The CM Staging for Carcinoma of City

Just finished reading the new book from Jeffrey Archer.  It was called “Mightier than the Sword”.  It was the fifth book of the “Clifton Chronicles”, and the sixth is to come in 2016.  The first book of the series, “Only Time Will Tell”, was released in 2011.  It was the story of how a shipyard boy, Harry Clifton, born in 1920 England, became the owner of a shipping line.  In “Mightier than a Sword”, Harry was in his fifties.  He became a writer of detective stories.  In this book, Jeffrey Archer told, though very briefly, how a writer’s pen could be mightier than a sword.

After 4 years and 5 books, the story began to lose heat.  It was still typical Jeffrey Archer, but the writer tended to have his attention lapsed.  He was more interested in lingering on than developing the story.  Plots were often oversimplified, sometimes to the point of absurdity.  Harry was able to beat the IRA (Irish Republican Army) and the KGB of the former Soviet Union single-handed.  His escape from danger was purely due to luck.  A hand-shake was as good as a contract.  Public officers would promptly step down when public opinions were against them.  Even the most shameless bad guy killed himself in this book when his crime was exposed.

Wait!  How come I equated valuing a hand-shake promise, or stepping down of public officers with fighting IRA and KGB single-handed as absurdity?  Weren’t these common believes?  Weren’t these once core values?  Had I been changed without noticing it myself?  Are prevaricating and obfuscating the norm now?  Then I read 2 articles in the Next Magazine issue 1304.  Stephen Vines wrote about an enormous scandal in Britain in which advertisers influenced the editorial content of the Daily Telegraph.  What he actually wanted to say was clearly spelled out in the title of the article: No scandal here… unfortunately.  The following page was an article in Chinese by LAM Pun Lee.  He noticed the recent attacks on the University of Hong Kong by different people in different fronts.  He concluded that it was the result of high-rank HKU management bowing to the rich and the powerful in recent years.  The title of the article said HKU invited others to follow suit by insulting herself.

I am not going to exclaim, in high pitch, that “This city is dying!”  But I know that this city is changing.  Or, at least, I am changing.  Motivational interviewing says that changes take stages.  When you try to move someone, you need to move him through such stages.  Buddhism teaches that one should be mindful of his state of mind (leaving alone those masters who can master emptiness).  I thus sat down and contemplated various scenarios in which common core values should have applied.  There were plenty of such.  All I needed to do was just to go through recent newspaper clips.  Though, common core values were no longer common.  I worked out the following 6 stages.

1. Realize that there is a problem and voice out
2. Realize that there is a problem and do nothing
3. Realize that there is a problem and try to take advantage of it
4. Ambivalent about whether there is a problem, as such things are common
5. There is no problem, this is the norm
6. There is no problem, and such practice should be encouraged and promoted

I used my experience as a real life example to illustrate.  In a meeting, a member made an interesting complaint, stating that the inspectors of the Food and Environmental Hygiene Department should be selective in their prosecution.  They should be sympathetic to poor citizens who worked hard to earn their livings in this hostile economic situation.  Obviously this member was at Stage 6.  I was at Stage 2.  I could identify problems with selective prosecution.  The inspectors would soon be threatened with violence or got corrupted.  However, the member looked serious and fierce enough for me to keep my mouth shut.  I was amazed to find that members were roughly evenly distributed among the 6 stages, with the legal advisor assuming Stage 1.  I guessed she was paid to do so.

I believed no one would be interested in the state of my mind, nor whether it had changed to the better or the worse.  However, it might be worthwhile to understand more about a committee, a tribunal or an organization.  How about a city?  My mind reverted back to that of a doctor.  A doctor tended to associate staging with cancer.  The TNM staging might not be appropriate.  Then I remembered the Gleason grading system for prostatic cancer.  We could randomly sample a city, challenged the samples with different staging scenarios and worked out a score.

I could not come up with a better name for the ingeniously invented staging system.  So, I called it the CM staging for carcinoma of city.    

(Source: HKMA News March 2015)

身體健康

(Source: HKMA News February 2015) 

It Is Not Easy

During the holidays I went to Chimelong Amusement Park in Guangzhou again.  Yes, again.  As I like that Park.  You can walk along in the Zoo and have close contact with quite a numbers of animals.  You can get a very close look at twenty odd pandas, a much closer look than in the Chengdu Panda Base, though you cannot pay 2000 dollars to take pictures with them.  You can also visit the 3 newborn panda triplets.  Maybe they are not quite happy with their funny new names, they are asleep most of the time.  For other animals, you can get into contact with them.  There are elephant rides, koala petting and animal feeding.  I like feeding giraffes most.  They fancy a certain type of leaves.  You can attract them by waving that kind of leaves only.  While it grabs the whole branch with its long tongue, you have ample time to take close-up pictures of its long eye-lashes.

During night time, there was nothing else to do except watching the International Circuit show.  Actually the show was great and well organized.  You must not miss it.  However, it might not appear as interesting after you had watched it a few times.  So in the intervals between pop corns and whatsapp messages, I began to notice some not-as-big-and-interesting events in the show.  There were athletes jumping from a wall and then bouncing back from a trampoline repeatedly.  That looked like cartoons and was quite funny.  My sister thought that there was no difficulty in it.  I recalled my high school days when I struggled clumsily on a trampoline and nearly broke my neck.

Many things are easier watched than done.  General practice is no exception.  I have been in general practice for more than 2 decades.  Academic-wise, I am not as bad as my trampoline skill.  I still find general practice far from easy.  Laymen, or even some colleagues, might think that general practice is seeing URTIs.  Well, yes.  General practice involves many URTIs, especially in Hong Kong.  However, among the URTIs, there are a few lung cancers, a few serious pneumonias, a few heart failures, and more asthmas than you expected, and once in a while, even a fatal syndrome we have never encountered, which was later named as SARS.  And sorry, I have to correct you that general practitioners are not seeing URTIs.  We are seeing patients with URTIs.  We see patients.  Among the patients with URTIs, there are patients with hypertension, patients with diabetes, patients with hidden colonic cancers, patients with depression, and once in a while, a patient with a rare disease that the professors in the 2 Universities have never encountered.  The scope of general practice is too large.  We are expected to know a bit of everything.  But that “a bit” is the essential bit to recognize early sinister conditions, to keep our patients healthy, and to relieve their immediate sufferings.

People like to talk about the importance of primary care and general practice.  Do they realize that general practitioners are fighting a deem-to-lose battle everyday?  Each and every of our patients will eventually develop one of the diseases that we are assumed to prevent.  There is no end point in preventive medicine.

How about the government which has been the biggest lip-service provider in primary care?  Do the officials know primary care?  Do they have a fair and accurate assessment of the importance of general practitioners?  Hong Kong is proud of the longevity of its citizens.  This fact often serves as evidence of the success of the Department of Health and the Hospital Authority.  The role of general practitioners is never mentioned.  It is estimated that general practitioners are seeing around 100,000 patients a day.  Some of them are working 7 days a week, and most of them more than 350 days a year.

On the contrary, the importance of general practice is often undermined, and general practitioners are openly attacked.  Vaccination is considered a purely mechanical procedure and can be done by non-healthcare personnel with minimal training in injection technique.  For a proper consultation, explanation of vaccination, consent signing, injection of vaccine and the taking care of any adverse reactions, a fee of $50 is paid by the government.  It has been hinted that it is a generous sum.

Another example: the Healthcare Voucher Scheme.  I am not going to repeat how absurd it was to focus on accusing general practitioners overcharging without any solid evidence.  No one was interested in investigating such matter.  No one was found overcharging and punished.  But the names of general practitioners were not cleared either.  What I wanted to remind you was the stated objective of the Scheme.  It was announced at the beginning and then reiterated in the first review that the Scheme served to encourage routine body check.  General practitioners were frowned upon for not achieving this mission impossible.  While most of the elderly were struggling with acute anomalies, they were expected to use the minimal sum of $250 for body check.  There was no added resource or facility to cater for those screened positive.

General practitioners are trained to modify behavior.  The gist of primary care rests on behavior modification.  People are encouraged to live health life styles, to vaccinate, and to look for early signs and symptoms of serious illnesses.  Behavioral modification is never easy.  The government has spent lots of money to promote vaccinations, to promote smoking cessation, to encourage regular exercise, and you name it.  It is hard to say any one of them is successful.  It is sure that sitting in the ivory tower and trying to modify the behavior of people over 70 with $250 will never succeed.

To young general practitioners and to my colleagues: don’t forget that in the course of modifying others’ behavior, our behavior is being modified too.  Our physical health might deteriorate because of the long working hours and the lack of exercise.  We might become more pessimistic and less compassionate because of repeated frustrations.  Have the government done anything to help?

(Source: HKMA News January 2015)

In Vitro versus In Vivo

What works in theory does not necessarily work in practice.  It is common knowledge that a drug that works in vitro (literally meaning “in glass”, which is in experiment settings) might not work in vivo (literally meaning “in life, or in human”).  Among other factors, the absorption, distribution, metabolism and elimination of the drug affect the concentration of it at its target site.  You might never reach the effective in vivo concentration in vivo without causing toxic effects to other organs.  However, another hard-to-believe but disturbingly true explanation for a drug not working in vivo is that, for one reason or another, the patient does not take the drug.

That also happened to my suggestion made to the Medical Council about not to criminalize doctors who had forgotten to renew their Annual Practicing Certificates.  In the Editorial of the September issue, I identified a situation where an apparently harmless mistake (forgotten to renew the Annual Practicing Certificate) might end in criminal conviction of the doctor and inability to practice for a long period of time.  This was because the doctor’s honest declaration that he had been practicing during that “window period” was taken to the strictest sense.  He was reported to the police for practicing while his name was not on the General Register.  I pointed out that in a similar case (Fong Ngai Chiu), the judge dismissed the criminal charge because he accepted the defense that the doctor believed for good and sufficient reason, although erroneously, that his name were on the General Register.  I pleaded the Medical Council Members to consider adopting the reasoning of such defense to exempt the absent-minded doctors from police investigations and criminal charges.

The suggestion was not going to work because Members did not take it.  There was legal advice stating that judgment from a district court had no binding effect on others.  Also, it was difficult for a doctor to say that he reasonably believed (erroneously) his name to be on the General Register because the Medical Council had sent out repeatedly registered letters to remind him.  That in itself was a reckless act.

Obviously this was not true.  It was hard to believe hundreds of doctors behaved recklessly every year.  The defense was not from the point of view of the Medical Council.  It should be from the point of view of the doctor.  A simple reason to explain how an absent-minded doctor could believe his name to be on the General Register was just that he had forgotten to update his address.  He was wrong to do so.  He had made a careless mistake.  But this should not be criminal.

Some members had different opinions.  Some insisted that such act was criminal and the Secretariat should report to the police whenever she encountered such declarations.  Some believed that the Medical Council was not in a position to give legal advice to doctors, especially those who had erred.  Some shared no sympathy with the absent-minded doctors and believed that harsh punishment was deserved.  Some found no problem with the current situation.

In conclusion, my suggestion did not work in vivo.  What I can do is to remind readers here to check whether you have renewed your Annual Practicing Certificate.  And I shall remind you later repeatedly.  However, I hope such act would not make the absent-minded doctors deemed more reckless.

Another sad outcome was from the Student Movement.  It was the situation where what worked in vivo did not work in vitro.  All along, scientists have been making various observations on things that happen in certain patterns, or something that work in certain ways.  The real challenges are how to elucidate the reasons behind such observations.  Why and how do things work?  Without knowing the true reasons behind, it would be difficult to reproduce the effects in artificial conditions with certainty.

For the Student Movement, it was planned to be the Occupy Central action which involved an estimated 1000 people to occupy Central for a day or so during a public holiday.  The aim was to arouse attention of Hong Kong citizens and international media on the issue of Chief Executive Election.  As you all know, it turned out to be near 10,000 people occupying different sites including major roads for more than 70 days.  No one knew exactly how these were sparked off.

In late November, while the Movement seemed to be caught in a dead end, student leaders tried to reproduce what happened in September 28.  Occupiers were asked to march against thousands of pre-informed police.  Sadly, what worked in vivo before did not work in such artificial conditions.  Many occupiers were injured, and so was the image of the Movement.

But I am not blaming any of the students.  Right from the start, no one would have expected them to achieve a political reform overnight.  Neither does Hong Kong need any revolution.  No matter how the Movement ends, their aim of sending a clear message to Hong Kong people has been achieved.  All of us will remember the yellow umbrella, the giant banner at Lion Rock, and various art works.

The Student Movement reminds me of Buddhist teachings.  The Buddha is not bringing you to the moon.  His teachings serve as a finger that points the way to the moon.  The right direction has been shown.  Everyone of us should work hard accordingly towards that direction.

(Source: HKMA News December 2014)

醫學會在哪裡？

假如說醫學會在「佔中」事件中表現令人滿意，相信未必會得到大部分人同意。可能不少會員心裡會問：「究竟醫學會在哪裡？」

這裡可以由兩個互相關連的情況分析：首先，醫學會在「普選」和「佔中」問題上比較沈默。尤其是「佔中」初期的一連串引起市民及各個界別關注的事件，醫學會並未發聲。今年三月，醫學會就政府政改咨詢向會者做了問卷調查，並就文件提供了調查結果和意見，開了記者招待會。之後，8 月 31 日，「人大」就普選方法提出「框架」，內容和醫學會會員意見有明顯落差；醫學會並未有跟進。9  月 28 日，87 枚催淚彈事件，市民及義工受影響；醫學會並未發聲。10 月 3 日，「子彈清場」威脅，醫學會並未見公開表示。終於，10 月終，醫學會大幅見報。亦有會長及會董蔡堅於不同媒體作訪問，內容卻是「佔中撕裂醫學界」、「醫學會政改民調激辯」、「佔領觸發醫學界師徒反目」等負面內部新聞。引發原因，卻是應否就「佔中」和普選等事件再作會員民調。噪音過後，就大家關注的普選與「佔中」事件意見，醫學會回復沈默。

第二點，是醫學會定位究竟在哪裡？究竟醫學會是否代表醫學界？醫學會又是否代表你？代表我？10 月 21 日，600 多位年輕醫生在報章刊登聲明，發表了他們對普選的意見。之後，醫學會收到會員要求，就該聲明用上了「醫學界」字眼澄清。醫學會當真計劃發表聲明，指 600 多醫生聲明「與醫學會無關」。但計劃被會董否決。10 月 28 日，另外 500 多位醫生於報章發表公開聲明，表達他們不同的立場和意見。之後，兩大醫學生出信回應。各種媒體亦就這兩則不同聲明有不少訪問和討論。11 月 4 日，首先發聲明的 600 多位醫生到醫學會遞交會員簽名信，要求就 831 方案等作會員民調。大家可能覺得，醫學會誰也不代表。

醫學會究竟在哪裡？遇上大事件，她何時會發聲？她的定位和立場在哪裡？是否有原則可跟從？又怎樣處理不同會員意見？

醫學會聲稱緊抱中立原則，特別是有關政治議題。背後理論是醫學會並非政治組織，而且會員有不同政見和立場。不過，在功能組別中，在「選委」中，在「提委」中，醫學界也是一個獨立而重要界別。醫學會又是否保持中立，不作參與？醫學會就政改咨詢表達了會員意見，任務是否就已完成？831 框架的明顯落差，醫學會又有否責任去了解會員意見，並且跟進表達？況且，世間上任何事情，不論政治與否，都很少會所有人意見一致。那麼醫學會的中立，如何執行？面對大是大非時，何時應放棄所謂中立的立場？

政治與否，很難定斷。連辦公室內也有所謂辦公室政治。面對暴力事件等明顯是人道問題，醫學會又如何一方面保持政治中立，一方面維護民康、保障會員？不表態、不發聲、不了解、不調查，又是否中立的表現？

就著這些和大家息息相關的問題，《會訊》決定做一個專題訪問。畢竟，醫學會的訊息，大家不應該只是從報章雜誌中得知。我走訪了會長史泰祖和蔡堅，因為他倆是今次「見報」主角。訪問當然會觸及事件前因後果。但爭拗雖然熱鬧，重點還是大家都屬於的醫學會。會員民調，暫時是不會進行的了。希望通過這次訪問，大家會更了解醫學會在政改和「佔中」的立場，和了解醫學會怎樣處理會員不同的立場。

最後，為了受訪者設想，和保持醫學會的中立，要附加一則重要聲明。為了視覺效果，我們一起到金鐘佔領區影相，時間是11 月 8 日下午 3 至 4 時。大家到場只是為了取景，並沒有參與集會式佔領行動。而且，當時下著不大不小的雨，所以大家都撐傘。而雨傘顏色純屬巧合，並不反映相中人對「佔中」的任何立場。

很累贅囉嗦啊！沒辦法啦！

 

(Source: HKMA News November 2014)

From the Editor

(Source: HKMA News October 2014)

Self-incrimination

This is very important.  A common minor mistake can turn into a criminal offence and prevent you from practicing for years.  Such mistakes are made every year by hundreds of doctors.  You might be one of them.

In 2013, a doctor was arrested in his clinic because of “practice of medicine without registration”.  He was then found guilty and fined $20000.  That was not the end of the story.  Since he had committed an offence punishable with imprisonment, he was caught by another section [s21(1)(a)] of the Medical Registration Ordinance (MRO) and he would need to go through investigations by the Preliminary Investigation Committee (PIC) of the Medical Council, and then might need to face an inquiry.  By the time, his name was still not on the General Register (GR).  He would need to wait for procedures such as a restoration hearing before he could start to practice again.

What had this poor colleague of us done?  Actually he had forgotten to renew his Annual Practicing Certificate.  After repeated reminders from the Medical Council, his name was removed from the GR.  He was caught not because he ignored the removal notice from the Medical Council and continued to practice after he knew of the removal.  He was caught because he incriminated himself when he filed the application form for restoration.  I have to tell you that there is a serious problem with the application form for restoration.  The applicant will end up either incriminating himself or making a false declaration.

To understand this typical “Catch-22” situation, I have to first get straight some facts:

1. A doctor has to renew his Annual Practicing Certificate before the end of each year.  If he fails to do so, after a grace period of 6 months, his name would be removed from the GR.
2. According to section 28 of the MRO, it is a criminal offence to call himself a doctor if his name is not on the GR.  He will be liable to a fine and imprisonment up to 3 years.  It is another offence if he practices medicine when his name is not on the GR.  He will be liable to a fine and imprisonment up to 7 years.  Moreover, he has to get rid of most of his medication stocks as he is no longer entitled to possess them.  Otherwise he would be liable to other fines and sentences of imprisonment according to the Pharmacy and Poisons Ordinance, the Antibiotics Ordinance and the Dangerous Drugs Ordinance.
3. When he is (finally) notified by the Medical Council that his name is removed from the GR, as a good and sensible citizen (as he is no longer a doctor), he will stop his practice and immediately file for restoration.  In the application form for restoration, he needs to make a declaration.  He needs to declare whether he has practiced medicine during the period when his named is removed from the GR.  It is this part of the form that makes him liable no matter what he declares. 
4. Obviously, if he is not aware of the fact that he has forgotten to renew his Annual Practicing Certificate, there ought to exist a period that he is still practicing before he is notified of his removal.  Our afore-mentioned colleague was honest enough to answer “Yes” to this question.  The result was that it amounted to self-incrimination and the police was notified.
5. What about answering “No” to that question?  In the notification of removal, the date of removal is given.  That means the doctor should be fully aware that he has been practicing between the date of removal and the date of being noticed.  He will be making a false declaration.  This, again, is a criminal offence.

Do readers feel akin to the ice-bucket challenge after reading the above facts?  Starting with a relatively minor mistake with no malice or fraudulent intent, a doctor can end up with criminal charges and be unable to practice for a long period.  This situation was brought to attention to the Medical Council.  However there had been to no avail.  The legal advice was that the applicant for restoration could choose not to answer that particular question.  Such advice was obviously nothing but absurd, if not an affront to common sense.

But don’t worry!  I have some important observations here for our members.  Every year, there are hundreds of doctors being removed from the GR in July due to failure to apply for the Annual Practicing Certificate.  They have to apply for restoration.  In all these years, I am not aware of any doctor being caught and found guilty of making false declaration.  You might draw an inference that the Medical Council is more tolerable to false declarations than self-incrimination.  I must point out firmly that I am not hinting such inference.  My advice is: try not to forget to renew your Annual Practicing Certificate.

As a member of the Medical Council, I think it is prudent to work out something more concrete to solve this problem than to provide facts for colleagues to draw inference.  I go through relevant sections of the MRO, procedures for restoration and cases on this matter.  There was a similar case in 2009 (Tong Ngai Chiu) and the judge dismissed the criminal charges.  The defense counsel brilliantly relied on the important defense developed from the case Fong Chin Yue.  I summarize as follows:

1. Section 28 of the MRO should not be interpreted in a way that there would be a “gap through which the innocent might fall to their harm”.  Criminalizing absent-minded-mistakes should not be the intention of the Ordinance.
2. Thus, there existed a defense to the charge.  “If the accused could prove on a balance of probabilities that he believed for good and sufficient reason, although erroneously, that the provisions of the Ordinance had been complied with”, he would not be guilty of the charge.
3. “A magistrate should approach such defence with fairness, common-sense, relevant consideration should be… whether the accused gained or stood to gain by offending the extent of any such gain, and how it compared with what he could earn by honest means.”

Following the decision from Tong Ngai Chiu, I suggest adding the following items to the restoration application forms:

1. Date of knowledge of being removed from the GR
2. Period the applicant has been practicing after his name was removed from the GR, if any
3. A declaration by the applicant that he believes for good and sufficient reason, although erroneously, that his name were on the GR during the period mentioned above

I believe (hopefully not erroneously) that such approach, with some refinement, can solve the Catch-22 situation for good.  I shall write to the Chairman of the Medical Council and introduce this approach for discussion.  In the meantime, please make sure you pay and apply for the Annual Practicing Certificate before the end of this year.  Since those absent-minded colleagues are removed from the GR in July each year, I don’t think anyone needs to draw any inference now.

(Source: HKMA News September 2014)