Paper presented at the Islamic Medical Education Workshop held in conjunction with the 3rd Federation of Islamic Medical Associations (FIMA) Scientific Convention held in Jogjakarta Indonesia on 21st July 2006 by Dr Omar Hasan Kasule MB ChB (MUK), MPH (Harvard), DrPH (Harvard) Professor of Epidemiology and Islamic Medicine, Institute of Medicine Universiti Brunei Darussalam
ABSTRACT
Modern secular-oriented medicine is fragmented by organ as well as disease process and is not holistic. It lacks a sense of balance, mizaan. It is atomistic and not synthetic because it does not have an underlying integrative paradigm. It is disease and not health-oriented. It has a uniformly negative view of illness and does not acknowledge the positive aspects. It ascribes cure of disease to human effort and does not recognize divine intervention. It focuses on quantity of life and not on quality. Islamic medical education can overcome the limitations mentioned above. Islam can provide an integrative tauhidi paradigm to replace the non-tauhid world-view in medicine. The Qur’anic concepts of wasatiyyat, mizaan, i’itidaal, and tadafu’u provide a conceptual framework for balanced medical teaching and medical practice. The aim of Islamic medical education is producing physicians whose practice fulfills the 5 purposes of the Law within a holistic tauhidi context. Further reform of medical education will involve using a wide range of admission criteria and not relying on academic grades, reforming the curriculum to have more apprenticeship, and research-based education and training.
1.0 A MUSLIM CRITIQUE OF MODERN SECULARIZED MEDICINE
1.1 Fragmentation of Modern Medicine
European medicine is characterized by narrow specialization and fragmentation. Physicians know more and more about less and less. The trend toward specialization in medical practice has strongly influenced medical educators to accommodate each specialty by diminishing the practical content of the crowded undergraduate program or transferring some modules to post-graduate or vocational training. A new graduate from medical school is therefore unable to treat a patient on his own until he becomes a specialist. Specialty practice however has the great disadvantage of fragmenting patient care among several specialists such that there is no one doctor to care for the whole patient. The fragmentation of medicine is reflected in the balkanization of administration (by department), stages of education (pre-medical, pre-clinical, and clinical) and by discipline or specialty. In many cases each department teaches independently of others. Specialist physicians find it difficult to teach students who are just being introduced to medicine.
The following attempts have been tried to overcome the problem of fragmentation with varying degrees of success: interdepartmental or inter-disciplinary programs, integration of clinical and basic sciences, generalist and not specialist medical practice, vertical integration (linking early with later years in the same discipline), horizontal integration (linkage between different disciplines), teaching by organ systems, and using the problem-centered approach.
The concept of integration has been well accepted and propagated but not understood well when it came to practical application. Attempts at integration are a response to a felt problem and are certainly a step in the right direction however they have not solved all the problems; they even succeeded in creating a few new ones. Uncoordinated integration has succeeded in producing a hypertrophic curriculum. There is pressure from each discipline to ‘integrate’ its material into the curriculum. New disciplines such as genetics, statistics, epidemiology, demography, anthropology, and sociology are at the door claiming their share of the undergraduate curriculum. New disciplines have been created to ‘integrate’ or bridge the gap between pre-clinical and clinical disciplines eg clinical biochemistry, clinical pathology, clinical epidemiology. Interdisciplinary teams have been used as a tool of ‘integration’ in community medicine.
The hypertrophic curriculum has been defended in a humorous way as exposure of undergraduate students to all medical disciplines so that they may make informed choices about postgraduate training. The end-result may be an ‘accomplished’ physician who is familiar with everything but knows nothing. The process of continuous additions to and pruning from the curriculum is going on and has been dramatically described as integration, re-integration, and disintegration.
Fragmentation is a reflection of an underlying European secular world-view and did not come about in medical education by accident. This world-view started with the renaissance when religion was separated from public life and science. This set in motion centripetal forces that continually separate, fragment and sub-divide. The body was separated from the soul. The mind was separated from the body. Science was separated from art in medical practice. Each disease or organ was isolated and was dealt with in isolation.
It must however be recognized that specialization has been responsible for much of the progress in scientific medicine because of the concentration of the researcher’s energy on a narrow focused issue. It is not surprising that in a context of increasing fragmentation, the concepts of ‘total health’, ‘total disease’ are not easily accepted. It is not the ‘total human’ who gets sick but his organs or tissues. It is however very surprising that Claude Bernard’s concept of a harmonious ‘milieu interieur’ and the appreciation of the biochemical unity of all life did not motivate practice of ‘total medicine’.
Many physicians in the west have recognized that fragmentation is a major problem and have set about attempting to achieve integration in medical treatment and medical education. Some of these attempts were described above. Their limited success is due to lack of a guiding vision.
Integration is not just putting two or more disciplines together. It is a fundamental philosophical attitude based on a vision and a guiding paradigm. Only Islam can provide this paradigm. Criticism of the fragmented medical curriculum is actually criticism of the underlying European non-tauhid world-view. The fundamental reason for failure of integration efforts is that the European world-view is atomistic, it is good at analysis and not synthesis. It is incapable of synthesis because it lacks an integrating paradigm like tauhid.
1.2 Lack of Balance in Modern Medicine
Lack of equilibrium is a secondary manifestation of lack of integration. A lot of human illness is due to lack of balance and equilibrium; for example excessive intake of some foods leads to disease just as inadequate intake leads to ill-health. The Qur’an calls for observing the equilibrium (miizaan, wastiyyat). Violating the rule of the golden middle is associated with many problems and is variously condemned by the Qur’an as taraf or israaf.
Ancient Muslim, Indian, Chinese, Greek medical systems understood the concept of equilibrium. Modern European medicine lacks the concept of equilibrium or balance. It is replete with examples of overdoing a good thing beyond the equilibrium point and creating even bigger problems. Some therapies are worse than the disease they are supposed to cure. The quality of life of terminal cancer patients is made worse by chemotherapy and radiotherapy than the original disease perhaps they could have been left to die in dignity. Pesticides were used to eradicate malaria but they led to human disease. The best treatments of yesterday are known causes of malignancies today. Some physicians trained in the European tradition recognize the problems of balance and integration but they cannot propose a comprehensive solution because of lack of an underlying paradigm.
1.3 Disease Orientation vs. Health Orientation
The disease model predominates in European medicine. The disease model involving a biological or physical insult to the tissues is the main causal mechanism recognized and other contributors to the final causal pathway are not emphasized. The bias to the disease model explains European medicine being more curative than preventive. Since health is the original state and illness is the exception, medicine must be health and not disease oriented. The main responsibility of the physician is to maintain health; cure of disease should be the exception rather than the rule. The ancient Chinese were nearer to our view of medicine and the role of the physician. They paid their physician as long as they were in good health. Payments would be suspended on falling sick. They would resume when the illness was cured.
1.4 A Uniformly Negative View of Illness
European medicine has a negative view of disease and does not seem to acknowledge some of its positive aspects. Illness to a Muslim has its positive aspects and can be a blessing and a reason for expiation of sins. The trial of illness is a source of much good for a believer. An incident case of illness should not be looked at in isolation. When viewed in a larger context, illness or disease need not always be seen as bad. The Qur’an teaches that a human may like something that is bad for him or may hate something that is good for him. Falling ill, may save a person from going where he would be hurt, or where he could commit a sin. Patho-physiologically the symptoms of ill health are useful even if people complain about them. Pain directs us to tissue injury so that corrective measures may be taken before the injury becomes more extensive. Exhaustion and collapsing may be the body’s way of forcing us to take a rest when we are over-stressed or overworked without adequate rest. Much of what manifests as disease are the body’s attempts to return to the natural or normal state.
1.5 Arrogance about Cure of Disease
European medicine being secular does not acknowledge sources of cure for disease outside the realm of the empirical. Islam asserts that ultimate cure of illness is from Allah. The attending physician must realize that his efforts will succeed only if divine will intervenes and should therefore not be to arrogant. He should be aware that his efforts may fail or succeed. Physician arrogance and overuse of biomedical and technological interventions has sometimes led to the excesses of modern medicine in the form of side-effects (short and long-term) or iatrogenic diseases that are on the increase today.
1.6 Focus on Quantity and Not Quality of Life
From an Islamic point of view, the aim of medicine is to maintain or improve the quality of remaining life. Medicine does not have as an aim the prevention of death or prolongation of life; the time of death, ajal, is in the hands of the Almighty. Life on earth has a fixed and limited span and no one has the power to extend it even for a brief moment. The importance of the quality of life is recognized by some physicians trained in the European tradition but lacking an integrating tauhidi paradigm, they fail to define this quality in a holistic way. Islam can provide them with paradigms that enable them to pull everything together.
The Islamic concept of quality of life arises from the tauhidi integrative paradigm and is a comprehensive measure involving social, psychological, physical, spiritual, and environmental parameters. The quality of life is closely related to man’s understanding of the purpose of creation and the mission of humans on earth. Life becomes degraded, hayatan dhankan, in the absence of this understanding.
The quality of life is also closely related to lifestyle. A good healthy lifestyle is associated with a higher quality of life. A bad unhealthy lifestyle is associated with a low quality of life. Lifestyle is directly related to the risk of physical and mental illness as well as the response or adjustment to that illness. A healthy lifestyle is characterized by: piety, generosity, charity, chastity, humility, trust, balance, moderation, patience, endurance, honor and dignity, integrity, moral courage, and wisdom.
An unhealthy lifestyle is mainly a manifestation of one of diseases of the heart: associating anything with Allah, shirk; denial and rejection of Allah, kufr; false pride, takabbur; envy, hasad; anger, ghadhab; hypocrisy, nifaaq; miserliness, bukhl; and negative thoughts about others, suu al dhann. These diseases sooner or later lead to either physical or psychological transgression, dhulm, against self or others. Most human diseases can be traced to this transgression. Epidemiological studies if interpreted in an objective way provide sufficient data to relate ill-health to lifestyle and to quality of life.
2.0 OBJECTIVES OF ISLAMIC MEDICAL EDUCATION:
2.1 Purposes of the Law, maqasid al shariah, in medicine
The Islamic paradigmatic approach to defining the purpose of medical education can be derived from the paradigm of tauhid and the general theory of the purposes of the Law, maqasid al shariah. The majority of scholars concur that the following 5 purposes are protected by the law: (a) religion, diin (b) life, nafs (c) procreation, nasl (d) intellect, aql (e) wealth, maal. Medical practice is intimately involved with all 5 of them but most so with nafs, nasl, and aql. Once the purposes of medical intervention are established, the aim of medical education should be to produce physicians who in their practice of medicine will fulfill that purpose or maqasid within a holistic context to ensure harmony and equilibrium.
Medical education systems should aim at producing a physician who will be health and not disease oriented. He will have the humility to know that he will exert his best and trust in Allah to cure the disease. He will not have the arrogance to feel that he can prevent death but will strive to improve the quality of life for people knowing that the Islamic index of the quality of life is derived from the holistic tauhidi view: physical, spiritual, social, psychological aspects and proper balance between them. The physician should in addition have the following practical and conceptual skills: understanding of the society, epidemiological understanding of health problems, scientific capability, clinical expertise, and leadership. These qualities must be in a context of iman, tauhid and fulfillment of the general purposes of the shariah.
2.2 The tauhidi paradigm, integration and balance:
Tauhid is the main paradigm in Islamic civilization that forms a backbone of all intellectual discussion of medical education. Tauhid al rububiyyat motivates the appreciation that there is only one creator and that thee is unity, harmony and useful interconnections among different forms of life and the physical environment. Tauhid al uluhiyyat motivates the appreciation that the creator has definite purposes from creation and that human life must fulfill those purposes. This implies that there are certain laws that lead to a fulfilling life. Obeying those laws is associated with a healthy high-quality life-style. The tauhidi paradigm implies integration and harmony of matter and soul, body and mind, parts and the whole.
The physician should be trained to practice medicine as a total holistic approach to the human in the social, psychological, material, & spiritual dimensions and not an attack on particular diseases or organs. The example of the early Muslim physicians is worth emulating. They were well rounded in their education and their practice of medicine. They were also integrated in the sense that their medical practice fitted in well with other social activities. Al Qadhi Abd al Razaaq used to teach medicine and mathematics in the mosque in Bukhara until his death. Muwaffaq al Diin Abd al Latiif al Baghdadi taught medicine in the Azhar mosque during his stay in Egypt. Thus the context and the environment in which the teaching was carried out were integrative. It integrated medicine with the mosque and worship.
The tauhidi approach to integration is putting medical knowledge, teaching and practice in a larger context to making sure it is in harmony and is well coordinated with other related medical or non-medical phenomena. It is therefore possible to envision a very ‘integrated’ doctor who at the same time is very specialized. Such a doctor will approach the patient as a whole human and not just as organs or tissues.
3.0 REFORM OF MEDICAL EDUCATION
3.1 Selection of Students into the Medical School:
Many of the qualities of leadership needed in a future physician are not identifiable from the academic record. It is risky to admit students without the required personal and ethical qualities in the hope that they will be taught by the medical school. The medical school cannot teach all these qualities; they have to be taught by society before entry into medical school. The medical schools will have no choice but to select candidates with acceptable academic and non-academic qualifications, quite a small pool.
Research is needed on whether there is a definable personality profile for those attracted or admitted to medical schools. Anecdotal observations indicate that physicians in several countries and practice settings share some characteristics among which are: bad handwriting, a big ego, mastery and self-control, hard work and activity. It could be possible to define a new personality profile including some of the good qualities and excluding the bad ones and submitting it to experimental verification over a period of 10-15 years.
The process of selection needs to be reviewed to identify those students who have the required qualities. Medical schools will have to draw up criteria, academic and non-academic, suitable for their community and use them in selecting physicians. The future behavior of the graduates should be used as an evaluation tool of how good the criteria were.
Students admitted, in addition to academic competence, should possess the following qualities: a comprehensive holistic approach based on tauhid, a service vocation, ethical and community leadership, and motivation to get knowledge. A heavy weighting may have to be given to the non-academic qualities such that some students may be admitted with lower academic standards if they have the ethical and personality traits need in a good physician. Entry into medical schools is basically dependent on academic credentials. There is no clear-cut evidence that good grades are related to being a good and successful physician. Intrinsic motivation, personality, attitudes, values are not usually considered.
3.2 Curriculum Reform:
The curriculum of the medical school will have to be reformed along 2 fronts: (a) increase of methodological subjects and decrease of biomedical information and (b) early involvement of students in health care delivery not as bystanders but as actual providers. What is suggested is a medical curriculum that provides the future physician with basic methodological tools that he can use for life-long learning. Such a curriculum will be limited to the essentials that remain relevant for a long time. It will not be burdened with bio-medical information that is either made obsolete at the time of teaching or soon after by the rapid scientific progress or is forgotten by the student even before graduation and should not have been taught in the first place.
A curriculum emphasizing basic methodological and conceptual issues can aptly be referred to as usul al tibb. The relation between usul al fiqh and fiqh is a very good model for reforming medical education. Usul al fiqh is a methodological subject that provides tools that can be applied to various situations n order to derive a legal ruling, hukm shara’i. Fiqh is the law derived by use of usul al fiqh. It is almost impossible for one jurist, faqiih, to study all what is available in fiqh and to know the legal ruling in any situation that comes to him. Some of the legal cases that the jurist is called upon to decide are novel and have no precedents. He is however not afraid to deal with any case because his training in usul al fiqh gives him methodological tools that can be applied to old and new situations.
It is suggested that the student should spend 30-40% of his time at medical school involved in direct health care delivery. This direct contact will provide the student with practical skills, attitudes, and motivation needed in a physician by an apprenticeship process. The laws of medical practice may have to be revised to accommodate the apprenticeship system. Apprenticeship as a method of medical education needs to be revived. Ancient Muslim medical schools in Egypt, Syria, and Iraq taught most by apprenticeship. Teachers were practicing physicians who did most of their teaching at the bedside. Another dimension of leadership in medical education is the mentor role of the senior physicians who are supposed to be a model especially in the domain of physician-patient relationship. Besides facts and skills, medical education imparts attitudes and assumptions. These are part of the non-factual learning that students acquire by watching their teachers. Students are wont to follow what their teachers do and not what they say.
For apprenticeship to produce the physician with the desired qualities, the ambience in the hospital or primary health care setting must reflect the Islamic teachings and should be set up in such a way that there are many formal and informal learning opportunities.
A system under control of the medical school should ensure systematic continuing medical education; the exact form and nature of this education can be worked out. Knowledge either becomes obsolete or is irrelevant to the particular circumstances in which the physician is practicing. Whatever useful knowledge the graduate may retain is the real education that he/she got since education can be alternatively defined as ‘what you know minus what you leaned at school’. Much of what is taught is soon overtaken by new medical discoveries.
3.3 Educating a physician with character: iman, taqwat, amanat, & akhlaq.
Iman
Three aspects of iman bear directly on medical practice: tauhid; predetermination, qadar; and contemplation, tafakkur. The integrating paradigm of tauhid enables the physician to practice integrated and balanced medical care as explained before. Belief in qadar guide the physician in his work to know and understand that Life and health, and illness & 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 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 contemplates, 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 dawa 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’awa 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. 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.
4.0 RESEARCH-BASED MEDICAL EDUCATION
4.1 Wide Scope for Research:
The hadith of the Prophet that for every disease there is a cure opens a wide door to research. The Qur’an presents a wide scope of knowledge. It calls upon humans to explore the signs of Allah in themselves and the universe around them. The Qur’anic condemnation of blind following and taqliid is a motivation for research. The Qur’an calls for use of evidence-based knowledge. Research is a type of ijtihad. Research by understanding the signs of Allah leads to even more iman as we learn from the story of Ibrahim (baqara). A story reported about Abu al Hasan al Anbari al Hakiim when he was studying engineering shapes and he said he was reading the verse of Allah ‘didn’t they look at the sky how we built it?’. The human researcher learns to appreciate the majesty of Allah by finding that human knowledge is limited. There is always more to be discovered about Allah’s signs.
4.2 Shift from ‘Consumption’ To ‘Production’ of Knowledge:
The physician of the future will have to change easily between three inter-related roles: research, teaching, and care delivery. The research called for is not a full-time occupation and will normally be carried out as a multi-disciplinary effort. The need for research capability is motivated by the fact that the undergraduate curriculum cannot provide all the knowledge that a physician will need. There is thus a need to acquire new knowledge on a continuous basis by reading and research. Medical graduates are not prepared to be researchers. They lack curiosity and initiative. They have underdeveloped ability to observe and interpret phenomena.
The medical curriculum should aim at preparing the student to be a researcher, mujtahid, who will extend the frontiers of medical knowledge. The paradigm shift involved here is to change the student and future physician from a consumer to a producer of knowledge. The physician must be trained to be a life-long learner. Research is the best way to learn and stay on the frontiers of knowledge because it is learning by doing and being the midwife of new knowledge. In practical terms, preparation for research means increasing time devoted to subjects on basic research methodological tools and decreasing the amount of biomedical scientific information that is either forgotten or becomes obsolete by the time of graduation. Student research projects are a good introduction to life-long curiosity in science and discovery.
4.3 Balance among Research, Medical Care, and Teaching:
Physician actively involved in research will be more dynamic and innovative in caring for patients. Research combined with patient care fulfils the Prophetic guidance to look for useful knowledge, ilm nafei, because the practitioner does not have the luxury to research into esoteric problems and leave challenges that face him daily in the clinic or hospital. Applied research is needed to find out how available bio-medical knowledge can be used. Knowledge alone is sometimes not enough for a good health outcome. Physicians who know the dangers of alcohol are sometimes the worst abusers. The most challenging topic for research as far a Muslim physician is concerned is to understand what constitutes quality of life since this is the main aim of medicine. A researcher who is a teacher will always have something new and interesting to share with the students. His teaching will be exciting and students will look forward to it. A question of balance arises. The teacher will have to find the right balance in time allocation between research and teaching. The practicing physician will have to strike the right balance between research and patient care.
