Faezah Siddiqui  ( Pak Red Crescent Medical and Dental College, Lahore, Pakistan )
Ali Awais Malik  ( Department of Medicine, King Fahad Armed Forces Hospital, Jeddah, Saudi Arabia. )

Over the past decade much attention has been focussed on medical professionalism. However, the main dilemma in Pakistan is that both the teachers and the students are too occupied in covering the cognitive knowledge that they are unable to spare time to practice the necessary skills, behaviour, and attitude. In order to understand how culture affects professionalism, one must first have a clear understanding of Pakistani culture. According to our best educated guess, we have suggested a few teaching methods which can assist in teaching culturally sensitive issues. Despite our suggestions, one cannot ignore the limitations in terms of constantly changing culture, difficulty in introducing unfamiliar teaching strategies and the ample time required.

 

Keywords: Medical Professionalism; Culture; Doctors; Teaching and Learning.

 

DOI: https://doi.org/10.47391/JPMA.150

 

Introduction

 

In the past decade much attention has been focussed on medical professionalism. And now it has become a term that is commonly used among medical practitioners and the public.

However, the main dilemma that the traditional medical curriculum face is that both the teachers and the students are so preoccupied in covering the cognitive knowledge that they are unable to spare time to practice the necessary skills, behaviour and attitude.

Being professional has always been part of our culture, even if we go back to the Islamic history about thirteen centuries ago. Accordingly, since the lifetime of the Prophet (PBUH), ethical controls and principles have been established for medicine to guide physician’s behaviour.

As quoted by Abu Na’eem: the Prophet, blessing and peace be upon him, said, “If a person who practices medicine while he is not known to be medically proficient, causes death or a lesser injury, he is held accountable.¹

The Medical Professionalism Project launched by the American Board of Internal Medicine Foundation, the American College of Physicians Foundation, and the European Federation of Internal Medicine, in 2002, published a professionalism charter that has been adopted by many major professional physicians’ organisations.

The Professionalism charter defined three fundamental principles:

1-       The primacy of patient welfare:

This principle focuses on altruism, trust, and patient interest. The charter states: “Market forces, societal pressures, and administrative exigencies must not compromise this principle.”

2-       Patient autonomy:

This principle incorporates honesty with patients and the need to educate and empower the patients to make appropriate medical decisions.

3-       Social justice:

This principle addresses physicians’ societal contract and distributive justice, that is, considering the available resources and the needs of all patients while taking care of an individual patient.²

After reviewing the three fundamental principles of professionalism, one can easily relate the similarities to the teachings of Islam and beautiful books written by Muslim physicians and scholars on ethics and professionalism.

An example is Al-Razi, who wrote a special book one thousand years ago under the title Akhlaaq al-tabeeb (Ethics of the physician). It has a note addressed to his students:

“A physician should be gentle with people, refrain from talking ill about them in their absence, and keep their secrets. A person may be afflicted with a disease which he keeps secret from the closest people to him, such as his father, mother, and children. He hides it from those close to him and, out of necessity, reveals it to his doctor. If the physician treats one of a man’s women folk, girls, or boys, he should cast down his eyes and not look beyond the afflicted part of the body”.³

In our understanding of professionalism, it is not the work we do as doctors but the reason we do it and how well we do it. Patients consider physicians as healers, and put their trust in them. It is our role to protect this trust as we develop a covenant, a bond and a relationship that is unlike any other profession.⁴

This relationship of trust between a patient and a physician should be the guiding light of professionalism.

A physician needs to put emphasis on not only the premise of the patient but also the welfare of the patient in the context of:

•        Evidence-based care

•        Team-based care

•        Appropriate use of resources.

As physicians, we are obliged not only to give our best, but also reflect on everything we can do to regulate and monitor ourselves. We can also discuss with our colleagues, nurses, paramedics, pharmacist and hospital administration regarding further improvements in professionalism.⁵

In order to propose an understanding of how culture affects professionalism, one must first have a clear understanding of Pakistani culture.

Pakistan is an Islamic state and has the second largest number of Muslims in the world. Then there are the Hindus, Christians, and other minorities. Religion is an integral part of culture that shapes symbols, beliefs, values, norms, and even language.⁴ It inspires the way one thinks and considers issues such as morality, well-being, traditions and local practices. However, our culture is also framed with history, geography, and the present policy. It can be explained very beautifully through five elements of culture as proposed by Edward B Tyler, a well-known anthropologist.

Symbol: In our society, a person’s dress is a symbol of his social or professional status. As a doctor is considered of high esteem, we expect our physicians to appear well groomed.

In the quest to appear good, some of the young doctors are accepting materialistic  gifts like expensive watches, smartphones, or cars. And in doing so, some of them have to compromise on their morality. This includes accepting gifts from patients, bribes from pharmaceutical companies, and even doing illegal procedures, like organ trade in black market.

 

Language: The relationship between communication skills and professionalism is very crucial. In our country the official language is English but the national language is Urdu. In our culture, people consider their physician as healer and expect him to listen to all of their problems whether related to the diagnosis or not. Most patients also have difficulty in understanding medical terms so it is the doctor’s duty to explain the condition in layman terms which the patient can understand. The same applies to taking consent and counselling of the patient and his/her family. Doctors who are good at communication skills are considered competent, and the rest with fancy terms are not. There are a lot of examples where a doctor and the patient’s family get into a conflict due to communication gap.⁷

One cannot ignore the fact that every individual whether rich or poor, literate or illiterate, young or old has the right to know his medical condition and all possible treatment options.

 

Beliefs: In our culture, there are a variety of belief systems. Two most notable are religious beliefs and mystic beliefs. The doctors and patients both believe that they are being watched over by Allah and whatever they do in this world they will be rewarded or punished in this world or hereafter.⁸ We also have a strong belief in the saying ‘what goes around comes around’. This aspect affects professionalism in a way that we do our duty and work for humanity with a view to be rewarded by Allah.

But the mystic beliefs accepted by the patients that their disease is due to demons, black magic or the spell of evil eye are an important part of our culture. There are also strong myths regarding the side effects of medicine and complications of surgical procedures. And sometimes it becomes extremely difficult for the doctors to deal with these concerns.

 

Values: Pakistan has a collectivist culture in which if someone deviates from the norm he is considered weak or bad. Kinship, family, and community are extremely important. The extended family has significant influence, and the oldest male in the family is often the decision maker and spokesperson. The interests and honour of the family are more important than those of the individual family members. Women are respected but due to cultural gender discrimination, their opinion regarding treatment is often ignored.

Our cultural values also teach us to respect authority and not to question or challenge it. This leads to another professional problem in which junior doctors remain quiet and do not report medical errors of their seniors in order to avoid a cold shoulder from the medical community.

 

Norms: Cultural norms are the standards we live by. They are the shared expectations and rules that guide the behaviour of the people within social groups. Cultural norms are learnt and reinforced from parents, friends, teachers, and others while growing up in a society.

The cultural norms are further classified into four categories.

1. Folkways: They are simply accepted customs e.g. shaking hands while greeting or leaving your seat for a senior or elderly.

 

2. Morals: This refers to the moral standards and their violation comes with a price. Sadly, in our culture, due to poverty, illiteracy, and injustice, loss of morality is very common. This culture affects professionalism in a very serious way. Taking credit for others' hard work whether clinically or academically is very common. One of the reasons for this behaviour might be preference of quantity over quality. Young professionals look for shortcuts and, in doing so, they do a lot of things which are damaging to the profession and ethics.

 

3. Taboos: In our society, HIV, sexually transmitted diseases, drug addiction, homosexuality, psychiatric illnesses, and physical and mental disabilities are considered absolute taboos. When it comes to dealing with these problems, we occasionally observe unprofessional behaviour from health professionals.

 

4. Laws: The culture of following law is also very poor in our society due to corruption. This is the reason, a lot of malpractices — ranging from medical negligence and quackery to organ smuggling, and illegal abortions — have become common.

 

Teaching culturally sensitive issues: According to our best educated guess, some of the teaching methods which can help in communicating culturally sensitive issues are discussed as follows.

 

Brief introduction on orientation day: During the white coat ceremony for the first year, a formal address from the Dean, Principal or any other notable medical figure on culture, ethics and professionalism can be incorporated. This can help in establishing expectations and boundaries for acceptable behaviours in medical students throughout their journey.⁹

 

Build a code of conduct: To teach cultural sensitivity and professionalism, a code of conduct must be built relevant to the societal needs, not downloaded. At the beginning of each academic year, the document should be revised and updated before distributing to the faculty and students.

 

 

 

Professionalism curricula: Whether a medical institute is following the traditional or the integrated curriculum, culturally sensitive issues can be taught through various methods. Some of the feasible methods are as follows:

Didactic lectures: Didactic lectures are an efficient method to teach a cognitive base of professionalism to a large number of students. To make lectures more interactive, videos showing clinical scenarios followed by discussion from students can facilitate learning.^9,10 When teaching infectious diseases, we can show documentaries on patients of HIV, hepatitis or tuberculosis and their daily hardships.

In the reproductive system, social issues regarding contraception, infertility, and pregnancy in unmarried girls can be discussed.

Small group discussions: Small group discussions e.g. project based learning (PBL), community based learning (CBL), tutorials and lab practical can be made very effective.

In PBL, taboos of addiction can be discussed. In CBL, examination of female patients and cultural issues regarding privacy and exposure can be critically analysed.

While doing lab work, communication skills and professional attitude towards paramedics and helping staff can be taught to students.

Role Modelling: Students learn a lot from role models who have clinical competence, excellent teaching skills, and desirable personal qualities.¹¹ In OPD or clinics, how medical teachers interact with patients from low socioeconomic status, including their queries related to their medical condition, is considered an excellent approach.

In clinical clerkship, students watch and learn the professional attitude of their teachers, when offered gifts or foreign trips by pharmaceutical companies.

Role play: In role play, we can give students a scenario and ask two or three of them to act, while the remaining class can observe and later discuss among themselves. Speaking up against an impaired colleague or reporting medical negligence by a senior are some of the culturally sensitive issues, which can be recognised through role play.

Reflective Writing: After interacting with patients, we can ask our students to reflect on their experience and write down what went well and what could have been done better.^12,13

One example can be a conflict between a surgeon and a patient’s husband regarding consent for hysterectomy. Another scenario can be delivering sad and unexpected news to the patient and his/her family.

Environment of Institute: Finally, to achieve our goals we need to seek institutional support. The environment of the institute must be ready for change in policies. The hidden curriculum (that influences structure, function, and culture of an institute) must be in harmony with the formal curriculum.¹⁴

 

Limitations

 

In our humble opinion, teaching culturally sensitive issues is a domain beyond the scope of this short communication due to the following limitations:

 

a)       Culture of our region is constantly changing.

b)      Designing methods for teaching sensitive issues is easy but implementing them is very difficult.

c)       Assessment of students regarding learning and attitude is a time consuming process and can be only assessed during real clinical situations.

Despite the limitations, an initiative has to be taken, to make our graduates professional and community oriented.

 

Conclusion

 

In conclusion, a number of methods suggested above can assist our medical graduates in teaching medical culturally sensitive issues. Despite our suggestions mentioned above, the limitations; in constantly evolving culture, changing environment one cannot ignore difficulties faced by educators, in introducing unfamiliar teaching strategies and time required. Therefore, it lies in our hands to undertake the necessary reforms in communicating culturally sensitive issues and preparing our medical graduates in light of medical professionalism.

 

Disclaimer: None.

Conflict of Interest: None.

Funding Disclosure: None.

 

References

 

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