Beyond Medicine

(Source: HKMA News Aug 2019)

From the Editor

(Source: HKMA News Jun 2019) 

Dad, are we moving to HK just because you don’t need to take an exam?

After the Medical Council Saga on April 3, 2019, the “facilitation for qualified non-locally trained doctors in taking Licensing Examination and internship assessment” issue had escalated to receive the attention of the Chief Executive of Hong Kong.  The discussion had shifted from “facilitation in taking” to total abolishment of the internship assessment.  Even the Licensing Examination was deemed obsolete and dispensable.  I am not going into anti-intellectual arguments of whether all Hong Kong citizens should be able to have GOPC appointments whenever they like to, or to have their cataracts done immediately at $100.  Even if Hong Kong is flooded with doctors, these objectives are unattainable for obvious reasons.  Rather, as a doctor who has seriously thought about practicing abroad, I analyze below whether exemption of the Licensing Examination would be a crucial factor in the decision making.

Doctors are all specialists in examinations.  We are selected by examinations and then trained to tackle and to pass various examinations.  This is part of our skills.  Of course, it would be a merit if there is no need to sit for and pass an examination before one can practice.  However, it is unlikely a major concern.

To practice in Hong Kong means to migrate to Hong Kong.  Few doctors would act like domestic helpers.  We do not expect them to earn a living here to support their family abroad, or to work for several years, save some money and return to their homeland.  The decision is whether to live and to work in Hong Kong, not just to work here.

We are not supposed to provide basic specialist training to attract non-local doctors.  Front-line doctors and medical students are already foreseeing shortage in training opportunities.  In addition, it is hard to prevent a doctor from leaving Hong Kong immediately after he finishes his training.  We are talking about increasing the supply of manpower, and not promoting training centers.  However, to attract doctors who have finished their trainings and have establishment in their careers is more difficult.  The working environment in our public hospitals under the Hospital Authority is by no means pleasant.  It is true that some of the private specialists in Hong Kong are earning incomes even envied by the rich Legislative Councilors.  But they are the lucky few and they still need to face long working hours and the stress of private practice.  To most non-local people, living is much more than turning precious lifetime into clinic and surgery hours and money.

The living standard in Hong Kong is notoriously high worldwide.  A 3-bedroom 1000 square feet flat in non-rural area easily costs $30 million.  A balcony is a luxury.  Backyards are for tycoons.  A car park space costs $3 million and you still need to walk with an umbrella in a rainy day to get your car.  Unless the doctor is from a comparable city, it is not easy to adapt to such cramped living environment.

The next generation is likely to complain more.  The curriculum of local schools is uniquely designed for the DSE.  Immigrant doctors might need to explain to their kids what “learning” means here.  Starting from kindergarten, seats for good schools are sacred.  Seats for international schools are not only sacred, but also expensive.  Doctors in Hong Kong work hard so as to send their kids to study in UK, USA, Australia, New Zealand and everywhere.  It would be soul searching if immigrant doctors need to send their kids to universities back in their homeland.

Living is not just working or going to school.  Other factors that need to be considered include: language, culture and leisure facilities, air pollution, attitude of citizens towards foreigners, freedom and political stability.  The list is never exhaustive.  It is also highly individualized.  I am not saying that Hong Kong is not good and no one wants to migrate to Hong Kong. But it is a fact that Hong Kong people are always enthusiastic in emigration, or to secure a foreign passport even in Vanuatu.  It is an important decision to uproot a family and move to another country.  With so many factors at stack, it is hardly likely that an examination, which doctors are trained to handle, serves as a significant determining factor.  Some Legislators suggest that we should attract Hong Kong citizens who are practicing abroad.  If family reunification is not a strong enough urge, there must be factors other than an examination that deter the doctor from coming back.

It is thus improper to dispense of the Licensing Examination as an important and fair means to assess the standard of non-local doctors.  It is tedious and it needs some hard work to prepare for the Licensing Examination.  However, medical work is tedious.  It needs some practice to spell the word “chloramphenicol” correct.  It is tedious to follow standard procedures in performing surgeries.  It needs some hard work to stay updated with new medications for the treatment of cancers.  Are we really looking for doctors who would jump to Hong Kong just because they are exempted from taking an examination?   

 

(Source: HKMA News May 2019) 

All Hell Broke Loose

All hell broke loose when the Medical Council announced the results of voting on the proposal for “exemption from internship assessment for non-locally trained doctors who have passed the Licensing Examination” after its policy meeting on April 3, 2019.  The results were that all 4 options from the proposal were voted down upon.

This mess could be traced back to June 2017, when the Steering Committee on Strategic Review on Healthcare Manpower Planning and Professional Development issued its review report.  In July 2018, the Food and Health Bureau invited the Medical Council to consider plans to take forward the recommendations in Chapter 5 of the review report.  One of the key recommendations was the “facilitation for qualified non-locally trained doctors in taking Licensing Examination and internship assessment”.  The Medical Council then set up a Task Force to look into these matters.

There was general agreement among the Task Force members that the internship assessment period could be shortened.  At present, the assessment period after a candidate passes the Licensing Examination is 12 months, after which he can get his full registration.  However, candidates can apply for exemption up to 6 months if he has a specialist qualification comparable to a Fellowship of the College of the Hong Kong Academy of Medicine.  So, practically we were talking about whether to shorten the assessment period of another 6 months only.

It was also agreed by Task Force members that candidates who applied for the exemption of the remaining 6 months should have worked for a certain period in institutions in Hong Kong.  This was in line with the principle for the requirement of internship.  After practicing in Hong Kong, the doctor should be familiar with the local scenarios including the healthcare system, epidemiology and culture.

There were 2 areas not in agreement:

1. The period that the candidate was required to work in Hong Kong.  This covered both the length of the period, and whether the candidate needed to work for a further fixed period after he passed the Licensing Examination. 
2. The institutions concerned.  The disagreement was whether it should only be the Hospital Authority, or it should cover all 4 institutions including the Hospital Authority, the 2 Universities and the Department of Health.

So, there came up with 4 options for the full Council to consider and to vote upon during the policy meeting on April 3, 2019.  Basically, all 4 options included that the candidate should have passed the Licensing Examination; and should hold a specialist qualification.  The differences were:

• A. A total of 3 years’ experience (including the period before he passed the Licensing Examination) in any of the 4 institutions under limited registration.
• B. After passing the Licensing Examination, he had to work for another 3 years in any of the 4 institutions under limited registration.
• C. A total of 3 years’ experience in the Hospital Authority under limited registration.
• D. After passing the Licensing Examination, he had to work for another 3 years in the Hospital Authority under limited registration.

Actually the 4 options were in pairs.  They differed mainly by the period of experience, and where the candidate was to work.  It was like an “chicken or egg first?” argument for the period to work before a candidate could apply for the further exemption.  Obviously 3 years might be enough to gain his local experience.  A shorter period might help to attract more candidates to apply.  However, he might leave the public institutions immediately when he got his full license.  That did not serve the purpose of alleviating the shortage of manpower in the public institutions.  For the same token, allowing the candidate to work in any of the 4 institutions might defect the purpose of attracting overseas doctors to work in the Hospital Authority.  It is common knowledge that the working environment in the Hospital Authority cannot be described as attractive compared to the other 3 institutions.

There had been diligent lobbying by government related persons, and among the Medical Council itself.  It was debatable whether one should concede when matters concerned important principles.  However, in this matter, the number at stake was estimated to be a handful of candidates a year.  It might not be a good time to drag on when there was so much sentiment orchestrated in the public.

Before the voting, there had already been common consensus reached.  Whichever of the 4 options came out, there was unlikely to be vigorous action of opposition.  However, it messed up.  It was described as “the worst show-hand” where the player messed up with the best cards he had ever got.  A new set of voting rules was used.  Although there was no problem with the set of rules, when applied in these particular conditions, all it did was to foul up.  The procedure of the meeting did not reflect the opinions of members present.  The voting did not aim at problem solving and decision making.  The consensus was ignored, and all 4 options were defected by the dividing of votes because of fine details.

After that, all hell broke loose.  There were press releases, there were finger-pointings, there were words of regret from the government, there were open accusations, there were open letters, there were demonstrations.  And of course, there were back-stabbing.  And there were more orchestrated sentiments.

The newest progress as on April 12, 2019 was another press release from the Medical Council Chairman.  It stated that “in view of the importance of the subject issue”, he was going to propose to suspend the operation of the Standing Order of the Medical Council “so that the Medical Council may reconsider and decide the various matters on exemption of internship assessment for non-locally trained doctors by a voting arrangement to be agreed.”

It was not common when consensus could be reached by all stack-holders, and an even rarer occasion that it then got all messed up. 

(Source: HKMA News Apr 2019)

What Most Private-Practicing Doctors have to do under the Private Healthcare Facilities Ordinance (Cap. 633)?

The Private Healthcare Facilities Ordinance (Cap. 633) is the new law passed to regulate private healthcare facilities which include private hospitals, day procedure centers and clinics.  Nearly all private practicing doctors will be affected. 

Dated back to 2012, there was concern over the safety of procedures done in private clinics.  In October 2012, the Steering Committee on Review of Regulation of Private Healthcare Facilities, chaired by the Secretary for Food and Health, was established.  It was followed by a consultation period from December 2014 to March 2015.  In April 2016, a consultation report was published.  In June 2017, the Private Healthcare Facilities Bill was introduced into Legislative Council.  The Bill was then passed by Legco and it was Gazettal on November 30, 2018.  From 2019 onwards, there will be phased implementation of the new regime.  

The mode of regulation is through licensing.  Health services establishments listed in Schedule 9 to the Ordinance are to be regulated.  These include private hospitals, day procedure centers and clinics.  Private hospitals are premises with lodging.  Day procedure centers are premises without lodging, and providing “scheduled medical procedures” as listed in Schedule 3.  Clinics are premises without lodging and not providing “scheduled medical procedures”. 

Most of the private practicing doctors in Hong Kong practice in clinics.  Under the new law, clinics need to be licensed.  However, exemption arrangement is available for eligible small practice clinics.  Although the doctor needs to apply to the Director of Health for a letter of exemption, the requirements are less stringent than those for applying for a license.  The criteria are:

1. The clinic is operated by at most 5 registered medical practitioners, who are not under limited registration, as sole proprietor, partners or director of a company.
2. The sole proprietor/partner(s)/company director(s) have exclusive right to use the premises.
3. Only the sole proprietor/ partner(s)/ company director(s) can practice in the clinic.
4. Locums are exceptions.  They can work for each sole proprietor/ partner/ company director for less than 60 days in a calendar year; and less than 180 days per clinic in a calendar year.
5. Each registered medical practitioner (not under limited registration) can operate at most 3 exempted clinics.

  

We have to note than exemption is not automatic.  A doctor has to apply for a letter of exemption by providing proof to all of the above criteria.  Exempted clinics will not be subjected to the code of practice applicable to licensed clinics under the new regime.  For a clinic without exemption, it needs to apply for a license.  The license needs to be renewed.  There will be regular inspection.  And there are other requirements to fulfill such as the requirement of a chief medical executive. 

There are different arrangements for doctors who are with limited registration under Promulgations No. 3 and 4 of the Medical Council since 1995 and 2001 respectively; and who are practicing in clinics registered under the Medical Clinics Ordinance (Cap. 343).  Since Cap 343 will be repealed under the new regime, these clinics will be registered as “scheduled clinics” under Cap. 633.  The license will be valid for one year or less.  And these clinics will be subjected to the same code of practice as other licensed clinics. 

For all other private healthcare facilities, application for licenses is required.  A licensee has to be wholly responsible for the private healthcare facility’s operation.  Also, he has to appoint a chief medical executive.  The chief medical executive has to take charge of the private healthcare facility’s day-to-day administration.  There are requirements set for the chief medical executive, which are different for different types of private healthcare facilities.  For all private medical facilities, the chief medical executive has to be a registered medical practitioner.  One interesting point to note is that there is no offence under the new ordinance that targets at the chief medical executive specifically.  It is the licensee who is ultimately responsible for the operation of a private healthcare facility. 

There are regulatory measures to tackle with breaches of the law and licensing requirements.  A private healthcare facility service can be suspended.  A license can be cancelled.  To deter serious and intentional non-compliance, a licensee can be subjected to sanctions for certain contraventions.  For example, the maximum penalty for operating a private healthcare facility that is not licensed or exempted is a fine of $5 million and imprisonment for 5 years.  So, when the time comes, remember to apply for a license or a letter of exemption (and I am going to tell you when).  Another example is that for failing to comply with a suspension order to suspend a private healthcare facility, the maximum penalty is a fine of $1 million and imprisonment for 2 years. 

It is also statutory requirements to have complaints management system in place.  A licensee has to set up a complaints handling procedure at source.  Unresolved complaints will be handled according to a centralized mechanism.  A committee on Complaints against Private Healthcare Facilities will be set up. 

The above-mentioned licensing procedures will be implemented in phases.  For private hospitals, applications will commence in mid-2019.  Regulations are anticipated to take effect in early 2021.  For day procedure centers, applications are anticipated to commence in 2020.  The first batch is anticipated to take effect in early 2021.  For clinics, applications for licenses and letters of exemptions are anticipated to commence in 2021 at the earliest.  The anticipated date for measures to take effect is to be announced later.  

(Source: HKMA News March 2019)

The Oracle Said So

 

I don’t know since when there has been a tradition that on the second day of the Lunar New Year, officials of the Hong Kong Government or VIPs will go to the Che Kung Temple in Shatin and draw a fortune stick for Hong Kong.  This year, stick number 86 was drawn.  The oracle read: 石田為業喜非常，畫餅將來未見香。怎曉田耕耘不得，那知餅食不充腸。

The oracles from the Che Kung Temple are user-friendly because, unlike oracles from other temples such as the Wong Tai Sin Temple, they are written in simple Chinese language.  They are not in parables.  You can try to interpret the oracles yourselves without any knowledge of ancient stories.  Metaphors, when used, are also often easily understood.

Literally, the oracle said that it was nothing joyable to own a field composed of stone.  Bread drawn on a piece of paper would not smell good.  These were because a stone field could not be cultivated to yield; and a picture of bread would never lead to satiety.  The VIP who drew this fortune stick extrapolated the oracle and urged Hong Kong citizens to support government policies.  An expert in oracle interpretation, however, explained that we should instead be skeptical in government policies and visions.

This incident was widely reported in news.  Interestingly, another piece of news was that the winter surge of influenza highlighted the shortage of doctors in Hong Kong, and the government was considering inviting overseas doctors to practice in Hong Kong with all sorts of exemptions.

It was nothing new that GOPCs, A&E departments, medical wards and pediatrics wards became war zones during influenza peak seasons.  Patients had to wait hours or even days to be seen.  Occupancies of wards reached statistically impossible data of over 100%.  Doctors and nurses were seriously over-worked.  These happened every year since I was old enough to read news, that was more than 45 years ago.  I guessed reporters could just copy and paste their reports from previous years.

An amateur’s knee-jerk reaction would be to increase manpower: If there were more doctors, everything would be okay.  However, upon second thought, one should realize that merely having more doctors would not solve the problem.  Would there be more GOPC sessions or more sites?  Could A&E departments increase their turnover?  How about medical wards?  Would more doctors mean more beds?

Healthcare management requires special knowledge and skills different from any medical specialties.  That was the reason Hong Kong had to pay much for management personnel of the Hospital Authority.  When we heard complaints of extremely heavy workloads from frontline doctors, we expected more than producing and disseminating “add-oil videos” from TV stars.  When we read complaints from frontline doctors on wasting time on paper works and meetings, it should be understood that they were not asking for snacks or fish balls.  When we saw fleeing of doctors from the HA, we knew that there were management problems.  

However, what we encountered were propaganda here and there and everywhere that increasing the number of doctors instantly from allowing overseas doctors to practice in Hong Kong would be the magic bullet.  Suggestions were many, some innovative, most impractical.  Loopholes were poked in the MRO.  The Medical Council was asked to cater for it through the route of Limited Registration.  Various exemptions were proposed to attract overseas doctors.  Even the Licentiate Examination was deemed exemptible.

Ignoring the root cause of management problems and focusing on increasing the number of doctors was exactly like ploughing a stone field.  No matter how hard you worked, it would yield no crop.  It was a waste of time and effort.  The harder you worked on it, the further away from fruitful results you were.

Promising the public that no more chaos would be encountered in future influenza peak seasons after overseas doctors were allowed to practice in Hong Kong was exactly like drawing bread on paper.  No matter how beautiful the vision was pictured, it would not smell good, nor would it be of any practical use.

Actually, I am not against overseas doctors working in Hong Kong.  This is not something new.  There are recognized and time-honored routes.  The Licentiate Examination and the application of Limited Registration are open and fair.  Of course, there can be discussion on how to modify such procedures.  However, over-emphasizing overseas doctors and forget about solving the real problem is obviously 耕耘石田 and 畫餅充腸.  It would just serve to out-focus the discussion.  Worst, it would jeopardize the standard of doctors in Hong Kong.

Doctors should have scientific minds and should be evidence-based.  It is no way that we are going to rely on fortune sticks and oracles to guide patient treatment and healthcare system management.  We are not the superstitious types.  However, chanting that overseas doctors can solve the coming influenza surge crisis is no better than fortune telling.

It might work to beat superstition by superstition.

So I preach: THE ORACLE SAID SO!

 

（Source：HKMA News Feb 2019）

新春大吉

(Source: HKMA News Jan 2019)