October 2011, Volume 61, Issue 10

Opinion and Debate

Medical education: value based teaching

Haider A. Naqvi  ( Department of Psychiatry, The Aga Khan University, Karachi, Pakistan. )
Ather Hussain  ( Section of Nephrology, Department of Medicine, The Aga Khan University, Karachi, Pakistan. )

Education which does not inculcate values has great perils. Is it beneficial to carry the burden of formal education and be un-amenable to reason or logic? A surgeon without internal (thought through) value system is worse than a technician, who is expected to be better skilled in the procedures. It is the distinction of knowing when not to operate (rather than how to operate) which defines a distinguished surgeon from a good one. The issue of ethics in the field of biomedical research and practice has gained attention in recent times. Physicians find themselves at the receiving end with declining standards of practice and abuse of their status.
Question to ask is: are we producing the physicians with robust moral values? It is one thing to be a doctor, prescribing medications and performing procedures while quite another to be a \\\'moral entity\\\', making difficult choices on day-to-day basis. As individuals attempt to climb the (academic) ladder of success, do they trample upon the \\\'values\\\' which define professionalism, integrity and hard work? Unless and until this issue is addressed at the very beginning - the moment of choice - the decision between diverging paths (of right and wrong) would be difficult. The pressure to produce results would be too great to resist temptation.
In the scenario of Publish or Perish, the idea of quality-science and the ghost of plagiarism will haunt many individuals. Sitting late in the night, the impulse to cut-paste a paper as you have to submit a report, could become a liability. Unless these tendencies have been worked through, during the training, one could fall prey to misconduct. Software\\\'s which could detect plagiarism have been in use since some time. Individuals who copy material from other sources without due reference have been asked to step down from their academic positions. But plagiarism has many shapes and forms. Copying some ones idea or repeating your own previous work may also come into the definition of plagiarism. It is an established fact that critical thinking and research-writing is a skill which needs to be inculcated through (years of) practice. However individuals\\\' resort of political networking and using influence of one sort or other to get their academic work done rather than pursuing the good science themselves. It is ethical to write manuscripts in your own words use parenthesis with proper references for original source in your manuscript and go through the manuscript again and again to identify any possibility of plagiarism.
Another example of the same sort is gift authorship. Primary investigators work on the data collection and analysis but in the end additional names appear on the paper who never actively participated in the study or research work. Instead of adding someone\\\'s name in the manuscript, guiding them in the right direction to do scholarly work would probably be more fruitful and long lasting.
Similarly, slandering about a colleague also depicts how you are so mindful of shortcoming in others, while ignoring your continuous professional needs. The more organized form of malicious envy, where one wishes ill for others, entails vicious gossip, spreading rumors and hurting the others reputation. The critical issue in this debate is how far the regulations have had impacted the practices in the domain of biomedical sciences? Take physicians waiting time for an example: patients generally have to wait for hours before they see a doctor; this is in the context when there is a fixed appointment schedule. Does monitoring of doctors time, freeing them of emergency work ensures that they will be on time? It has to be an internal values system when a doctor comes on a scheduled time. No amount of external monitoring would control for shoddy behavior. Good behavior needs to be inculcated from the early years of training. The skill as well as morality of practice needs to be taught, through role-modeling and discussions.
Problems have been around since sometime but there is little discussion on the solutions. Where should we start at? Should it be right from the beginning of medical school or at graduation? It can also be part of residency training programmes. In western countries, direction is to limit interaction of medical students, trainees and faculty with pharmaceuticals. This is a fine line as we all do conduct clinical trials which are funded by pharmaceuticals but results of which help in making important decisions regarding our patients. Dogmatism in the domain of ethics is dangerous. One runs the risk of becoming a moral force on to oneself, criticizing anyone and everyone. This is fraught with difficulties. One walks a thin line between inspiring people to follow a higher path and reciting the nauseating mantra of ethics. Since no \\\'independent\\\' individual likes to live under theocracy, how you inspire others to good behavior becomes a contentious issue. In the words of Rumi, "Preaching of ethics is only for prophets and vicegerents of God, others only talk out of their arrogance."2 The moral dogmatist\\\'s view require — for their own sanctification - a public display and recognition of moral courage. What is the right course of action then?
It is best for an individual to seek first the right of way of thinking and behaving and then encourage people to seek righteousness themselves. Having done this one becomes an instrument of change for others. Intuitively, it makes sense: if I have a clear understanding of the right and wrong, the good from bad, the choices become very easy. No amount of lure, public pressure or fear of personal isolation would dissuade me from the right path. This needs to be done before someone joins the public office, involving decision making regarding self and others.
Another aspect of our training is to identify deficiencies in continued medical education in our graduates who practice in hospitals, academic institutes or as solo clinicians. Do we know if everyone who has a doctors\\\' clinic is also registered with some governmental agency? Does everyone have evidence to show off their medical education? In most of the world, to keep a medical license, physicians need to acquire certain hours of continued medical education every year, this keeps them up to date. In addition, there is usually a periodic re-certification exam to keep them updated of the current medical knowledge. In Pakistan, once someone passed FCPS, this is good for lifetime. Periodic revalidation of medical knowledge by recertification or other measures would help to keep the knowledge/skills current.
Ethics and Morality has to be inculcated through medical education. The scenario in Pakistan, whence humanities and social sciences are not part of the curriculum, breed doctors with poor moral conduct. Recently, Aga Khan University started the series of lectures on Humanities and Social Science for Medical students. This is a first step, albeit small, in the right direction. Humanities and Social Sciences (HASS) go a long way in inculcating a reflective attitude towards life and self. Art and Literature primes you to guard against treating people as \\\'objects\\\', inculcates right values in the individual. Learning a new language also builds a bridge (of understanding) in to a different culture, making a person more attuned to the norms in his own tradition. Classes on (Persian, French, etc.) languages provide this avenue of development for those who are undertaking language courses. The purpose of whole exercise is that doctors have to become a moral entity - independently thinking about right and wrong in varied situations. In the words of Mark Twain, famous American writer, Education is that which reveals to the wise, and conceals from the stupid, the vast limits of their knowledge.


1.Naqvi H. Thesis theft: [On line] 2008 [sited June 18, 2008]. Available from: URL: http://www.dawn.com/2008/06/12/letter.htm
2.Dunn P, Mascetti MD, Nicholson RA. The Mathnawi - Rumi: A treasury of wisdom from the poet of the soul. Harper Collins Publishers, 2000. Pg. 20-59
3.Das N, Panjabi M. Plagirism: Why is it such a big issues for medical writers? Perspectives in Clin Research 2011; 2: 67-71.
4.Prospectus, 2008, The Aga Khan University. Available from : URL: http://www.aku.edu/Admissions/pdfs/AKU_Prospectus_2008.pdf.

Journal of the Pakistan Medical Association has agreed to receive and publish manuscripts in accordance with the principles of the following committees: