Drs. Ajlouni and Khalidi bring into the spotlight a fact widely unknown about medical record-keeping and peer review as practiced in the Arab world in the 11th century.1 Although there is a widely held assumption that regular record-keeping about patients was invented only in the last two centuries, it is difficult to accept that a sophisticated profession dealing with the very precious subject of human health would be left without written documentation for so many centuries. Judges, dealers, merchants, revenue collectors and teachers used records of their work from the earliest time. Why would physicians have been an exception, especially given the fact that their work is liable to challenge in case of an undesirable outcome? Dr. Ajlouni refers to the system of “Hisbah” (quality control) as applied to medicine in the 11th century. While hisbah involves supervision of the application of practice standards, the standards themselves must have existed earlier, in fact, much earlier. The book of “Ethics of the Physician” (Adabul Tabib) by Ishap bin Ali Al Rahawi, who lived circa 854-931 in Al Raha, in northern Syria, describes the process of licensing physicians, keeping patient records and their use in education, quality control, and litigations as follows: “...the physician was not allowed to sit for treating patients until after he passes the generally aforementioned tests and examinations. If he passes, he will be allowed. The earlier physicians [Hakims] have made them a chair called the wisdom chair * for its benefits and good appearance. No one shall sit in that chair except physicians. Until now, this chair is set up by some physicians in the Cham** and they sit in it. It used to be known that whoever sits in that position had been satisfactorily examined. “The physician, when entering a patient’s place to visit and treat, first calls for a blank white paper to write on, after pondering the patient’s condition: I entered the (named) patient’s place on the day of (such), which is the first, second or third day of his illness (as it is). I found his illness (named). This was indicated to me by the following conditions, the condition of his urine bottle, his pulse and the signs named such and such. I prescribed for him such and such drugs and such and such diet. He then leaves what had been written with the patient’s family. When he comes back, he sees what has changed or happened and records it in the same way, and so on in every visit. If he sees a sign that warns of worsening, he mentions that. If worsening does occur as he warned, he records it until the
end of the illness and the patient encounter. If the patient recovers, he takes that record to keep as a resource or a reminder if another condition happens to that human. If the patient dies and someone raises the question of a mistake committed by the physician, the physician meets
with the experienced people, he brings out the record to be examined by knowledgeable professionals in medicine. If the disease proves to be the same as was told, and the signs
were the signs of the disease that are characteristic for it, and the drugs and management were satisfactory, the physician would be thanked and would leave. If not, he shall get what he deserves. . .” 2 The above documented practice standards were common knowledge and were adapted and modified after the Greek medical heritage. Later on, these standards were enforced by law when the Abbasid Caliph “Al Muqtader” decreed in the year of 391 AH or 931 AD, that
no physician be allowed to treat patients unless he is examined and given a written certificate to show that he passed the exam.3 The Ethics book documented these practice standards at least two centuries earlier than the Al Shaizari book on Hisbah.
**Cham is the old term referring to the geographic area of Syria, Lebanon, Jordan and Palestine. More specifically, Cham as a name of a town refers to Damascus.
1. Ajlouni KM, Al-Khalidi. Medical records, patient outcome, and peer
review in eleventh-century Arab medicine. Ann Saudi Med
2. Ishaq bin Ali Al Rahawi. Adabul Tabib (Ethics of the Physician).
Verification by Dr. Muraizen Saeed Assiri. Issue No. 9. Riyadh: King
Faisal Center for Research and Islamic Studies, 1992:264-5.
3. Ibn Abi Osaibiaa. Uyunul Anbaa fi Tabaqatil Atibbaa (Sources of the
News in the Ranks of Physicians). Verification by Nizar Reda. Beirut:
Al Haya House, Beirut, 1992:302.