Medical Education, by Dr. Shabih Zaidi, Chancellor, Al Sadiq International Virtual University

SIVU Al Sadiq Virtual International Univeristy
SIVU Al Sadiq Virtual International Univeristy

The  Voyage of knowledge

Knowledge was best defined by the Philosopher -Soldier- Saint, Ali Ibne Abi Talib as follows. “Its head is humility, its eye is freedom from envy, its ear is understanding, its tongue the truth, its memory is research, its heart is a good intention, its intellect is the gnosis of objects and matters, its hand is compassion, its foot is visiting the learned, its resolution is integrity, its wisdom is piety, its abode is salvation, its helmsman is well being, its mount is loyalty, its weapon is the softness of speech, its sword is satisfaction, its bow is tolerance, its army is a debate with scholars, its wealth is mannerism, its stock is abstinence from sins, its provision for the journey is a virtue, its drink is gentleness and politeness, its guide is divine, its companion is the love of the elect… and without matching skills it is like a bow without an arrow. It encompasses all attributes of knowledge.  One cannot better this definition, as the whole philosophy of education revolves around the fulcrum of the welfare of mankind.

Plato called knowledge a virtue. The time tested theories of good and its perpetual battle with evil are well documented in the annals of human history. One is reminded of a tale of a Greek god called Prometheus, who was punished by his cohorts for throwing down an ember from the heavens into the abyss of ignorance in the earthly abode of mankind. An ember, which was the first source of knowledge that sparked the evolution of the human mind. That tiny ember, though inconspicuous, brought about a revolution eventually challenging the authority of the mighty and the resourceful false gods.

Education is either formal or informal. Informal education begins as one enters this world. Both processes continue through life. Each living being is granted four basic instincts by nature. They are hunger, security, curiosity, and companionship. So as the baby is born he wants to suckle to quench his hunger and thirst. That struggle to fulfill his bodily needs perseveres throughout life. And that is the very basic animal instinct.

This process of learning by exploring continues throughout life; and that is best described as informal education.

Security is what urges a baby to seek protection in a mother’s lap and that animal instinct is seen throughout the animal kingdom, varying in intensity and needs with the advancement of age. 

Maslow the illustrious psychologist has given huge importance to the instincts of hunger and desire to excel, as indeed the need for security, massive importance in his numerous studies and in his own particular philosophical style. His theory called the hierarchy of needs clearly identifies the steps towards achieving self actualization.  

The third instinct that all animals including the Homo sapiens possess is that of curiosity. And that is one immensely important attribute that they possess. The moment a baby is born, he begins to explore his surroundings, his habitat, his location, his requirements, etc. employing the natural senses of vision, hearing, smell, and taste. Obviously, the brain of a newborn is like a clean slate. So each experience is recorded and each exposure to anything new is duly matched with the recorded e experience, and duly stored in the deep layers of the cerebral cortex, in the gyri and sulci dealing with memory and recall.

The well-known facial expression of a baby displaying the so called innocence, surprise, fear, anxiety, and simple curiosity, duly display the underlying ignorance. As the baby advances in age, the learning process changes the expression and attitude from not knowing a thing to knowing it all. Even the fundamental startle reflex so typical of the fear and flight phenomenon is seen in the early days gradually disappears and a confident approach takes over.

This process of learning by exploring continues throughout life; and that is best described as informal education. The basic difference between the animal kingdom and mankind in terms of instinctive evolution is best described by Bergson. He defines it as a distinctive attribute of reasoning and intellect possessed by mankind but not the animal world.  So, although an offspring of an animal and a human being may behave identically in the face of exposure to danger, the latter would gradually learn to overcome and counteract that danger, while the former shall always seek an exit through escape, unless of course if you are talking about a predator, who is born to kill or maim; though sadly enough even some human beings have the same tendency too, often called the animal instinct.

Finally, the instinct of companionship is like second nature to all animals. in the case of mankind, the curiosity to avail of companionship depends and nurtures with the upbringing and the environment afforded to him in early years. If the growing environment is healthy, one will obviously look for, develop and cultivate human relationships and bondage with good people. If otherwise, he will become a part of an evil gang. So, although the desire for acquiring companionship is natural in the entire animal kingdom, unlike the rest the mankind has the option of harnessing the best through choice, thus nurturing playing a significant role in the development of a personality.

Savants advise us that informal education begins at the mother’s knee and ends with death. It is certainly more valuable in the development, cultivation, and modulation of a personality. Many a renowned philosopher, scientists, and scholars did not have an ideal formal education, but they had a personality like a sponge, imbibing every bit of learning experience from the wise for the welfare of the unwise and to save themselves from the follies, as they moved on with their lives.

The second component is obviously formal education. It begins at home when a child is taught the first word, or a sentence or a lesson, and continues throughout the most adult life. The process of schooling followed by either a university or an apprenticeship to acquire suitable skills to live off them is what is described as formal education. Those who endeavor and are fortunate enough to go through the entire learning process of the university and academia, obviously do much better in life than others. And that is why the old dictum that education only for the sake of learning may not always be true. Yes,  in the olden days, when the scholars were hired, employed, or given stipends only for their scholarly pursuits are gone forever. Now, the fundamental application of the process of education is to earn a living; which is regrettably a sad situation; nevertheless true.

Those who endeavor and are fortunate enough to go through the entire learning process of the university and academia, obviously do much better in life than others.

Education is a process that brings about a visible, palpable, tangible change in a human being.  The process of education is a long and demanding activity. It may be so; but at the end of a long and tortuous journey, the satisfaction that one gain is simply indescribable. People immersed in knowledge live a different life than others. They live in a celestial world, where nothing material matters to them. They live a life of peace and tranquility; a life full of joy and happiness; a life full of glory and inner satisfaction. Some pundits have rightly labeled it as Nirvana. But not all can reach that stage; not all can achieve those high altars. The fortunate few who do, become a beacon of light for the rest of the world.

Medicine is an ageless profession. Magic and sorcery was a common practice in China, and one might say that dragons and the use of Hippo corn, etc are still cardinal features of the Chinese medicine witnessed in most China towns. The Chinese practice of Acupuncture and Tai Che exercises have stood the test of time and are now taught through instructional sessions in the modern world as indeed must have been the norm in the olden days.

The earliest recorded evidence of medical education can be traced back to prehistoric days. This region has been described in the books of history as Mesopotamia. It is also called the cradle of human civilization. The mighty Saharas of Nejd -o- Hejaz border this region on the northern side with Asia Minor’s hills standing guard in the neighborhood. The fertile lands of ancient cities of Hilla, Kifl, and more famous Babylon lie in the valleys of two mighty rivers namely Tigris and Euphrates. Not more than a hundred meters from the Euphrates rests the antiquated ruins of the Babylon, where once stood the hanging gardens, duly watered by the Jewish prisoners of Nebuchadnezzar. The mighty kingdoms of Sumer and Akkad flourished in these regions for more than a couple of millennia. The city of Ur was the very pinnacle of human endeavours all those years ago, now frozen under the avalanches of history. Architectural excavations in this region have found small copper knives, considered to be surgical instruments. Many clay tablets carrying medical writings were also discovered. The archaeologist guide and a physician by profession, who is a professor of epidemiology in the University of Babylon told this author ( Zaidi), that the clay tablets were indestructible as the natural clay of Babylon contained substantial quantities of oil, and lead, giving them unprecedented strength. Unlike the Papyrus used by the Pharaonic Egyptians, the Babylonian tablets are more lasting. A seal of a Babylonian medical commissioned about 2,300 BC is still present in the Louvre museum. Similarly, Summerian seals are present in the Welcome museum not far from Euston train station., in London.

So, formal medical professions existed in the early Summerian and Babylonian civilizations. These men of wisdom or Hikma must have transferred their knowledge and skills through long apprenticeship to their pupils. Not just that, but the most essential component of the medical profession indeed education, i.e. ethics traces its origin to the first documented evidence of the principles of moral conduct.

Hammurabi (2000BC approx)  gave a code of conduct, now preserved on a clay tablet in the famous Louver museum. It defines the fundamental principles of ethics giving specific directions regarding the benefit that a physician must provide to a patient, duly complemented with the instructions of avoiding harm to a patient, who is harmed must be duly compensated by equal and matching punishments such as an eye for an eye or limb for a limb.

The illustrious historian Herodotus described in his writing about 430BC that Babylon had many physicians and even a common citizen took care of notifying any ` developed or knew of anyone in the community, to give and seek advice. The ancient cuneiform clay tablets depict the pictures of the liver, as indeed the clay models, showing a deep knowledge of these ancient priestly physicians.

One presumes that men of knowledge were men of importance and possibly belonged to the elite class of priests. As has been customary in the religious circles since time immemorial, the method of transference of knowledge was a long and protracted association between the priest or the guru and the pupil or the chela.

Ancient Egypt had many priestly physicians. Their main job must have been to serve their masters, but also the poor and the needy ones. Ebers Papyrus is the source of information on ancient Egyptian medicine. Strange concepts prevailed in the profession, such as the heart being the principal organ controlling the brain. The importance of the heart is noted down in many divine scriptures also. For instance Quran, the final testament describes Qalb, Lub’ab, Fua’ad as the seat of emotions, intellect, and reasoning. It does not, once, mention the role of the mind in this respect per se.

The teaching of the art of healing was through practical demonstration and application of the technology in a living patient. Description of management of a dislocated jaw is a good example to quote (pp26, A history of medicine.). The teacher advises his pupils as follows ” “if you examine a man having a dislocation of his mandible, should you find his mouth open, and his mouth cannot close for him, you should put your two thumbs up on the ends of the two rami of the mandible inside his mouth and your fingers under his chain and you should cause them to fall back so that they rest in their places “. How apt! Those of us who have had to deal with such situations in practical life can hardly improve upon this mandate given the ancient Egyptian masters, so very long ago!

Pathology was certainly the main field of research and education in ancient Egypt. The most obvious example of the discoveries of those masters is still visible across the world, in the museums, which display the mummies of ancient Egyptians. During the process of mummification, the post mortem was carried out by the pathologists,   technicians, and their disciples. Firsthand knowledge of the bodily organs was taught through the process of hands-on training, including the employment of alchemy such as the myrrh, spices, cassia, and other preservatives.

The formal teaching of medicine as a profession may be witnessed in the ancient Egyptian archives. Douglas Guthrie in his book called ‘ a history of Medicine, wrote: ‘ it may be said that the Babylonians and Egyptians practiced Magic and sorcery was a common practice in China. The Hebrews laid great stress on personal and social hygiene and were the founders of epidemiology and public health. The Hindus contributed materially to the art of surgery, while the Chinese were the originators of many discoveries in medicine which came into full action at later dates.’

All one can add to this wonderful summary is that the physicians and surgeons of these great nations transferred their knowledge and skills to their wards, pupils, and the chelas through long apprenticeships, and even more prolonged personal guidance and tutorship. Greeks, as in many other scholarly fields seem to have given the concept of one-to-one teaching in medicine. Galen alias Hakim Jalinoos is the father of modern medicine. His contribution is immense. Even today we teach of Galen’s discovery in Anatomy.

Pythagoras(580-498BC) was a sophist. Like Thales, he was one of the famous wandering philosopher-teachers of Ancient Greece. Every student of science must be familiar with his theorem in Geometry. He was an eccentric genius, who believed in the propagation of education at a fee. He appears to be the founding father of the discovery of numbers. We know well enough that no medical knowledge is complete without numbers. How can one conduct research in modern medicine without knowing reasonably well about figures, numbers, and statistics? He and his disciples founded a school that exercises a huge influence upon medicine, introducing the doctrine of critical thinking, synthesis of facts and figures as well as analysis to arrive at a conclusion. Infact he applied his mathematical genius into medical knowledge, not just to gain more but to propagate more in various fields of discoveries and research. Philosophically speaking, he was one of the first few to believe in the transcendence of soul, much like a later day scholar called Mullah Sadra.

It is said that Hippocrates benefitted from the Pythagorean principle called the ‘doctrine of numbers’ employing it into the concept of the critical time period in an illness and the highly influential concept of four humours and elements, which are still prevalent in Eastern cultures in Tibb and Ayurvedic. One of the disciples of Pythagoras by the name of Alcmaeon dissected animals and taught the principles of learning through dissection to his pupils. This man was not as famous as his teacher, but perhaps equally knowledgeable in sciences. His concept of the brain and not the heart is the focus of human feelings, senses, sensuality, and intellect is not far from present day notion.

Aristotle was a Botanist, Zoologist, mathematician, and philosopher par excellence. His contribution to medical education is formidable. He was a believer in the four humor theory. It became a popular subject in the early Arab and Persian medical teaching and practice. They practiced an empirical and enigmatic kind of medicine, regulated by a strict code but not inspired by a spirit of inquiry into the causes of disease. The Hebrews laid great stress on personal and social hygiene and were the founders of epidemiology and public health. The Hindus contributed materially to the art of surgery, while the Chinese were the originators of many discoveries in medicine which came to a fruitful action at later dates.’. All one can add to this wonderful summary is that the physicians and surgeons of these great nations transferred their knowledge and skills to their wards, pupils, and chelas through long apprenticeships, and even more prolonged personal guidance and tutorship.

Teaching and learning require a lifetime commitment. The formal education may end with the schooling at a professional college, or acquiring a degree from a higher seat of learning; but not a day passes by in a physician’s life that he does not learn something new. One statesman quite rightly said that three professions never retire, namely, the artist, the politician and the physician. Even after reaching the age of superannuation, a physician can be highly productive to his neighborhood, his family, and his community, by sharing his knowledge and experience with fellow human being.

Those who endeavor and are fortunate enough to go through the entire learning process of the university and academia, obviously do much better in life than others.

Organized medical education began in the nineteenth century. Abraham Flexner, a career educationalist was hired by the Carnegie Foundation to design a curriculum. His famous report published in 1910 may be called the founding brick of modern medical education. Since then many changes have occurred in the curricula. The most salient being the McMaster initiative of introducing Problem Based Learning.

Education is meant to improve the life of an individual but professional education such as medicine is helpful in improving the life and its quality of the public at large. In other words, the very purpose of education i.e reformation is best achieved through medical education. Between both of us, we have learnt and taught for several decades. The experience thus gained must be shared, or it loses its value.

Values & Aims by SIVU
Values & Aims by SIVU

Medical Education

Health is an important, personal as well as a community issue. It has been defined by WHO as not simply freedom from disease or disability but a state of the physical, mental, social, economic, and overall state of well-being. In other words, health means holistic wellbeing. Ancient populations gave it due to importance as their daily bread depended upon hard work such as tilling the lands.  It was not possible to do so without robust health. So fresh food, clean water, and unpolluted air was an accepted norm of society.

When they fell sick they approached a man of knowledge and practical wisdom.to heal them fast. This man was called Hakeem a word derived from the root word Hikma. A Hakeem enjoyed a special place in the society just as the religious scholar, a teacher, and a judge did. For generations, the art of healing was transferred to the next generation by the master or the guru to his devoted pupil or chaka through prolonged apprenticeship. A process of osmosis worked well for the pupil to imbibe knowledge and practical skills from the master. He also picked up bedside manners or etiquette of dealing with his patients. No formal education was practiced.

In Greek physicians the sign of Jupiter as an Rx was used as the first letter of a prescription. In Muslim societies it was the word Ho wal Shafi ie thou are the healer has been in vogue. Paternalistic approval continued for millenniums the master and pupil continued to grind the herbs and seeds and barks and minerals into pastes, lotions, and lotions.

But there was no formal education until the 19th century. Enter Carnegie, a poor miner from Scotland. He migrated to the US and earned huge amounts of money. Eventually turned into a philanthropist, he realized that many people dues due to improper health care. So the Carnegie foundation hired an educator called Abraham Flexner to investigate the causes of such a malady. To Flaxner’s surprise there was no formal curriculum or teaching strategy or assessment available in the hospital and educational institutions. He couldn’t believe it.

After traveling through several states of America he identified the cause and sat down to find the remedy.1910 has to get called a watershed year when Flexner report emerged on the science and medical education wall solemnly formalized. Since then we have followed the curriculum designed by Mr. Flaxner. It was, however, full of faults and deficiencies such as the lack of inclusion of humanities. It was also very voluminous and based purely upon rote memorization.

By the end of 2nd world war experts were already beginning to feel the need for a change in medical curricula as the knowledge based curriculum did not serve the physicians well in many situations. Often enough they lacked skills and problem-solving capacity. In the late 1950s, Mcmaster and McGill, and other universities came up with the concept of Problem Solving Medical education. A new vista of formal education soon followed.

Problem based learning slowly replaced the traditional curriculum. It offered many advantages such as the application of knowledge for curing and healing. Small group discussion replaced the large halls filled with the sleepy audience listening to a professor regurgitating and dictating volumes of notes in long drawn out classes and so forth. British GMC published a monumental report called the Tomorrow’s Doctor in 1993 which opened new vistas of organized education.  About the same time, the system for surgical training in the UK underwent significant alterations under the supervision of Sir Kenneth Calman, chief medical officer for England. This resulted in an annual review of competency progression (ARCP) and the inclusion of a logbook to enable review of surgical experience. The initial aim of these ‘Calman reforms’ was to streamline the progression of middle grades in order to produce clinically competent consultants much earlier than in previous years. Satisfactory completion of these elements enabled progression to the next year. Calman- Hein report disciplined the training programs in the UK to make them more structured. Regular monitoring and modifications are continuously carried out by the competent authorities in every country  

The new millennium has seen numerous revolutions in the field of medical education. Currently, we are going through a rather fluid state of medical education. It is undergoing experimentation to match with times. The introduction of computers and innovative technologies such as Artificial Intelligence and Simulation, Augmented Reality, etc are just the beginning of a totally new era.

 Medical education is now formally recognized as a specialty in its own right. And those who want to enter the faculty of medical education must earn a certificate diploma or a degree before becoming a recognized teacher in a medical school or a university. 
Al- Sadiq Virtual University has employed digital technology to disseminate knowledge and skills through webinars and virtual workshops since the malady of COVID-19 hit us.

SIVU is dedicated to serving the cause of medical education for many many years through the use of modern technology. E-learning has become the norm as man-made geographical borders of a brick and mortar University have succumbed to digital technology. The fritters at the ankles of education or the chain around the neck of education have been shattered. Knowledge is free. 
Knowledge is for all knowledge seekers. 
SIVU is a partner in this worthy cause. Join us to learn and leave to serve humanity is our motto.

Ref.

.A history of medicine. Doughlas Guthrie 1960. Pub.Thomas Nelson and Sons Ltd.London, Ed, Paris, Melbourne, Toronto, NY.

Shabih H. Zaidi, MBBS; DLO-RCP & RCS (London), FRCS(Ed), FACS(USA), FICS, FCPS(Pak).

Mona Nasir, MBBS;  MCPS (Pak), FCPS(Pak), Ph.D. (Canada).

Ref. Teaching and learning methods in medicine. Springer 2015

 

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