Distinctive Attributes of Being a Good Doctor

Dr Maung Maung Nyo M.B., B.S. (Rangoon), Ph.D.(London)
M.A.(Medical Education, Michigan State), FOMERAD, M.D.(USA)
Professor, Block 1 Coordinator, FMHS, UNIMAS, Kuching, Sarawak,Malaysia;

Formerly: Professor of Anatomy and Medical Educationist, Institute of Medicine 1 and 2, Rangoon (Yangon), Burma (Myanmar); Member of the Anatomical Society of Great Britain and Ireland, Editor of the Burma Medical Journal; Editorial Member of the Universities Research Journal and Pyinnapadetha Sarsaung ( Universities Academic Journal), Myanmar Encyclopedia Yearbook.

( Dr Maung Maung Nyo at a UNIMAS Workshop)

Preamble

For most people in Asia, a “doctor” means a medical doctor, but in the West, if you say you are a doctor, they would ask, ”What doctor?” Once I was buying some food at a grocery store in London and the shopkeeper asked me,” What do you do here?” as I had become her customer for some time. I told her, “I’m a doctor doing research here.” She asked, ”What doctor?” I had to answer again, “ I’m a medical doctor doing research for my Ph.D.”

(Bust of Hippocrates)

My friend Dr Viji Thambyrajah (2006) had a different experience. He told me that once he was on an airplane the stewardess came to him asking advice as a man was fainting. He had to tell her he was not a medical doctor and did not know how to treat him. The air stewardess apologized him saying, “ I saw your name as Dr Viji and I thought you are a medical doctor.” He had to say, “All right, I’m a biochemist and not a medical doctor.”

So, there are many kinds of doctors apart from medical graduates. The American Heritage Dictionary (2006) classifies the doctor as follows:

(Cover of Institute of Medicine 2 for Saya Puza)

Doctor (Noun)

A person, especially a physician, dentist, or veterinarian, trained in the healing arts and licensed to practice.
A person who has earned the highest academic degree awarded by a college or university in a specified discipline.
A person awarded an honorary degree by a college or university.
Abbr. Dr. Used as a title and form of address for a person holding the degree of doctor.
Roman Catholic Church An eminent theologian.
A practitioner of folk medicine or folk magic.
A rig or device contrived for remedying an emergency situation or for doing a special task.
Any of several brightly colored artificial flies used in fly fishing.

(Burmese Doctors Attending to Victims of cyclone Nargis

in Burma)

Who is a medical doctor?

The question then is who is a medical doctor. The layman’s description would be the one who treats patients. Scientifically, a medical doctor is defined as follows:
“ A professional, qualified by education and authorized by law to practice medicine. The essence of being a professional is an ability to find solutions to difficult problems for which there are no easily discovered answers and to effectively handle medical situations where no two patients are identical even if they have the same condition. This differentiates the professional, who must deal with complex problems that tend not to have unambiguous, clear-cut solutions, from the technician.” (Cruess, Johnston & Cruess, 2004).

(A Burmese Doctor involved in Disaster Relief)

In a broader sense, a medical doctor is one who meets the following requirements:
(1) A learned person
(2) A healer
(3) A person certified by a professional body to practise medicine like apothecaries
(4) A medical graduate holding an M.B.,B.S. or an M.D. degree with or without other qualifications
(5) Any person allowed or licensed by the medical council of a country to practise medicine in that country.

(Hippocrates Refusing Gifts from Alexander)

Rights of a registered medical practitioner

In this modern world, the right to practise medicine is granted by the medical council of a country concerned like the Malaysian Medical Council (MMC) for Malaysia, Myanmar Medical Council (MMC) for Myanmar (Burma) and the General Medical Council (GMC) for Great Britain and Northern Ireland (UK). Generally, the rights are as follows:

(1) To add the prefix “Dr” in front of one’s own name like Dr MM or Dr XYZ
(2) To open a clinic or surgery
(3) To heal the sick
(4) To certify medical certificates
(5) To issue death certificates
(6) To prescribe drugs or medicines
(7) To author health education articles or books
(8) To appear in court as an expert witness
(9) To participate in all professional activities.

So, a medical doctor is a privileged person endowed with many advantages in the society. He is registered with the medical council that will safeguard his name, practice and position as belonging to the medical profession.

What is a profession?

A profession means a kind of livelihood with higher calling. It is not a trade or an amalgamation of different trades under an umbrella organization like a trade union. Nor is it a college of co-workers like barbers’ union. A profession is defined as follows:
"Profession: An occupation whose core element is work based upon the mastery of a complex body of knowledge and skills. It is a vocation in which knowledge of some department of science or learning or the practice of an art founded upon it is used in the service of others. Its members are governed by codes of ethics and profess a commitment to competence, integrity and morality, altruism, and the promotion of the public good within their domain. These commitments form the basis of a social contract between a profession and society, which in return grants the profession a monopoly over the use of its knowledge base, the right to considerable autonomy in practice and the privilege of self-regulation. Professions and their members are accountable to those served and to society." (Cruess, Johnston, and Cruess, 2004)

(Hippocratic Oath Original in English)

Code of Ethics for medical doctors

All medical doctors have to take an oath of medical ethics of one sort or another. During our graduation day, we have to take the Hippocratic oath translated and modified into Burmese (Myanmar). Many countries also adopt the Hippocratic oath partially or wholly with or without modification. The original Hippocratic oath runs as follows:

(Sone Inscription of Hippocratic Oath in Greek)

Hippocratic Oath (Classical Version)” I swear by Apollo Physician and Asclepius and Hygieia and Panaceia and all the gods and goddesses, making them my witnesses, that I will fulfill according to my ability and judgment this oath and this covenant:To hold him who has taught me this art as equal to my parents and to live my life in partnership with him, and if he is in need of money to give him a share of mine, and to regard his offspring as equal to my brothers in male lineage and to teach them this art - if they desire to learn it - without fee and covenant; to give a share of precepts and oral instruction and all the other learning to my sons and to the sons of him who has instructed me and to pupils who have signed the covenant and have taken an oath according to the medical law, but no one else.I will apply dietetic measures for the benefit of the sick according to my ability and judgment; I will keep them from harm and injustice. I will neither give a deadly drug to anybody who asked for it, nor will I make a suggestion to this effect. Similarly I will not give to a woman an abortive remedy. In purity and holiness I will guard my life and my art.I will not use the knife, not even on sufferers from stone, but will withdraw in favor of such men as are engaged in this work.Whatever houses I may visit, I will come for the benefit of the sick, remaining free of all intentional injustice, of all mischief and in particular of sexual relations with both female and male persons, be they free or slaves.What I may see or hear in the course of the treatment or even outside of the treatment in regard to the life of men, which on no account one must spread abroad, I will keep to myself, holding such things shameful to be spoken about.If I fulfill this oath and do not violate it, may it be granted to me to enjoy life and art, being honored with fame among all men for all time to come; if I transgress it and swear falsely, may the opposite of all this be my lot.”

(Statue of Hippocrates, Father of modern Medicine

and Prescriber of Medical Ethics bearing his Name,

the Hippocratic Oath)

Principles of Profession

However, the Hippocratic oath was promulgated in the days of Hippocraties when medicine was taught as a vocation from father to son or from the master to student by apprenticeship, attentive modeling and aphorisms. Medicine then was mostly an art and only lastly a science. In the modern days medicine becomes a science based on systematic teaching of basic medical sciences like anatomy, physiology and biochemistry, reinforced later by paraclinical subjects of microbiology, parasitology, pathology and pharmacology to learn the practice of medicine, paediatrics, surgery, obstetrics and gynaecology and forensic medicine. So, most modern doctors are more science-oriented than the doctors of bygone days starting from Hippocraties. Sir William Osler thus reminded us, “ The practice of medicine is an art, based on science.” His most famous quote is, “ Medicine is not only a science, but an art; it does not consist in compounding pills and plasters of all kinds, but it deals with the processes of life which must be understood before they can be guided.”

(Professor Dr Shwe Tin, Centre above and

Professor Dr Khin Myint Myint, sitting center,

below with Medical Graduates)

Modern methods of making (training) a doctor

Since the establishment of medical schools or faculties in the universities, future doctors are trained scientifically with teaching of basic medical sciences first either purely or combined with other paraclinical and clinical subjects. The traditional methods of teaching basic medical sciences like anatomy, physiology and biochemistry still remains in many medical schools including those at Oxford and Cambridge University. Some universities practiced an integrated method of teaching either horizontally or vertically like medical schools under the University of London or the Medical School of New Castle and of Edinburgh. A modern method of teaching is using the PBL method initiated by the McMaster’s University of Canada. The Faculty of Medicine and Health Sciences (FMHS) at University Malaysia Sarawak adopts a PBL method of teaching since its inception in 1995. This faculty (FMHS) has graduated many MDs since 2000. The mission, goals and objectives of the faculty are as follows:

Mission Statement

The Faculty of Medicine and Health Sciences, UNIMAS is committed to be an exemplary educational centre which will train men and women who will care for the health needs of the individual and the community and which will inspire them to do their duty with dedication and compassion and imbue them with a spirit of inquiry, integrity, creativity and courage.

(University Malaysia Sarawak,UNIMAS, new Campus)

Goal and Objectives

(1)To promote effective acquisition and understanding of the core knowledge of basic
medical sciences.
(2)To promote acquisition of knowledge and skills for competent patient care
and health promotion specifically at the primary level, but to be broad based enough to be a foundation for further training at secondary and tertiary levels.
(3)
To emphasize the importance of individual, family, community and cultural
differences in the manifestations and impact of physical and mental illness.
(4) To foster desirable attitudes to ensure humane, ethical and cost-effective health
care delivery.
(5) To encourage interest and skills in Self-Directed Learning (SDL) for life.
(6) To develop skills in information handling.
(7) To understand the concepts of scientific research methodologies.

(Faculty of Medicine and Health Sciences,FMHS, UNIMAS)

Objectives of Phase 1

General Objectives

To equip the Phase I Medical Programme students (Years 1 and 2) with a broad-based multidisciplinary core of knowledge, skills and attitudes required of Phase 1 students. This will include an appropriate level of understanding and knowledge of the normal structure (macro- and microscopically) and function of the human body, the aetiology and natural history of diseases, the effect and alterations of human body due to disease, the therapeutic interventions and its rationale, and the contribution of social, cultural and environmental factors towards health and illness.
To inculcate the appropriate the ethical, communication and interpersonal skills necessary for the Phase II Medicine Programme
To ensure that the students take the responsibility towards improving their
professional knowledge and continuing medical education.

Specific Instructional Objectives

At the end of Phase 1, the student should be able to demonstrate the following attributes necessary for progress to Phase II of the Medicine Programme:

a. Knowledge:

i. Understand and interrelate the normal structure and function of the body and its major organs systems.
ii. Evaluate the cellular, biochemical and molecular mechanisms that are vital in the maintenance of homeostasis in the body.
iii. Describe the various causes of disease and disease conditions and the underlying mechanisms involved.
iv. Explain the macro- and microscopic aspects of altered structure and function in disease.
v. Comprehend and justify principles of medical intervention to correct altered structure and function in disease.
vi. Principles of medical intervention to correct altered structure and function in disease.
vii. Application of basic biomedical sciences in learning and understanding clinical medicine and its problems.
viii. Define health and identify determinants of health. Able to calculate and interpret the health status indicators of the population.
ix. Explain the principles of health promotion and maintenance and relate the interrelationship between health and environment.
x. Understand and evaluate epidemiology of common diseases in the country and able to describe the health delivery system in Malaysia and identify the special features in Sarawak.
xi. Knowledge of some scientific methods of reasoning, study and research: able to collect, process, and analyse data using knowledge of basic statistical methods.
xii. Know some Information technology applicable to medicine.
xiii. Understand the implication of medical ethics and code of conduct for medical students and the medical profession.
xiv. The Generic and Complementary courses taught in UNIMAS.

(Sarawak General Hospital for teaching of UNIMAS Students)

b. Skills:

i. Ability to communicate clearly, considerately and sensitively with patients and their families, doctors, nurses, other health professionals and the general public.
ii. Ability to take a tactful, accurate, organised and problem-focused medical history.
iii. Ability to perform some basic physical examinations like inspection, palpation, percussion and auscultation.
iv. Ability to describe significant attributes of symptoms including location, radiation, intensity, quality, alleviating and aggravating factors, functional impairment and patients interpretation of symptoms.
v. Ability to utilise information technology to enhance ongoing learning, professional development, continuing clinical competence and research.
vi. Develop a critical understanding of the ‘health team’, its members, their relationship and method of working.
vii. Clarifying concepts and theories by thinking, discussing, accepting and seeing connections between normal and abnormal structures/functions.
viii. Ability to apply acquired knowledge in activities such as analysis, synthesis, evaluation, problem solving and decision-making.

(Dr Nan Ommar with Medical Students Presenting Elective Works)

c. Attitude:

i. Recognition that the doctor’s primary professional responsibilities are the health interests of the patient and the community.
ii. Respect for community values, including an appreciation of the diversity of human background and cultural values.
iii. An appreciation of the systems approach to health care safety, and the need to adopt and practise health care that maximises patient safety.
iv. A willingness to work effectively in a team with other health care professionals.
v. Demonstrate ability to identify areas of deficiency in his or her performance, and independently seek out appropriate information from available resources when needed.
vi. An appreciation of the responsibility to maintain standards of medical practice at the highest possible level throughout a professional career.
vii. Behave in an ethical, responsible, reliable and dependable manner, and project a professional image in interpersonal relationships, manner and dress that is consistent with the medical profession.
viii. To be aware of malpractice and bad behaviours that can tarnish the image of the medical profession, the university (UNIMAS) and the Faculty of Medicine and Health Sciences.

(UNIMAS medical Students Dancing at the Graduation Dinner)

Objectives of Phase II

To enable students:
i. Acquire knowledge and skills in comprehensive patient care in the various health settings
ii. Acquire knowledge and skills in disease prevention, health education and health promotion
iii. Practise medicine in a manner that is humane, ethical, moral and cost-effective
iv. Reflect and benefit from experience and
v. Adapt to change as part of the process of self-advancement and self directed learning.

(UNIMAS Professors of FMHS at Graduation of Their Students)

Bioethics and Medical Education

Medical ethics and codes of conduct as a doctor are important for a medical doctor to maintain his integrity and to keep his moral standard unimpeachable. One major function of every medical council is to maintain the ethical standards of its members. So, the teaching of medical ethics to medical students assumes an important role along side with the teaching of other disciplines. The FMHS is teaching medical ethics and codes of conduct to its students since its inception. This follows the pattern elsewhere (Van McCray, 2001 and Jafarey, 2003).

Why is there a need for ethics education to medical students and graduates?
The answer is: Inculcation of moral values in an individual starts from the cradle. By the time an individual starts medical schooling, basic values are assumed to be firmly and unshakably entrenched (Jafarey, 2003).

(Bust of Hippocrates)

The Malaysian Medical Council ( Abu Bakar bin Suleiman,2001) has emphasized the importance of medical ethics as follows:

The five basic ingredients of good medical practice are professional integrity, communication skills, ethical behaviour, treating patients with dignity and being a team player. A good doctor-patient relationship is encouraged as encompassing the following attributes;
(i) Be attentive and good listener
(ii) Avoid criticizing and admonishing patient
(iii) Be gentle and concerned while examining the patient
(iv) Be clear and discrete when discussing the possible diagnosis
(v) Give the relevant options when discussing treatment.

In the course of consultation,

(i) Be patient and compassionate
(ii) Avoid criticizing colleagues
(iii) Be gentle when seeking clarifications in the history
(iv) Cultivate a friendly and amicable relationship
(v) Avoid being business-like
(vi) Avoid presenting yourself as the embodiment of noble perfection
(vii) Avoid patronizing your patient
(viii) Remember that “customer is always right” for the patient
(ix) Act judiciously and tactfully if a patient requests a sick certificate feigning an illness
(x) Be positive in your view without belittling the patient
(xi) Never pre-sign sick certificate or prescription pads(xii) Never take advantage of a patient’ s predicament
(xiii) Maintain medical confidentiality for the preservation of the dignity, privacy and
integrity of the patient.

A good medical doctor as defined by the Malaysian Medical Council:

Practise with kindness, ethics and honesty.
Upgrade professional knowledge and clinical skills.
Maintain good patient records.
Maintain good communication with patients and relatives.
Maintain doctor-patient confidentiality.
Allow second opinion and referral to colleagues.
Maintain good working relationship with colleagues.
Be conscious of cost of health care.
Avoid publicity, self - promotion and abuse of position.
Be a partner in promoting global health.

Who is a good doctor, then?

We cannot say by the number of letters after his name (degrees and diplomas). Not by the school that he went to, amount of money he earns or the number and variety of cars ha has or the quarter he lives in or parctises. Certainly the definition of a good doctor lies outside the materialistic concerns (Shinder, 1998). A good doctor has the following attributes:

(i) He has an insatiable curiosity. This curiosity stems from a deep-seated need to understand the life process, its causes for being awry and measures to correct them.
(ii) He knows how to communicate, not just one way from him, but from the patient perspective as well. He is sympathetic as well as empathic.
(iii) He knows the power of belief and the magic in faith. He strives for the patient’s trust and belief in him.
(iv) He is a well-trained scientist. He knows medical science as expected of him.
(v) He touches the patient, not for information alone, but for transformation.
(vi)He is available at all times for the patient. He won’t avoid seeing a patient for a game
of golf with those in power and in wealthy position. The patient is the center of his
universe around which he revolves, towards which he tends and for whom he strives.”
(vii)Money does not come in his practice. Money is useful, but not essential for a good doctor.

(Dr Ba Than M.B.(Cal), FRCS (Edin), FICS,FACS

Professor of Anatomy, Surgery, Dean and Rector

Institute of Medicine 1, IMM, Burma)

Conclusion

Being a doctor carries a good social status, prestige and popularity among the people one serves. The doctor must always maintain that honour accorded to him/her by the community. To be a good doctor is to be a good, kind-hearted individual taking care of one’s brethren and their families in health and disease, in rain or sun, in woe and winning situation to make their lives better, happier and wiser. Whose life is better than being a good doctor in the world?

Dr Maung Maung Nyo
Professor, FMHS, UNIMAS
Kuching, Sarawak, Malaysia
(11.09.2006)

References:

Abu Bakar bin Suleiman, Tan sri Dato (2001). Good Medical Practice.
http://www/klinikong.com/good_medical_practice.html
American Heritage Dictionary (2006). Doctor.
http://education.yahoo.com/reference/dictionary/entry/doctor
Andrews, B.F.(2003).Sir William Osler’s Emphasis on Physical Diagnosis and Listening to Symptoms.
http://www.medscape.com/viewarticle/444905
Cruess, S., Johnston, S. & Cruess, (2004). Profession: A working definition or Medical Educators.
Guilbert, J.J. (1981). Educational Handbook for Health Personnel.
World Health Organization, Geneva , Switzerland.
http://www.aacom.org/education/journal-review/articles.asp?Id=333
Jafarey, A.M. (2003). Bioethics and Medical Education.
http://jpma.org.pk/JPMA/6june03/edit.html
Maung Maung Nyo & Ong Puay Hoon (2006). Medical Education: Teaching Medical Teachers How to Teach. An internal publication.
FMHS, UNIMAS, Kuching, Sarawak.
Shinder, T.W. (1998). Your Health Matters: The Art of Healing.
http://www.moondance.org/1998/autumn98/columns/yhm.html
The Free Dictionary (2006). Definition of Doctor.
Http://medical-dictionary.thefreedictionary.com/doctor
UNIMAS (1998 to 2006). Basic Documents.
UNIMAS, Kuching, Sarawak, Malaysia.
Van McCray (2001). The Role of Bioethics and Medical Education: A Crucial Profession Under Threat.
http://www.actionbioscience.org/biotech/mccray.html
Viji Thambyrajah (2006). Personal communication.