentation. He will not dispense forbidden, haram, medication.
1.1.3 Amanat
A believing physician will take his medical work as a trust, amanat. The trust involves three dimensions: commitment and sincerity of intentions, ikhlas al niyyat; quality work, itqan & ihsan; and the social responsibility of both da’awa and being a role model, qudwat. A sincere intention increases commitment. Medical practice is ‘ibadat for the pleasure of Allah. Medicine is also a form of charity. The motivation of the physician should therefore be service and not personal enrichment and material gain. A believing physician will try to excel in his clinical responsibilities by making sure that he tries to achieve perfection, itqaan, and excellence, ihsaan. Professional competence cannot be compromised in any way. It is a major sin to undertake any medical procedure beyond the level of competence of the physician. A believing physician knows that he is accountable before Allah, the profession, and society at large. He will discharge his duties honestly using the highest standards of good medical care. He will avoid harmful, doubtful, or unnecessary treatment. He will strive to have regular updating of his knowledge and skills. He will engage in research for new and better treatment modalities; every disease has a cure. A believing physician will know that he has societal responsibilities beyond the treatment of disease. He will use any opportunities available to make dawa to patients and their relatives. He will work to eradicate or alleviate social root causes of disease. In his personal life he will strive to be a role model of good character and behavior for the rest of society. He will not shy away from social leadership and advocacy for the less privileged or the oppressed.
1.1.4 Akhlaq
The physician must have humility, tawadhu’u, show brotherhood, ukhuwwat, and have social respectability, muru’at. He should show humility to Allah, to professional colleagues, to patients and their relatives. He should avoid show-off, riyaa, in its manifest and hidden forms. Brotherhood is manifested in the humane treatment and respect for all patients regardless of their disease and social status. The believing physician gives reassurance, empathy, consolation, psychological support for patients and relatives. He has a positive and optimistic attitude in the stress of illness. He also fulfils the basic duties of brotherhood with his professional colleagues. Social respectability is acquired by good public behavior and avoiding any negative behavior that violates this respectability, khariq al muru’at. This should not be a mere show or acting in public when in private behavior is despicable. It must be sincere and consistent with an overall good behavior.
1.2 PHYSICIANS DUTY TO HIMSELF: SELF IMPROVEMENT
1.2.1 Character development
Character, determined by personality, is internal. Its outward manifestation is behavior, good or bad. Consistent observation of behavior over a long time reveals true character. The following are some of the components of a positive character: Piety, generosity, charity, chastity, trust, humility, balance, moderation, patience, endurance, cooperation, forgiving, ignoring stupid company, reconciliation, honor and dignity, shyness, modesty, integrity, courage, and wisdom. These traits are best manifested in an atmosphere of positive attitudes, optimism, and behavior. Positive behavior includes: controlling appetites (eating little, fasting, sexual self-control), fulfilling needs of others, mercy, good words and acts; and good deeds which wipe out bad ones.
1.2.2 Self-improvement
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, assertiveness, self-confidence, and self reliance, and contentment.
1.2.3 Taking charge
Being assertive is learning to take control. A person who has self-control can stand up to the temptations of shaitan. The following are ingredients of self control: self-confidence, self-esteem, self-reliance, self-discipline, and self-development. 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-help and self-improvement are 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. An entrepreneurial attitude requires initiative, optimism, self-confidence, creativity, taking calculated risks, looking for and exploiting opportunities, perseverance and determination.
1.2.4 Social development
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.
1.2.5 Professional development
The factors behind professional success are 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 manipulating or exploitation. The networking starts within Muslim circles and extends to the wider professional and social circles. Nurturing contacts is very important otherwise they get lost. Economic empowerment should have the objective of eventual self-employment. A long-term development plan must be made. Putting side some of the monthly earnings for asset accumulation and investment ensures financial stability and expansion of the Muslim economic base.
1.3 PHYSICIANS DUTY TO HIMSELF: ETIQUETTE
1.3.1 Etiquette of teaching & learning in the health care team
The hospital health care team is complex and multi-disciplinary with complementary and inter-dependent roles. Members have dual functions of teaching and delivering health care. Most teaching is passive learning of attitudes, skills, and facts by observation. Teachers must be humble. They must make the learning process easy and interesting. 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. The student should respect the teacher 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 in the hospital and with their teachers all the time to maximize learning.
1.3.2 Etiquette of care delivery in the health care team
Each member of the team carries personal responsibility with leaders carrying more responsibility. Leaders must be obeyed except in illegal acts, corruption, or oppression. Rafidah was good model of etiquette. She a kind, empathetic, a capable leader and organizer, clinically competent, and a trainer of others. Besides clinical activities, she was public health nurse and a social worker assisting all in need. The human touch is unfortunately being forgotten in modern medicine as the balance is increasingly tilted in favor of technology.
1.3.3 The health care team: general group dynamics
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 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).
1.3.4 The health care team: special group dynamics
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.
1.4 PHYSICIAN DUTY TO HIMSELF: DEALING WITH STRESS
1.4.1 Definition of stress
Stress is a psychological, emotional, and physiological reaction to a stressor. It is considered part of normal human adaptation if it is within certain limits. It becomes abnormal or pathological in situations of over-reaction such that the adverse consequences of the stress reaction cancel out the advantages. The stress threshold varies from person to person and from stressor to stressor. What stresses one person may not stress another one. The same individual could react to the same stressor in different ways depending on the social and personal context. The underlying cognitive and spiritual qualities modulate reaction to stressors.
1.4.2 Mention of stress in the Qur’an
The Qur'an has described stress as tightness, dhiiq[1], especially as tightness of the chest, dhiiq al sadr[2]. It also has described stressful life as constricted life, ma’ishat dhankan[3]. The opposite of stress is breadth of the chest, inshiraah al sadr[4]. Stress involves psychological stress, dhiiq nafsi with physical symptoms and signs appearing later. Stress is breakdown of normal psychological equilibrium, i’itidaal
1.4.3 Causes of stress
Stressful events are traumatic, uncontrollable, and unpredictable. Examples are: trauma, temperature, emotions. Travel is a cause of stress likened to punishment[5]. It is part of human nature to be inpatient, al ajalat fitrat insaniyat[6]. Thus when confronted by a problem that cannot be resolved quickly they become stressed. Life is full of difficulties. Allah helps those in difficulty. He causes difficulty to be removed by ease, zawal al usr bi al yusr[7]. Each difficulty, ‘usr, is accompanied by what makes it easy, yusr[8]. Patience is called for in moments of difficulty. However many people when in trouble forget this and fall into stress.
1.4.4 Reaction to stress
Psychological reactions to stress is anxiety, anger, aggression, apathy and depression, cognitive impairment. The physiological reaction to stress manifests as the usual signs of adrenaline releases. Long-term stress affects good health.
1.4.5 Coping with stress
People cope with stress in different ways. Coping with stress may be by denial, projection, repression, rationalization, or reaction formation. The type of reaction also depends on the personality type, spiritual preparation, and experience in life.
1.5 PHYSICIANS DUTY TO HIMSELF: OTHERS (Ethics of the Medical Profession by the Saudi Council for Medical Specialties)
· Contentment with what Allah has provided
· Control the tongue
· Seeking knowledge
· Perform religious duties
· Good intentions and sincerity
· Take care of appearance
· Maintain high moral standards
· Join scientific societies
· Act earnestly and diligently
· Take care of physical and psychological health
· Protect himself from medical malpractice risks
· Abide by professional rules and regulations
· Seek advice from senior doctors
· Know the limits of his professional ability
2.0 PHYSICIAN"S DUTY TO THE PROFESSION:
2.1 Service
Medicine should be taught as a social service with the human dimension dominating the biomedical dimension. Medicine should be practiced as of mutual social support. Medical education should prepare the future physician to provide service to the community. This will require skills of understanding and responding to community needs that can be acquired by spending part of the training period in a community setting away from the high technology hospital environment.
2.2 Leadership
The medical school curriculum and experience should be a lesson in social responsibility and leadership. The best physician should be a social activist who goes into society and gives leadership in solving underlying social causes of ill-health. The physician as a respected opinion leader with close contact with the patients must be a model for others in moral values, attitudes, akhlaq, and thoughts. He must give leadership in preventing or solving ethical issues arising out of modern biotechnology. He must understand the medical, legal, and ethical issue involved and explain them to the patients and their families so that they can form an informed decision. He should also provide leadership in advocating for the less privileged and advocacy for human rights.
2.3 Research
2.3.1 Importance of research in Islam:
Islam puts emphasis on seeking knowledge. The search for knowledge is a difficult but necessary process as we learn from the story of Musa and the righteous man. Islam encourages benefiting and using knowledge. There is no consideration for knowledge not accompanied by practical application. Tadabbur involves critical observation and consideration of information. Tadabbur involves critical consideration of information. Humans are encouraged to derive empirical knowledge from observation of the earth and their own bodies. The observation referred to is serious and deliberative, al nadhar bi al tadabbur. Tadabbur is required even with the holy text of the Qur’an. Thought can be based on empirical observation. The observation can be of the earth. It can also be by observation of the human body. Islam encourages active intellectual effort in looking for knowledge. The process of ijtihad is exertion of maximum intellectual effort to discover the truth or understand the relation between truths. Ijtihad is also used to discover and identify falsehoods. There are parallels between the tools of ijtihad used by classical Muslim scholars and the processes of reaching conclusions in modern scientific research. The process of inductive logic used in medical research is the same as qiyaas usuuli used by scholars of the methodology of the Law. The process of reaching a scientific consensus is similar to the process of scholarly consensus. The prophet taught that there is a cure for every disease. There is an injunction to search for cures by processes of medical research.
2.3.2 Developing a scientific culture:
· The mind must be trained to observe, analyze, think and act in a scientific manner. Blind following is condemned. Knowledge should be spread. Ignorance spreads when knowledge is lifted. Knowledge removes blind following. Knowledge is acquired by study. Humans were ordained to read. Knowledge is so important that migration in its search is encouraged. Travel in search of knowledge is encouraged. Severe punishment is reserved for those who know and hide their knowledge from others. There is punishment for speaking without knowledge. Knowledge by itself is not useful unless it is associated with work
· Understanding: understanding is deeper than knowing. It is possible but not desirable to know without understanding. Understanding is not possible without knowing.
· Thinking: thinking is very important in science. Thinking can lead to new knowledge or to deeper understanding or appreciation of existing knowledge. Thinking by observing the environment around us: living and non-living things. Thefreedom of thought and freedom of belief are necessary for thought to flourish.
· Description of the constant laws of nature: the laws of nature are fixed and stable. The laws operate in various situations: in change, reproduction, parity, in the past and in the present. Order is one of the most important laws of nature.
· Evidence-based knowledge and action: knowledge must be evidence-based. Certain validity conditions must be fulfilled before evidence is accepted. False evidence is rejected. Knowledge not based on evidence such as sorcery is rejected. Speculation or conjecture are rejected because they are the most untruthful discourse not being evidence-based. Speculative or hypothetical thinking not related to reality is condemned. Human thought is a tool and not an end in itself. It operates on the basis of empirical observations and revelation, both objective sources of information. Thought that is not based on an empirical basis or revelation is speculative and leads to wrong conclusions. Care should be taken in giving opinions on matters for which there is no evidence.
· Objectivity: objectivity is enjoined in measurements. Subjective feelings should not be followed. Personal whims should not be followed because they lead to falsehood.
· Drawing conclusions from empirical observation: reliance of observation and not speculation is emphasized. Humans should observe the signs of the creator in the universe and in humans. They however should be aware that human senses have limitations.
· Rational thinking and logical operations: assertions based on reason have rational thinking behind them. Logical operations related to rational thinking can be identified.
· Prudence in reaching conclusions: even with the most rigorous empirical observation, care must be taken in reaching conclusions because errors are always possible.
· Asking questions: questions can be for finding out information. Too much speculative questioning on hypothetical situations is discouraged.
· Respecting the other opinion: opposing opinions should be listened to and should be respected. They should never be suppressed.
· Abandoning false premises: if a person gives an opinion on a matter and then receives a correct information or interpretation, he should give up his previous opinion.
· Truth: fear of people should be no reason for not revealing the truth. Deception is condemned. The truth of any assertion must be checked. Certainty is the basis of knowledge; speculation is not.
· 2.4 PHYSICIAN'S DUTY TO HIS PROFESSION : OTHERS (Ethics of the Medical Profession by the Saudi Council for Medical Specialties)
· Personal conduct, personal appearance, and devotion to the profession
· Avoid actions that cause contempt for the profession
· Contribute to the scientific and practical development of the profession
· Avoid misusing the profession for personal gain
· Respect standards of behavior in the conduct of the work
· Observe standards of the medical profession
· Take appropriate measures when a member of the profession does not follow accepted standards
· Honesty and integrity in dealing with patients
· Avoid hasty decisions in risky procedures
· Avoid seeking fame at the expense of the profession
NOTES