>Medical records, patient outcome, …in 11th century in arab medecine by Kamel M. Ajlouni, MD, FACP; Usama Al-Khalidi, PhD

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Another interesting article on records keeping in the 11 th century in the arab world (Annals of Saudi Medicine, Vol 17, No 3, 1997), by the same authors. The authors emphasis on the impact of disponibilty of resources and reference which permitted to evaluate situations and benefit from experiences and previous practices and to avoid errors. As they wrote “The purpose of this article is to report some new information about medical record-keeping, outcome of care, and peer review in 11th-century (505-590, Hijra calendar) Arab medicine. Quality control was an important part of medical practice in that period, and detailed lists of requirements and conditions were therefore applied to the practice of medicine, such as compulsory examinations, delivery of the Hippocratic oath in public, mastery of anatomy, and familiarity with medicinal preparations and their uses“. Let us discover this fascinating points through the following lignes.
The practice of medical record-keeping dates back to the fifth century BC, when medical practice was dominated by Hippocrates and his followers. In the Hippocratic literature, medical records were used to demonstrate the cause and course of a disease. It was not until the 20th century that clinical records were routinely used as a tool to assess the quality of medical care, to educate physicians, and to evaluate the outcome of therapy 1,2 and management. Because of the increasing significance of medicolegal issues and their implications, the medical record has become an important means of evaluating the quality and outcome of patient care and of identifying errors and deficiencies in patient management with the subsequent legal responsibilities.1,2 It has been generally assumed that the clinical record was not used as a legal and educational tool before the middle of the 19th century, with most physicians relying on memory for the details of patient history and treatment and later describing them anecdotally. The authors became interested in the history of informed medical consent and medical record-keeping for legal purposes after finding a document of legal medical consent dating back to November 10, 1677.3
The purpose of this article is to report some new information about medical record-keeping, outcome of care, and peer review in 11th-century (505-590, Hijra calendar) Arab medicine. Quality control was an important part of medical practice in that period, and detailed lists of requirements and conditions were therefore applied to the practice of medicine, such as compulsory examinations, delivery of the Hippocratic oath in public, mastery of anatomy, and familiarity with medicinal preparations and their uses.4 The System, the Book, and the Author The system of Hisbah (quality control) was highly developed in the Arab world, during the 8th and 9th centuries. It involved quality control of everything in the marketplace, including scales, weights, produce, and services. A handbook for the Muhtasib (quality controller with the powers of a judge) was written in the 11th century by Al-Shaizari (died Cina 1094). 5 Several manuscripts of this book were copied in the 12th and 13th centuries, edited and published by Al-Baz Al-Arini in Cairo in 1946, and reprinted in Beirut in 1981.
The system of Hisbah was first brought to the attention of the Western world in 1860 by Walter Behrnauer. 6,7 The following is a translation of Chapter 37 of Al- Shaizari’s book. On Supervision (Hisbah) over Physicians, Oculists, Orthopedists and Surgeons Medicine is a theoretical and practical science which Sharia (Muslim Law) has permitted to be learned and practiced because of its (medicine’s) ability to preserve health and ward off maladies and diseases from this honored human body.
A physician is a person who knows the body’s structure; the temperament of organs; the diseases that afflict them; the causes; symptoms and signs of such diseases; the medicines useful therefore; substitutes for these medicines in case they are not available; methods of their preparation; and ways of their action so that he may keep a balance between disease and the quantity of medicines and differentiate the qualities among medicines. He who is not qualified to do that is not entitled to treat sick people or embark upon a risky medical treatment; nor should he deal with what he does not master of the above. It is said that their practice of appointing a physician in every city who was famed for his competence in medicine and then make him examine the other medical doctors in the city was started by the Greek kings. Those whom he found not to be up to the standard were ordered to dedicate themselves to more learning and were forbidden from treatment of patients. When a physician visits a patient, he must enquire from him about the causes of his disease and the pain he feels (and know the cause, the sign, the pulse and the drugs). Following that, he should write down a prescription for him that includes drinks and other things. Then he has to write down a copy of what the patient told him and of the prescription he has prepared to cope with the disease and then hand over the copy to the patient’s near relatives with those who were present with him in the patient’s room as witnesses. On the following day, he should come again, look into the disease, enquire from the patient about his condition, write down a prescription accordingly, and make a copy of what he has written and hand it to the patient’s household. He is to repeat that on the third and fourth day and so on until the patient either recovers or dies. If he recovers, the doctor will get his fee and bonus. But if the patient dies, his next of kin will go to the well-known Physician (“Hakim” or Chief of Physicians) and show him the copies written down by the doctor. If this physician finds them complying with the requirements of medical craft and rules, without any negligence and carelessness on the doctor’s part, he will tell them that. But if he finds otherwise, he will tell the deceased patient’s relatives: “You should claim damages for the death of your relative from the doctor who killed him out of malpractice and heedlessness.” So much were they honorably careful so that medicine should be practiced by qualified people and so that the practicing doctor may be deterred from any negligence whatsoever. The Muhtasib should make physicians swear Hippocrates’ oath, which he prescribed for all physicians to take, pledging themselves thereby not to give anybody a harmful drug, prepare a poison for anyone, describe amulets to any layman, tell women about medicines leading to abortion, or tell men about drugs causing sterility; and not to look at females when he comes to visit and see patients, divulge secrets or violate privacy.
Comment
It is of great interest to note that a set of standards was in place in 11th-century Arab medicine to qualify and license physicians. Also in place was a set of rules regarding patient care and treatment, starting with the history and examination of the patient, written orders witnessed by those who were present, with a copy of those records to the patient’s relatives, and daily follow-up with a written documented progress report and new written orders if necessary. The review of the records by the Chief of Physicians after death occurred represents the postmortem
examination of the outcome of therapy by a peer and may be the first documented reference to the practice of peer review.
References
1. Reiser SJ. The clinical record in medicine. Part 1: Learning from cases. Ann Intern Med 1991;114:902-7.
2. Reiser SJ. The clinical record in medicine. Part 2: Reforming content and purpose. Ann Intern Med 1991;114:980-5.
3. Ajlouni KM. History of informed medical consent. Lancet 1995;346:980.
4. Al-Asali KJ. An Introduction to the History of Medicine in Jerusalem. Amman: University of Jordan Publication, 1994.
5. Al-Shaizari AR. Attainment of the Highest Rank by Seeking the Hisbah (Edited in the 12th century, published in Cairo in 1946 by Al-Baz Al-Arini). Reprinted in Beirut: Dar Al-Thaqafah, 1981.
6. Behrnauer W. Memoire sur les Institutions de Police chez les Arabs, les Persans et les Turcs Journ. As 5e Serie 1860, T, XV:461-509, T,
XVI:114-90.
7. Behrnauer W. Notice Particuliere, Sur La Charge de Mouhtasib par le Scheikh Annabrawi Journ. As 5e Serie, 1860: T, XVI:347-92, 1861: T, XVIII:5-76.

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