060205P - PROFESSIONALISM IN MEDICAL PRACTICE

Paper Presented by Professor Dr Omar Hasan Kasule Sr. MB ChB (MUK), MPH (Harvard), DrPH (Harvard) Professor of Epidemiology and Islamic Medicine at Universiti Brunei Darrussalam at the Annual Health Islamic Conference held at Faculty of Medicine University of Indonesia Jl Salemba Raya No 6 Jakarta Pusat held on 3-5 February 2006 and organized jointly by Forum Ukhuwah Lembaga Dakwah Facultas Kedoketran se-Indonesia and Forum Studi Islam Kedokteran Universitas Indonesia.

CHARACTER OF THE IDEAL PHYSICIAN: iman, taqwah, amanat, & akhlaq

Iman: Three aspects of iman bear directly on medical practice: tauhid; predestination, qadar; and contemplation, tafakkur. The integrating paradigm of tauhid enables the physician to practice integrated and balanced medical care. Belief in qadar guides the physician in his work to know and understand that life and health, and illness and cure are in the hands of Allah. He will understand that he is a tool and not the reason for the cure; all cure if from Allah. The physician has limited knowledge and limited ability, qudrat, and should therefore 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.

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.

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 social responsibility of da’wa 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 da’wa 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.

Akhlaq: The physician must have humility, tawadhu’u, show brotherhood, ukhuwwat, and have social respectability, muru’at. The physician must have a balanced character, tawazun. He must have a sense of accountability, muhasabat. He must work for the benefit of the patients and the community, maslahat. 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, kharq 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.

VALUES

The physician should also follow the following guidelines from the sunnat: good intentions, avoiding doubtful things, leaving alone matters that do not concern him, loving for others, causing no harm, giving sincere advice, avoiding the prohibited, doing the enjoined acts, , renouncing greed, avoiding sterile arguments, respect for life, basing decisions and actions on evidence, following the dictates of conscience, righteous acts, quality work, guarding the tongue, avoiding anger and rage, respecting transgressing Allah’s limits, consciousness of Allah in all circumstances, performing good acts to wipe out bad ones, treating people with the best of manners, restraint and modesty, maintaining objectivity, seeking help from Allah, and avoiding oppression or transgression against others.

MEDICAL DECISIONS

No medical procedures can be carried out without informed consent of the patient except in cases of legal incompetence. The patient has the purest intentions in decisions in the best interests of his or her life. Others may have bias their decision-making. The patient must be free and capable of giving informed consent. Informed consent requires disclosure by the physician, understanding by the patient, voluntariness of the decision, legal competence of the patient, recommendation of the physician on the best course of action, decision by the patient, and authorization by the patient to carry out the procedures. The patient is free to male decisions regarding choice of physicians and choice of treatments. Consent can be by proxy in the form of the patient delegating decision making or by means of a living will.

Valid consent must be voluntary, informed, and by a person with capacity to consent. It involves explaining the procedure contemplated, making sure the patient understands, and offering the patient a choice. Consent is limited to what was explained to the patient except in an emergency. Refusal to consent must be an informed refusal (patient understands what he is doing). Refusal to consent by a competent adult even if irrational is conclusive and treatment can only be given by permission of the court. Doubts about consent are resolved in favor of preserving life. Spouses and family members do not have an automatic right to consent. A spouse cannot overrule the patient’s choice.

Advance directives, proxy informed consent by the family are made for the unconscious terminal patient on withholding or withdrawal of treatment. Physician assisted suicide, active euthanasia, and voluntary euthanasia are illegal. A do not resuscitate order (DNR) by a physician could create legal complications. The living will has the following advantages: (a) reassuring the patient that terminal care will be carried out as he or she desires (b) providing guidance and legal protection and thus relieving the physicians of the burden of decision making and legal liabilities (c) relieving the family of the mental stress involved in making decisions about terminal care. The disadvantage of a living will is that it may not anticipate all developments of the future thus limiting the options available to the physicians and the family. The device of the power of attorney can be used instead of the living will or advance directive. Decision by a proxy can work in two ways: (a) decide what the patient would have decided if able (b) decide in the best interests of the patient. Informed consent is still required for physicians in special practices such as a ship’s doctor, prison doctor, and doctors in armed forces. Police surgeons may have to carry out examinations on suspects without informed consent.

CONSENT OF THE INCOMPETENT

Competent children can consent to treatment but cannot refuse treatment. The consent of one parent is sufficient if the 2 disagree. Parental choice takes precedence over the child’s choice. Courts can overrule parents. Life-saving treatment of minors is given even if parents refuse. Parental choice is final in therapeutic or non-therapeutic research on children. Mental patients cannot consent to treatment, research, or sterilization because of their intellectual incompetence. They are admitted, detained, and treated voluntarily or involuntarily for their own benefit, in emergencies, for purposes of assessment, if they are a danger to themselves, or on a court order. Suicidal patients tend to refuse treatment because they want to die. Nutrition, hydration, and treatment can be withdrawn in a persistent vegetative state since the chance of recovery is low. There is no moral difference between withholding and withdrawing futile treatment. Labor and delivery are emergencies that require immediate decisions but the woman may not be competent and proxies are used. Forced medical intervention and ceserian section may be ordered in the fetal interest. Birth plans can be treated as an advance directive.

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. Deception violates fidelity. If disclosure will cause harm it is not obligatory. Partial disclosure and white or technical lies are permissible under necessity. Disclosure to the family and other professionals is allowed if it is necessary for treatment purposes. Physicians must use their judgment in disclosure of bad news to the patient.

PRIVACY AND CONFIDENTIALITY

Privacy and confidentiality are often confused. Privacy is the right to make decisions about personal or private matters and blocking access to private information. 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. In routine hospital practice many persons have access to confidential information but all are enjoined to keep such information confidential. Confidentiality includes medical records of any form. The patient should not make unnecessary revelation of negative things about himself or herself. The physician can not disclose confidential information to a third party without the consent of the patient. Information can be released without the consent of the patient for purposes of medical care, for criminal investigations, and in the public interest. Release is not justified without patient consent for the following purposes: education, research, medical audit, employment or insurance.

FIDELITY

The principle of fidelity requires that physicians be faithful to their patients. It includes: acting in faith, fulfilling agreements, maintaining relations, and fiduciary responsibilities (trust and confidence). It is not based on a written contract. Abandoning the patient at any stage of treatment without alternative arrangements is a violation of fidelity. The fidelity obligation may conflict with the obligation to protect third parties by disclosing contagious disease or dangerous behavior of the patient. The physician may find himself in a situation of divided loyalty between the interests of the patient and the interests of the institution. The conflict may be between two patients of the physician such as when maternal and fetal interests conflict. Physicians involved in clinical trials have conflicting dual roles of physicians and investigators.

060215L - SELF-IMPROVEMENT AND TAKING CHARGE

Lecture by Professor Omar Hasan Kasule Sr.

1.0 SELF IMPROVEMENT

1.1 EFFORT TO IMPROVE

You can not improve yourself without effort. You must make the intention to be a better person and take action to achieve your goals. Life is not chance. Everything that occurs is pre-destined. You however do not know your predestination. You have to work hard, search for it, use your will power and choice that Allah gave you. Accept personal responsibility for mistakes. Do not blame others for your problems. Learn from your past experiences, positive and negative. Good manners or experiences should be reinforced while bad ones should be avoided. 

1.2 OBJECTIVES

(a) ULTIMATE OBJECTIVES

Keep in mind always the three ultimate objectives: (a) the pleasure of Allah, ridha al laah & marudhaat al llaah[i], (b) wisdom, hikmah, and (c) success, falaah. The real and ultimate success is that of the hereafter[ii].

(b) HAPPINESS

Happiness is not an objective in life. Pursuing happiness can be running after an illusion since happiness is not definable. The realistic objective is contentment and satisfaction with yourself and what you have. However contentment should not be understood in a negative sense of refusing to take active steps to improve some of the negative things in your character and behavior.

(c) NEEDS VS WANTS

Learn to distinguish between what you want and what you need. Wants are emotional; needs are rational. Always choose needs over wants. Be realistic. Do not live in a dream world. Dreaming is good in motivating you and developing your creative thinking. Dreaming has limits if it obscures correct perception of reality. Never entertain illusions about your strengths and weaknesses. Never deceive yourself. Never allow others to deceive you by praising you and giving you attributes you lack. Such persons are your true enemies. Confront your weaknesses and do not deny them. Do something about correcting them

1.3 INTER-DEPENDENCE

You can not succeed on your own; this is a world of interdependence. You must learn to net-work and collaborate with others in synergistic relations. Good manners and behavior are necessary for positive and meaningful interaction with people. You need to learn to respect and protect the rights of others so that your rights may also be respected. Every action, behavior, or habit has consequences. Always consider and think about the long-term consequences before you speak or act.

1.4 POSITIVE ATTITUDE

Develop a positive attitude. Be optimistic and develop positive behavior. The world is essentially good and the hereafter much better. There is more good than evil. You can always succeed in the long-run if you do not become pessimistic and give up. Look at problems of life in perspective. What may look big may not be so in the long run. You may hate today what turns out to be good tomorrow. See and emphasize the positive in  any problem.

1.5 FUTURISTIC OUTLOOK

You should consider yourself as living in the future. Life on earth is just a transition. Always prepare for the future (both what remains of your life on earth and life in the hereafter). A futuristic outlook will enable you to deal with setbacks of life. You should always know that the future could always be better.

 

2.0 TAKING CHARGE

2.1 ASSERTIVENESS

(a) Assertiveness: Assertiveness is a feeling of self-worth in dealing with others. It involves a lot of self-control. Non-assertive people may end up being influenced by a bad environment or they may make wrong choices that they regret later. Non-assertive persons can not interact well with others because they can not state their opinions or advance their interests or the interests of the group they belong to. A non-assertive attitude becomes in the long run a feeling of inferiority that could be exploited. Non-assertive persons may feel so bad about themselves that they eventually react in socially destructive ways. Non-assertive persons are easily influenced by bad company and end up committing evil. Assertiveness is not aggression but is closely related. Do not cross the line between the two. You can show anger without being bad. Learn to state your opinion without being hostile. Learn to defend your position without being defensive.

(b) Self-control: Being assertive is learning to take control. A person who has self-control can stand up to the temptations of shaitan. The following are needed for you to take control of your self: self- confidence, self-esteem, self-reliance, self-control, self-discipline, and self-development.

(c) Self-discipline: Self discipline is needed for success. Control your whims and emotions. Stickability is a good trait; do not accept defeat easily. Act according to long-term and not short-term interests. Do not act impulsively. Follow your head and not your emotions. Trust your instincts.

2.2 SELF CONFIDENCE and SELF ESTEEM

(a) Self-confidence: Self-confidence is to know yourself, your strengths and weaknesses, to be comfortable with what you are, and to be psychologically secure. Children are born with a lot of self-confidence. They lose it as they grow through various negative experiences. Others’ views and comparing one self with others are among the causes of loss of self-confidence. True confidence is expressed and shows quietly. Many inconfident people make noise to hide their inner weakness.

(b) Self-esteem: You can raise your self-esteem by being secure psychologically about yourself. You must accept and appreciate what you are. You have to love yourself and know that whatever Allah endowed you with is the best for you. Look around you and identify people you admire. Try to emulate the qualities you admire in them. Stay with good people who radiate self-esteem and confidence. Congratulate and encourage yourself on any progress you make in emulating good behavior. Learn to compliment and congratulate others who have traits and behaviors that you admire. This will keep you from negative attitudes and diseases like envy and will push you along on the road to developing your own self-esteem. Avoid people with bad character and behavior. Others who do not know will consider you to be one of them. It is easier for a big mountain to move than for bad character to change. Do not repeat a mistake. Remember that character is consistent. Bad behavior is rarely an accident. It can be forgiven but can not be erased

2.3 SELF-RELIANCE:

Self-help and self-improvement are very important for the individual. They are in essence taking charge of your life, relying on yourself in solving problems, and taking the initiative to improve. It is only emotionally mature individuals who can rely on themselves. Dependency is childhood. Self-help and self-reliance should however not be taken to the extreme. There are occasions when you need help and must have networks for providing this help. Refusing to ask for help when needed is a cause of stress and is not wise. Economic self-reliance is necessary in order not to be a burden on others and also to assert your self-esteem. However the need to keep your self-esteem should never make you refuse to seek help when you actually need it. A vital distinction must be made between being childish and child-like. Childishness is dependency and inability to achieve emotional maturity, self-confidence, and self-esteem. Child-like on the other hand is a very positive attribute. It emphasizes being explorative, taking initiative, being bold to experiment, being optimistic, and not feeling defeated or cornered. These behaviors are found in children and tend to annoy parents. They are very useful for the adult. The mistake is for children to grown up too soon or for adults to regress to childhood in the way they use these attributes.

2.4 PROJECTING A POSITIVE IMAGE

Projecting a positive image helps build credibility and leads to success. We are not talking about a phoney image that is discovered sooner or later with disastrous consequences. The image must be backed up by real achievements. It is better to under promise but over deliver. Perceptions are very strong determinants of behavior. You have to keep away from negative perceptions and cultivate positive ones. Two individuals looking at the same reality have different perceptions because of their prior life experiences. Always evaluate yourself. The perceived image may not be the intended image. The difference is crucial. Self- confidence and self-discipline are ingredients of a positive image. You have to start by discovering your strengths and enhancing them. You have to acknowledge your weaknesses and compensate for them. A positive image needs maintenance by regular self-evaluation and taking corrective action where needed. A positive image must be maintained in difficult times; this will require extra effort. Keeping company with people who have a positive self-image will help you develop your own image. Positive thinking is contagious; it spreads to those around. Your communication with others (letter, fax, telephone, and conversation ) is an exercise in image projection. Physical appearance (clothes, hair, cleanliness) also project image. Dress well but not for arrogance. Good manners, correct etiquette, and sensitivity enhance the image. Your voice, handshake, smiles, body language, and eye contact can make or unmake your image. Your posture and manner of walking can tell a lot about you. Solving your personal problems and keeping out of depression, anxiety or stress help maintain your positive self-image.

2.5 ENTREPRENEURIAL ATTITUDE

You need to develop an entrepreneurial attitude. This requires developing initiative, optimism, and self-confidence in order to bolster your creativity. Take calculated risks. Look for opportunities and exploit them. Perseverance and determination are necessary for continued success.

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[i] (Qur’an 2:207, 2:265, 3:162, 3:173, 4:114, 5:2, 5;3, 5:16, 9:21, 9:62, 9:72, 9:96, 9:100, 9;109, 19:55, 20:84, 20:109, 21:28, 24:55, 27:19, 39:7, 46:15, 47:28, 48:18, 48:29, 53:26, 57:20, 58:22, 59:8, 60:1)

[ii] (Qur’an 3;185, 4:13, 5:119, 6:16, 7:8, 9:20, 9:72, 9:89, 9:100, 9:111, 10:64, 23:111, 24:52, 33:71, 37:60-61, 39:61, 40:9, 44:51-57, 45:30, 48:5, 59:20, 61:12, 64:9, 78:31-35, 85:11)

060505P - MUSLIM PHYSICIAN EDUCATION: INDONESIAN EXPERIENCE and NEW CHALLENGES[1]

Paper presented at a 1-day workshop on the Muslim Physician Education held at the Yarsi University Faculty of Medicine on 5^th May 2006 by Dr Omar Hasan Kasule MB ChB (MUK), MPH (Harvard) and DrPH (Harvard) Professor of Epidemiology and Islamic Medicine, Universiti Brunei Darussalam.

ABSTRACT

Yarsi Faculty of Medicine has over the past 39 years succeeded in inculcating Islamic values in its graduates using a consistent and broad Islamic education program that is parallel to the medical curriculum. This paper describes the program suggests that the Islamic education program should be integrated into the medical program to be able to resolve the nagging problem of dichotomy in knowledge that is a major crisis in modern Muslim education

1.0  HISTORICAL BACKGROUND

My personal contact with the Yarsi education programs dates to 1980 when I met Prof Jurnalis at the First International Conference on Islamic Medicine organized by the Kuwaiti Public Health Ministry. I remember him describing in detail the Islamic input program for medical students that was used from the inception of the Yarsi Medical College in 1967 and continued after 1989 when the college became the Yarsi University Faculty of Medicine. The program is essentially 10 credit hours of Islamic instructions distributed in all the 5 years of medical training. In addition to classroom teaching students are expected to write a research paper and are also taught practical aspects of Fiqh as they relate to patients. The program has been maintained for the past 39 years. As we prepare to enter the fourth decade of Yarsi’s valuable contribution to Islam, we have a firm background to consider further developments in the program.

2.0 THE YARSI ISLAMIC INPUT PROGRAM[2]

The Yarsi University Faculty of Medicine was the first Muslim medical college in Indonesia established in April 1967. The Christian University of Indonesia School of Medicine had been established earlier in 1960. There are 56 medical schools in Indonesia, 27 being state-owned and 29 being private. There are 14 private Muslim medical schools.

The mission of the Yarsi Faculty of Medicine according to Prof Jurnalis is to ‘… produce a Muslim physician who is not only a qualified physician but also one who puts into practice his/her profession in line with Islam as part of his/her total obedience to Allah the almighty’. Over the past 39 years this mission has been pursued very successfully and with good results. This is in accord with the constitution of the Yarsi University that stipulates that the aqidah of the organization is Islam.

Regarding the graduates of the Yarsi Faculty of Medicine, Prof Jurnalis is of the view that Muslim physicians are those qualified physicians who practice their professional knowledge and skills in line with Islam and at the same time observe all their religious duties regardless of time and space. They are fully aware of the dual status: vicegerents of and slaves of Allah. They continuously obey Allah and His messengers regardless of time and space. Their goal is to pursue not only happiness in the world but also happiness in the hereafter. If choices are to be made, they prefer suffering and sacrifice of wealth as well as life in this world to guarantee happiness in the hereafter. To achieve these goals they will always stick to the basic guidance of the Qur’an and hadith and hold them as a paradigm of all their deeds including professional activities. Total obedience to Allah is the keyword of success in their lives. For Muslim physicians science and technology are merely a means to get them nearer God the almighty (takarrub ila al llaah). As a consequence they will never adopt anything that contradicts Qur’an and hadith, the basic guiding paradigms, except in cases of necessity.

According to regulations of the Indonesian Ministry of Education, the curriculum of a private university has to be distributed as 80% determined by the government and 20% determined by the private university. This enabled Yarsi to develop its Islamic input curriculum. Islamic religious classes are allocated 10 credits which is 5 times what is allocated in government universities. The allocation was previously 12 credit hours but had to be reduced to 10 due to introduction of classes on humanities, psychology, research methodology, medical ethics, and medical law. The total credit hours needed for graduation from medical school is 200 offered in 12 semesters. Thus Islamic religious classes constitute 5% of the total curriculum.

The Islamic classes are offered throughout the course with 2 credits in semester 1 and thereafter 1 credit for each semester from semester 2 to semester 7. The remaining 2 credits are for preparing a term paper based on researching an allocated health issue. In addition to classroom instruction, students trained in reading and writing Qur’an (if they did not do this earlier in life), memorization of some chapters of the Qur’an, recitation of the Qur’an according to the 7 styles of recitation, delivering Friday sermons (khutbah), and how to be Islamic propagators (muballigh). Practical instruction using simulation is given on performing acts of worship (salat, saum, & zakat) and funeral procedures (janazat).

A special class is offered on Islamic Medicine. Students can earn 1 credit hour for attending 16 sessions of 50 minutes each plus 2 sessions for mid-semester and end-semester examinations. The class has three topics: The concept of medicine as viewed by western philosophy and by Islam, the contribution of Islamic heritage in the development of science and technology, and materia medica as mentioned in the Qur’an, hadith, and classical as well as contemporary Islamic literature. The topics covered under the concept of medicine are: concept of knowledge, acquired and revealed knowledge, Islamization of knowledge, approaches to production of knowledge (eg rationalism, empiricism, deduction, & induction), concept of health, characteristics of Islamic medicine as contrasted to western medicine, health systems, Islamic vs Muslim medicine, alternative medicine, and fiqh rulings on various medical issues. Contributions of Muslims to medicine are illustrated by study of the work of the following physicians: al Razi, al Zahrawi, Ibn al Nafis, Ibn Hytham, Ibn Sina etc). The section on materia medica includes discussion of honey, siwaak, etc.

2.0  DIFERENT WORLD VIEWS

The system of medical education reflects the world-view of the educators. There are basically three world-views that we can discuss: the Christian, the secular, and the Islamic. Identification and discussion of different world-views is for purposes of improving mutual understanding and not debate or controversy.

The Christian world-view is promoted in Christian medical schools in Indonesia. According to Professor Jurnalis² ‘… all the Catholic and Christian schools right from primary up to tertiary education will imbibe the students with Christian norms and values. Christianity classes will be strongly recommended to all students regardless they are Christian or Muslim’.

The secular world-view is misunderstood because many people mistakenly take secularism to be absence of religion or treating religion as a private matter to be separated from public life. Modern secularism as imported from Europe is actually an extension of the ancient Greco-Roman world view. This world-view had suffered in oblivion in the period when the Christian Church was in the ascendant (4^th to 12^th century). With the renaissance the Church started losing its grip on European public life and Europeans rediscovered their Greek and Roman roots. Over the past 600-700 years the influence of the Church has been waning while the influence of ancient Rome and Greece was on the ascendant. Thus the secular out-look in its various manifestations (humanism, modernism, post-modernism etc) is a return to the European Greco-Roman heritage. When European powers colonized virtually the whole world by the 18-19^th centuries of the Christian era they spread the Greco-Roman world-view in many parts of the world. For purposes of communication and dialogue with people of religion, it would be appropriate to include secularism among belief systems that deserve to be tolerated like any other religion or belief system. It would be very confusing to consider secularism as absence of religion.

The Islamic world-view, al tasawwur al islami, is an integrative paradigm that underlies Islamic culture and all endeavors of an Islamic society. It is based on the creed of tauhid, aqidat al tauhid, which in essence if affirmation of One All-powerful God, tauhid al al dhaat al ilaahiyyat, the  Creator for the universe, tauhid al rubuubiyyat, and who is alone is to be worshipped, tauhid al uluhiyyat. Under the paradigm of tauhid the teaching and practice of medicine should be integrated into the norms, values, and laws of Islam.

3.0  THE PROBLEM OF DUALITY

There is a crisis of duality or dichotomy manifesting as teaching Islamic sciences separately from medical disciplines by different teachers and in different institutions. The duality may occur even within the same institution when Islamic and medical disciplines are taught separately under the same roof. Students may be confused when confronted by contradictions that they cannot resolve between assertions of medical disciplines based on the secular world-view and the assertions of ‘aqidat al tauhid reflecting the Islamic world-view. The crisis of duality is seen most acutely when matters of ethical nature are discussed. Both students and teachers unable to reconcile the contradictions just decide to have split intellectual personalities. They alternate between operating in the secular world-view and operating in the Islamic world-view which creates even more confusion.

4.0 TOWARDS AN INTEGRATED CURRUCULUM

The present challenge to Yarsi and similar Muslim institutions is to think seriously about integrating Islamic values into the medical curricular. This integration will resolve the crisis of duality by insisting that Islamic concepts should be taught by the same people who teach medical disciplines. This may require that medical lecturers go through a Diploma in Islamic Studies (DIS) to acquire the Islamic world-view. After this we must make sure that we integrate Islamic values and concepts in the teaching and examination of basic and clinical medical sciences. The expectation is that medical graduates will be able to integrate Islamic moral and legal values in their practice of medicine because they went through an integrated education system.

An integrated medical curriculum follows the Islamic paradigm of reading 2 books, the book of revelation, kitaab al wahy, and the book of empirical science, kitaab al kawn. Both books contain signs of Allah, ayaat al llaah, and must be read together. It is a mistake to read one of the books and neglect the other. The solution to the crisis of duality in the ummah starts from joint reading of the 2 books, al jam ‘u baina al qira atain. Thus medical scientists who are involved in IIMC read the signs in both books.

The vision of an integrated curriculum has two separate but closely related components: Islamization and legal medicine. Islamisation deals with putting medicine in an Islamic context in terms of epistemology, values, and attitudes. Legal medicine deals with issues of application of the Law (fiqh) from a medical perspective.

The integrated curriculum has 5 main objectives: (a) introduction of Islamic paradigms and concepts in general as they relate to medicine, mafahiim Islamiyat fi al Tibb. (b) strengthening faith, iman, through study of Allah’s sign in the human body (c) appreciating and understanding the juridical, fiqh, aspects of health and disease, al fiqh al tibbi. (d) understanding the social issues in medical practice and research and (e) Professional etiquette, adab al tabiib, from the Islamic perspective.

The integrated curriculum will prepare the future physician prepare for the heavy trust, the amanat of being professionally competent. He must be highly motivated. He must have personal, professional, intellectual, and spiritual development programs. He must know the proper etiquette of dealing with patients and colleagues. He also must know and avoid professional malpractice. He needs to be equipped with leadership and managerial skills to be able to function properly as a head of a medical team.

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[1] This paper write-up has incorporated comments made by the author during the discussion sessions following his paper presentation

[2]All this section is reproduced from an unpublished paper ‘Muslim Physician Education: The Indonesian Experience’ by Professor Dr Jurnalis Uddin Chairman, Board of Executives, Yarsi Foundation, Jakarta April 2006.

060615L - LEADERSHIP: BASIC CHARACTERISTICS, ATTRIBUTES, AND FUNCTIONS

Lecture to 5^th year medical students at the Kulliyah of Medicine International Islamic University, Kuantan, Malaysia on 15^th June 2006 by Professor Omar Hasan Kasule MB ChB(MUK), MPH (Harvard), DrPH (Harvard) Professor of Epidemiology and Islamic Medicine, Institute of Medicine Universiti Brunei Darussalam

1.0 BASIC CHARACTERISTICS

1.1 LEADERSHIP

Leadership is influencing people to do certain things or to move in a certain direction. Leadership can be learned. Good leaders persuade and do not rely on command, fear, or authority. They serve and do not dominate. They use leadership power to improve and make a change. They pull and do not push. They empower followers by coaching and delegation. Good leaders rely on personal power (character, expertise, charisma, and personal relations) more than positional power (formal authority, decisions, rewards, punishments, information, and organizational resources). Leadership credibility is based on competence, character, self-confidence, activity and drive, boldness and assertiveness. Leadership is a necessity and its absence means chaos. Good leadership leads to success; bad leadership leads to frustration and failure. One of the harbingers of doom is to place leadership authority in the wrong hands.

1.2 LEADERS

Leadership is exercised by almost everybody. Its effectiveness is increased by formal training or job experience. Its success depends on follower consent. Leaders face problems of loneliness, taking responsibility for failures, follower problems (disloyalty, poor values, dissent), external threats, and lack of privacy. A leader as a human has strengths and weaknesses. Leaders can be autocratic, democratic, and laissez-faire. They can be transactional, transformational, or charismatic. They can be task oriented or people-oriented. The appropriate style of leadership is determined by the situation on the ground. Some situations require combinations of leadership styles. Management and leadership skills and functions are different but are found in an individual in varying proportions. Leadership is about effectiveness, intuition, long-term vision, change, challenging the status quo, innovation, development, originality, and motivation of others. Management is about rational problem-solving, efficiency, process and mechanics, stability, harmony, status quo, short-term view, following and not innovating.

1.3 FOLLOWERS

Followers are described as lazy or hardworking, taking or shunning responsibility, 'yes people' following whatever is moving, survivors avoiding trouble, alienated and do not caring, and obedient or rebellious. Followers differ in intelligence, education, experience, honesty, respect for leaders, and gratitude. Followers are part of leadership situation, they play an important function in a leadership situation, and are not passive spectators. Books of history ignore follower. Followers close to the leader can guide or misguide him. The duties of the followers to the leader are obedience, respect, advice and correction, feedback, and loyalty. Leader must rely on the followers and make them know they are trusted and are valued. A good leader discourages false praise by followers and development of a personality cult.

1.4 FUNCTIONS & ACTIVITIES OF LEADERS

A leader may play one of the following roles/functions: clarification of vision, goals, and objectives; making decisions and solving problems; strategic and tactical planning; training; coordinating and integration; representation the organization; managing and resolving conflicts; motivation of followers; assigning tasks; maintaining positive and smooth working relationships; participation and not being aloof; evaluation of self and of followers; forming groups, coaching them and delegating responsibility to them; and communication (the most important function of leadership).

1.5 FAILURE OF LEADERSHIP

A leader fails due to several often inter-related causes: refusal to admit mistakes; feeling indispensable; dictatorship; fear for position and not developing replacements; disloyalty to superiors, peers, followers and the organization; lack of creativity; lack of common sense; lack of human skills; failure to produce results; following the crowd and not leading; condoning or tolerating incompetence; failure to recognize and reward good work, and hatred by the followers. A leader is hated for impersonal behavior, not listening to followers, self importance, wrong decisions, claiming credit for followers' work, blaming followers for his mistakes, secretiveness, withholding information, not protecting followers from external attacks and criticizing them in public, not consulting followers, and over-working followers, being arrogant and feeling indispensable, putting people down, mistrust and disloyalty, inaccessibility, poor human relations, and following the crowd. A leader hated by followers should resign in the interests of the organization.

2.0 LEADERS: ATTRIBUTES and SKILLS

2.1 ATTRIBUTES OF LEADERS

Most leadership personal attributes and skills (conceptual, practical, and human) can be learned. Personal attributes are character and personality. Conceptual skills are intellectual functions (analytic, rational, and intuitive) needed for planning, coordination and integration of activities. Practical skills are needed for technical performance. Human skills are needed to understand and motivate followers. Allah gives authority to whomever He wants among many qualified for leadership. Since not everybody can become a leader, everybody must be prepared to be a good follower. The best leaders have no ambition to lead, they lead when called upon but will equally be happy as followers. Effective leaders monitor and learn from the environment, benefit from opportunities, and avoid dangers. They time actions and interventions for maximum impact and advantage. They have positive attitudes (derived from right ideas) and moral values (derived from tauhid, khilafat, and ‘adl). Optimism and good behavior reflect a positive attitude. Pessimism, racism, and prejudice reflect negative attitudes. Leaders differ from non-leaders in drive, motivation, honesty, integrity, self-confidence, emotional stability, and intelligence. Drive includes desire for achievement, high ambition, high energy levels, tenacity and initiative. Successful leaders are motivation to lead, to take charge, to make a change, to improve, to influence, and to exercise power for achieving goals. A leader must have a strong personality, mental and physical stamina, and aptitude to take responsibility and to be accountable. Strength of personality is not violence, roughness or stubbornness. It is strength of character, sticking to moral values and attitudes, avoiding the immoral even if expedient and attractive. A leader must be brave so that the followers are firm and reassured in a crisis or danger. He must be objective and not confuse personal and organizational interests. He focuses on the organization, credits his work to the organization, does not overestimate his importance as an individual, and discourages development of a personality cult. He must have a healthy mixture of confidence (for the organization) and humility (for himself). He must have a dignified physical appearance without extravagance. He must accept and learn from previous mistakes, live a simple life away from extravagance, and not distinguish himself from the followers.  He must be hinest even in small matters, have financial integrity and transparency, and avoid any appearance of impropriety.

 

2.2 CONCEPTUAL SKILLS OF LEADERS

The conceptual skills are vision, setting goals, prudence, knowledge, and commitment. Leaders see far, have a broad view, are ummatic and not parochial. They see local issues from a holistic ummatic context but they use local solutions for local problems. They accept diversity, get consensus on strategic issues, set goals, avoid speculation, and balance risk with caution. They acquire basic knowledge but rely on others for specialized knowledge. They are committed to the organization (vision and values) and the followers. They fulfil promises and are committed to carrying out decisions. They are flexible in changing strategy and tactics when necessary but they remain committed to the permanent values of the organisation. Part of the leader’s commitment is to lead for no personal gain or ambition seeking leadership.

 

2.3 PRACTICAL SKILLS of LEADERS

The main practical skills of leaders are communication, decision making, planning and execution, team leadership, motivation, conflict resolution, and maintaining relations. Communication conveys vision and plans to the followers. Leadership fails if communication fails. Failure to make correct decisions on time or solving problems timely leads to leadership failure. Managerial functions are planning, setting goals & objectives, and evaluation. Leaders form and lead work groups. They coordinate their work and allocate tasks.

 

2.4 HUMAN SKILLS of LEADERS

Good leaders show concern, respect, and consideration for followers. They understand those below them as unique individuals to de dealt with in an individualized way. They have a firm belief in people. They have compassion and empathy. They have high consideration for others. They have no pride and are like their followers not seeking to be different from or superior to them. They are lenient and forgiving. They treat their followers well. They protect the followers from both physical and emotional hurt. They represent followers and their interests in front of others.

3.0 DISEASES OF LEADERS AND FOLLOWERS

3.1 BACKGROUND OF LEADERSHIP DISEASES

Leaders and followers have diseases. The diseases could co-exist alongside good attributes. Some bad leaders are actually psychologically sick: sadists, megalomaniacs, jealous, immature, or psychopathic personalities. Some have deviant values.

3.2 DISEASES OF LEADERS IN THE QUR’AN and SUNNAT

The Qur’an has told stories of bad leaders from which we learn a lot about leadership diseases. Examples of bad leaders are Fir’aun, Nimrod, Dhu al Nuwaas, and others.

3.3 DISEASES THAT MANIFEST IN THE PERSON

Disease related to the personality of the leader are pride and vanity, petty-mindedness, uncompensated weaknesses, ignorance, and lack of creativity.

3.4 DISEASES THAT MANIFEST IN DEALING WITH FOLLOWERS

Diseases that manifest in dealing with followers include seeking excessive veneration, oppression and injustice, manipulation, dishonesty, seeking false reputation, and abandoning followers

3.5 DISEASES OF FOLLOWERS:

Diseases of followers include hypocrisy, insincerity, bad advice for leaders, disloyalty, and flattery.

060625P - MEDICINE AS A PROFESSION

Presented at a MINI MEDICAL SCHOOL for High School students held on Sunday 25^th June 2006 at Dewan Cancelor Universiti Brunei Darussalam by Dr Omar Hasan Kasule, Sr. MB ChB (MUK), MPH, DrPH (Harvard) Professor of Epidemiology and Islamic Medicine, Institute of Medicine, Brunei Darussalam. WEB http://omarkasule.tripod.com

1.0 HISTORICAL BACKGROUND

1.1 Pre-Islamic period

Medicine was practiced from the start of human history. Ancient Egyptians learned a lot about the internal structure of the body and developed medical and surgical techniques because they preserved bodies of their dead. Babylonians who lived in what is modern Iraq knew how treatment of eye cataracts[1] and epistaxis[2]. Ancient Chinese developed acupuncture[3] and were experts in various branches of medicine[4]. Ancient Indian surgeons were experts in several surgical operations[5], anesthetics, and poisons. Indian physicians who lived in Baghdad played a role in transferring Indian medical knowledge to Muslims[6]. Greeks and Romans also made many contributions to medicine[7]

1.2 Islamic period

The prophet’s teachings gave a big impetus to medicine. He taught disease prevention, personal and environmental hygiene. He practiced medicine and urged his companions to seek cures for their diseases. Prophetic medicine, tibb nabawi, refers to words and actions of the Prophet with a bearing on disease, treatment of disease, and care of patients. In the Omayyad and Abassid periods many medical books were translated into Arabic. Muslim physicians carried out research on new treatments and added to medical knowledge. Medical schools[8] and hospitals[9] were established. Many of the textbooks used in ancient Muslim medical schools were translated into Latin and were used in European universities until recently. Muslims developed nursing[10]. Muslims made many discoveries in anatomy[11], physiology[12], infectious diseases[13], public health[14], blood circulation[15], allergy, dietetics, pharmaceuticals[16], ophthalmology[17], and general surgery, wound treatment, urology[18], gastro-enterology[19], otorhinolaryngology[20], plastic surgery[21], dentistry[22], and neurosurgery[23]. Out of concern for proper medical education, Khalifah al Muqtadiri ordered in 319 H that nobody would be allowed to practice medicine unless examined by Sinan bin Thaabit bin Qurra.

1.3 Transfer of medical knowledge to Europe

While Muslim medicine was flourishing in West Asia, Europe was in the ignorance and decline of its middle ages. Modern European medicine owes its origins to the knowledge transferred from the Muslim world to Europe. Constatine Africanus (d. 1087 M) translated the most important medical books from Arabic into Latin. This gave new life to the Salerno (Italy) school of medicine. After him more books were translated and were used in European medical schools. Europeans came to study at Muslim institutions in Andalusia and took back the knowledge to Europe.

2.0 MOTIVATION FROM ANCIENT PHYSICIANS

2.1 All-rounded medical professionals

Ancient Muslim physicians were encyclopedic in knowledge, all-rounded, motivated, hardworking, and productive. They excelled in medicine as committed Muslims because Islam is compatible with science. Their achievements are a motivator for today’s medical students and physicians.

2.2 West Asia

Abubakr Al Razi (251-313H),  wrote more than 100 books (the most famous being al Hawi al Kabir), investigated diseases (gynecological, obstetrical, hereditary, eye, small pox, and measles), discovered surgical sutures, used anesthetics, used ammonia to control diarrhea, considered psychological factors in disease treatment, and was director of hospitals in Baghdad and Rayy. Ibn Sina (370-428H) wrote many books (the most famous being al Qanuun fi al Tibb), recognized that TB was contagious, accurately described the symptoms of diabetes mellitus, discovered ancylostomiasis, and contributed to science, mathematics, chemistry, and philosophy. Ibn Al Nafees (d. 686H) described blood circulation before William Harvey and authored Sharh tashriih al qanuun in which he explained pulmonary circulation.

2.3 Andalusia

Al Zahrawi (d. 404H) had interest in surgery, pharmacology, and anatomy. He designed over 200 surgical instruments. His book Kitaab al tasriif, became a standard textbook of surgery. He was an expert in cancer surgery and tooth extraction. Ibn Zuhr (d. 487H), lived in Andalusia and Morocco and authored the book al Taysir translated into Latin and used in Europe. Ibn Rushd (d. 595H) was a philosopher and a medical practitioner. His book al Kulliyat translated in Europe. He made the observation that smallpox infected only once.

3.0 WHAT DO DOCTORS DO

3.1 Clinical Medicine

People who study medicine carry out a wide variety of activities in the following main areas: hospital care, public health, and medical research. Physicians who work in hospitals provide clinical care which includes diagnosis (finding out the type and cause of disease) and treatment (using drugs, surgery, radiotherapy, immunotherapy, and others). Investigation can be by taking a sample of blood, urine, or stool and examining in the laboratory. It may also be by using x-rays, CT scan or MRI to visualize internal body structures. Sometimes instruments have to be inserted inside the body for better visualization. For example an esophagoscope can be used to look inside the esophagus and a gastroscope can be used to look inside the stomach.

Treatment is determined by the diagnosis. Physicians can treat using medicine that are either swallowed through the mouth, are injected in the muscles or blood vessels, or are given through the anus. Treatment also can be by surgery in which the body is opened using special instruments in order to remove diseased parts or correct structures. Sometimes powerful energy sources like irradiation or laser are used in surgery to cut away or destroy structures that are diseased.

3.2 Public Health Medicine

Public health physicians also investigate and prevent diseases at the community level. They undertake immunization, control the environment, and other activities of disease prevention and health promotion.

3.3 Medical Research

Some physicians choose to work in research to advance medical knowledge. They may work in laboratories or may work in hospitals. Thos in a hospital setting usually test new drugs to see whether they are effective against disease.

3.4 Other forms of medical practice

There are other specialized functions that physicians undertake such as forensic physicians who examine patients or carry out post-mortem examinations to look for evidence required in a court of law. Sports physicians treat injuries of sportsmen and ensure that players are in good health.

4.0 HOW DO YOU BECOME A DOCTOR

4.1 Basic education

Medicine is both a science (academic study) and an art (apprenticeship learning on the job). Language skills (literacy) and mathematical skills (numeracy) learned in primary schools are the foundation on which future learning is laid. Sciences are very important in secondary school. In some countries students leaving high school enter directly into a medical school and graduate as doctors 5 years later. In other countries they need to obtain a bachelor of science degree before they enter a medical school as postgraduate students.

4.2 University education

The medical curriculum is divided into a pre-clinical phase (study of basic medical sciences) and a clinical phase (study by examining actual patients). On graduation young doctors work for 1 year under supervision before being registered as independent general practitioners.

4.3 Postgraduate training

Some may choose to become specialists in which case they enter a hospital based training program that lasts 3-4 years. When they acquire the necessary experience and pass the examinations they can then become specialists who are experts in a given branch of medicine.

5.0 MEDICINE AS COMMUNITY SERVICE and LEADERSHIP

Medicine is a service, khidmat, for the community. It is a form of mutual social support, takaful. It is social responsibility, amanat. 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.

6.0 COMPENSATION

The physician working in a materialistic society is torn between contradictory forces of greed and service. Service should have the higher priority but the material rights and privileges of the physician should not be forgotten because he also wants to live a happy life. The prophet talked a lot about payment of the physician. The physician fee should be fixed and known in advance. The prophet paid the cupper who operated on him[24].

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[1] Scar on the surface of the eye preventing proper sight

[2] Bleeding from the nose

[3] A form of medical treatment using needles applied to various parts of the body

[4] Hua Chu was a famous Chinese surgeon who lived in the 3^rd century M. He wrote about physiology (how the body functions), anatomy (structure of the body), pathology (science of diseases), and anesthetics (putting patients to sleep so that surgery can be carried out without pain). Chinese medicine reached Muslims through contacts in Central Asia. Yuan Chwang (630-645 N) and I Tsung (675-685 N) were Chinese physicians with contacts with Muslims in Central Asia.

[5] such as tonsillectomy (removing the tonsils that are swellings at the entrance to the throat), amputation (cutting off diseased hands and legs), tumor excision (removing swellings), hernia repair, repair of harelips, removal of bladder stones, couching cataracts, nose repair, and ceserian section (surgical delivery of women who fail to deliver naturally).

[6] Indian physicians such as such as Kankah, Urnda, Siddhayogar, and Zantah worked in Baghdad and were welcomed and respected by the Khalifah.

[7] Hippocrates (460- 377 BC) was a Greek physician who is called the father of European medicine and was the first to introduce scientific medicine. Romans leaned medicine from the Greeks and their most famous physician called Claudius Galen (130-201 BC) was a skilled Roman military surgeon whose medical writings were compiled and were translated into Arabic.

[8] The most famous medical college was Bayt al hikmat in Baghdad but others were attached to hospitals throughout the Muslim world.

[9] The most famous hospitals (called bimaristan) were built in Baghdad, Cairo, Andalusia, and Damascus.

[10] and Rufaidah bint Sa'ad al Aslami who lived at the time of the prophet is generally recognized as the first Muslim nurse.

[11] Science of the structure of the body

[12] Science of the functioning of the body

[13] Diseases that can be transmitted from person to person

[14] Science of prevention and control of disease in a community

[15] Movement of blood in the heart and blood vessels

[16] This term refers to drugs or chemical substances used in disease treatment

[17] Branch of surgery dealing with eye diseases

[18] Branch of surgery dealing with diseases of the urinary tract which consists of the kidney, ureters, bladder, and urethra including the prostate in males

[19] Branch of surgery concerned with diseases of the stomach and the intestines

[20] Branch of surgery concerned with disease of the ears, nose, and throat

[21] Branch of surgery concerned with reconstruction of parts of the body destroyed or distorted by disease or injury

[22] Treatment of teeth

[23] Branch of surgery dealing with diseases of the brain and nerves

[24] (Bukhari K34 B39)