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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 27th February
2012
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[i], especially
as tightness of the chest, dhiiq al sadr[ii].
It also has described stressful life as constricted life, ma’ishat dhankan[iii].
The opposite of stress is breadth of the chest, inshiraah al sadr[iv].
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[v].
It is part of human nature to be inpatient, al ajalat fitrat insaniyat[vi].
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[vii].
Each difficulty, ‘usr, is accompanied by what makes it easy, yusr[viii].
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
Discussion
1: Basic Character
·
I cannot trust
that doctor to operate on me. I saw him beating his son very cruelly and
abusing his driver
·
I am not willing
to follow that doctor’s instructions. I saw him driving through a red light
more than once. How can I trust that he is careful in his prescriptions
·
I am not bothered
about the doctor's personal life as long as he performs his work well
Discussion
2: Physicians Duty To Himself: Self Improvement
·
What concerns me
as a doctor is my technical efficiency. My character may be good or bad. It has
nothing to do with my profession
·
The doctor is
already an adult and his character is set. We just have to appreciate what is
positive and put up with what is negative
·
A good doctor
leaves his social problems at home. Home life whether good or bad has no impact
on professional performance
Discussion
3: Professional Development
·
I have divided my
life into two phases and will never allow the two to interfere with one
another. I will start by getting education and training. Then I will start
making money.
·
Attending medical
conferences is a good excuse for tourism. The academic discussions that take
place have no relation to the real work of practicing medicine
Discussion
4: Physicians Duty To Himself: Etiquette
·
Our consultant
told us to do what he said and not what he did
·
A healthcare team
is a hierarchical system led by a dictator
·
Interns and
medical students learn best when they fear the consultants
Discussion 5: Physician Duty To Himself:
Dealing With Stress
·
A neurosurgeon
should live within his means and never take any debt because financial stress
will affect his judgment
·
Stress is needed
for good practice. A relaxed doctor is likely to make mistakes
·
A doctor in
stress should never seek psychological help because he may lose his license
Discussion
6: Physician’s Duty To The Profession:
·
My duty is taking
care of patients I do not want to be bothered by administrative work
·
We have so much
clinical work to do we should not be bothered with research; we should be
consumers and not producers of knowledge
REFERENCES