The personality paradox

I got lost this month.

My small-sized brain could not understand why prominent people and public figures kept talking nonsense.  Frank lies were thrown in our faces.  Public declarations that were affronts to common sense were made.  I would not consider them stupid.  Experience told me that it was usually those calling others stupid who were themselves stupid.  These prominent people and public figures were well known to be reliable and smart.  They were supported by people I respected.  Even for the nonsense, the people I respected kept their faith in those prominent people and public figures.

There must be reasons behind their behaviors.  Such reasons must be beyond my ability to comprehend.  I had thought about Buddhism.  Could it be collective karma?  This explanation did have some calming effects when you found lies thrown in your face.  But it did not offer much help in explaining individual behavior.  It was the same for my favorite Mappo Theory.  Well, if you are reading this Editorial, that means the world has not ended by December 21.

I turned to psychology to seek for hypotheses and theories to explain human behaviors.  I came across personality theories.  Personality could be defined as “psychological quantities that contribute to an individual’s enduring and distinctive patterns of feeling, thinking and behaving.”[1]  There had been constant searches and researches trying to classify, to understand, to predict and to change human behaviors.  In the recent hundred years, personality theories went in a circular fashion.  It went through biological theories, psychoanalytic theories, type theories, trait theories, social learning theories, the Big Five theories, and then returned to biological theories.  Yet, there was not a single unified and simple personality theory that could fulfill all these functions.  Among them, I found the Personal Construct Theory by George Kelly enlightening when applied to the above scenario.

George A Kelly (1905-1967) was a clinical psychologist engaged in the treatment of patients.  He found his standard Freudian psychoanalytic training inadequate when managing his patients.  He then developed a new theory in personality: the Personal Construct Theory.  Kelly started to explain his theory by assuming that people were like scientists in the sense that they would postulate theories, test them, and use them in their daily lives: “We started out with two notions: (1) that, viewed in the perspective of the centuries, man might be seen as an incipient scientist, and (2) that each individual man formulates in his own way constructs through which he views the world of events.  As a scientist, man seeks to predict, and thus control, the course of events.  It follows, then, that the constructs which he formulates are intended to aid him in his predictive efforts”.[2]  Here, the term “construct” was introduced and it stayed the key word for the theory.  He then stated out his Fundamental Postulate: “A person's processes are psychologically channelized by the ways in which he anticipates events.”[3]

I try to summarize the theory, in over simplified terms, into the following components:

1. Although both the external environment and thinking are in real existent, people perceive the external environment differently.  They construct the external environment in their minds according to their own experience and interpretations.
2. People behave in a way best to anticipate the future according to existing constructs, and to avoid conflicts with and contrast to their own constructs.
3. Stress and discomfort would develop if the outcome or anticipation of outcome does not conform to the person’s construct.
4. The process of construct formation and the constructs themselves are dynamic and modifiable.

So it was “construct” that mattered. While it took two to dance, it took three to form a construct.  When someone was saying that something was white, he was actually taking another two things as references.  One was similar to the object which he referred to as “white”, and another one as different from the two.  We could never know what exactly he meant without knowing what the two references were.  Nonsense that was an affront to our common sense might not be an affront to the liar’s common sense.  He was taking reference to something or someone else.  He did so in order to predict and to control the event in his own manner.

Of course he might have pathology in his construct formation.  Ironically, the treatment for defective construct system was Fixed-role therapy designed by Kelly.  In this therapy, the therapist worked out a new role with new sets of constructs for the patient to follow.  The patient would try to think and to behave as if he were the new person as prescribed.

Thus, the personality paradox I mentioned in the heading was several-folded.  First, I could not be sure whether I was the one having defective construct system.  Those prominent people and public figures with their supporters-whom-I-respected might have perfect constructs that guided them towards their brilliant future.  Second, they might be having pathological construct systems and thus they might benefit from treatment.  Third, they might be already undergoing treatment with the Fixed-role Therapy, but God knows who the therapist was.  Sadly, this paradox could not be elucidated as even post-mortem could not give an answer to psychological myths. 

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[1] P. 8, Personality Theory and Research 11^th Edition, Lawrence A Pervin 

[2] P. 12, The Psychology of Personal Constructs Volume One (1955), George A Kelly, Universal Digital Library 

[3] P. 46, The Psychology of Personal Constructs Volume One (1955), George A Kelly, Universal Digital Library

(Source: HKMA News December 2012)

The criminal charge of indecent assault and the disciplinary charge of misconduct in a professional respect

On November 4, 2012, a young doctor was found guilty of misconduct in a profession respect after a disciplinary inquiry held by the Medical Council.  The Inquiry Panel ordered that his name be removed from the General Register indefinitely.  The Inquiry Panel further ordered that the removal should take effect immediately upon its publication in the Gazette.  The Inquiry Panel also stated that the young doctor could not be a fit and proper person to practice as a doctor and that he could not be restored to the General Register at all.  The media referred the sentencing as the heaviest penalty ever imposed by the Medical Council.  Comparisons were also made to previous cases in which the defendant doctors were found guilty in criminal courts.  In contrast, this young doctor was found not guilty for the criminal charge of indecent assault, which aroused from a similar set of events leading to his removal from the General Register.  I shall analyze all these from a legal perspective.

In April 2010, the young doctor faced a criminal charge of indecent assault after he allegedly performed per vaginal examination on and took photographs from a female patient who consulted him for herpes zoster involving the lower body.  There were two major factors for his acquittal.  First, for the charge of indecent assault, there needed to be two components: actus reus (the act) and mens rea (the intention).  The act of touching the patient’s private part could constitute the act of indecent assault.  However, the prosecution also needed to prove that the defendant did it with an intention.  For example, if you waved at a taxi but accidental touched the breast of a lady walking from behind, it would unlikely be indecent assault.  In a medical setting, consent from the patient would be a legitimate reason for the act.  So the judge had to decide on whether there was consent, or implied consent, and the scope of the consent.

Second, for a criminal charge, the standard of proof was that the charge should be proved beyond reasonable doubt.  The jury or the judge had to be one hundred percent sure that the defendant had the intention to act indecently.  In this case, the judge, after taking all material facts and statements from witnesses into consideration, satisfied himself that there was a chance, maybe a very slim one, that the defendant doctor lacked the intent to act in a criminal way.  His acts, though stupid or inappropriate, might be accounted for by his relative lack of clinical experience.

For disciplinary inquiries by the Medical Council, things were different.  One should note that if this young doctor had been found guilty of his criminal charge, he would have been charged under section 21 (1)(a) of the Medical Registration Ordinance (MRO): that he had been convicted in Hong Kong or elsewhere of any offence punishable with imprisonment.  For this charge, he would have been judged by the inquiry panel mainly on the gravity of his offence.  And it would not have been a decision on professional misconduct.

In this actual case, an acquittal would not in itself lead to a disciplinary inquiry.  The inquiry was held because the case was referred by the Preliminary Investigation Committee (PIC) after investigating into a complaint or complaints received.  Section 21 (1)(b) of the MRO was invoked.  Basically, the young doctor was charged for conducting improper and unnecessary physical examinations; and improperly taking photographs and videos of several patients during consultations without consent.  The decision was whether he was guilty of misconduct in a professional respect.  The test for professional misconduct was set by the judge in the case of Koo Kwok Ho v the Medical Council of Hong Kong to be "whether the doctor's conduct has fallen short of the standard expected amongst doctors".  Note that there was no involvement of intention in the test.  Even when there was good intention, not to say malice ones, the doctor could be found guilty if his acts or behavior fell short of peer standards.

The standard of proof in disciplinary proceedings had been a focus of controversy.  Recently, it seemed to have been settled by a Court of Final Appeal case [Solicitor (24/07) and the Law Society of Hong Kong (2008) 11HKCFAR 117].  In para 116, it was stated that “the standard of proof for disciplinary proceedings in Hong Kong is a preponderance of probability under the Re H approach.  The more serious the act or omission alleged, the more inherently improbable must it be regarded.  And the more inherently improbable it is regarded, the more compelling will be the evidence needed to prove it on a preponderance of probability.  If that is properly appreciated and applied in a fair-minded manner, it will provide an appropriate approach to proof in disciplinary proceedings.  Such an approach will be duly conducive to serving the public interest by maintaining standards within the professions and the services while, at the same time, protecting their members from unjust condemnation.”  So, the standard of proof was not the criminal standard of beyond reasonable doubt, but the civil standard of a balance of probability with a somewhat circular logic built in.

After deciding that the defendant doctor had more probable than not fallen short of expected standards, the defendant doctor was found guilty of professional misconduct.  The Inquiry Panel ordered the removal of the name of the defendant doctor from the General Register in accordance with section 21 (1)(i) of the MRO.  This was in contrast to section 21 (1)(ii) where a time period was fixed for the removal.  Seemingly, removal without a fixed period was a heavier punishment as it appeared in the sequence in the Ordinance.  However, technically, the defendant doctor could apply for inclusion of his name in the General Register again as soon as the removal of his name was published in the Gazette.  So for a clearer message, both to the defendant doctor and to the general public, the Inquiry Panel also opined that there was practically no chance for his re-registration.

Another point to note was that the Inquiry Panel also ordered the removal to take effect immediately upon its publication in the Gazette in accordance with section 21 (1)(iva).  This meant that the Inquiry Panel satisfied that it was necessary to do so for the protection of the public.  This also added to the gravity of the sentencing as in normal circumstance, the removal order would not take effect if there was an appeal lodged.  

(Source: HKMA News November 2012)

Cogito Ergo Sum and Brain Washing

“Cogito Ergo Sum” can be translated as “I think, therefore I am.”  Many people take the words in their plain meaning literally and interpret the statement as encouraging people to think, and to think more so as to make their lives meaningful.  However, some regard “Cogito ergo sum” as the important conclusion of Descartes’ deep meditation to prove his own existence because of the fact and the action that he engaged in thinking.  His focus was on the “I”.  He satisfied himself that there was a thinker existing behind the act of thinking.  This seemingly obvious thinker/thinking paradox has haunted many philosophers.  Also through deep meditation, an opposite conclusion was reached by the Buddha.  He realized that there was no real existence of the person.  There was no thinker behind the act of thinking.  Rather, the thinker was an illusion made up to explain the act of thinking.

There are many philosophers and scientists who also doubt the obvious, particularly in the fields of the brain, the mind and thinking.  In late 1880s, psychologist William James came up with a new theory to explain the relation between our emotion and our behavior.  He proposed that our behavior was something instinctive, and our emotion only came after the behavior so as to rationalize it, or to explain for it as a habit of experience.  So, by his theory, our common sense was reversed.  People did not run from a bear because they were afraid of it.  Rather, they became afraid of bear because of the act that they ran from it.  Similarly, people did not smile because they were happy, but they felt happy because they were smiling.

Then in late 1960s, a young psychologist James Laird encountered William James theory and designed an ingenious experiment trying to verify it.  He succeeded in showing that people making happy facial expressions really felt happier; while those making angry facial expressions really felt angry.  Amazed by the results, other psychologists carried out various studies, in equally ingenious but different designs, and confirmed his findings.    

Also in the 1960s, another psychologist, Stanley Schachter, extended William James’ theory into bodily sensations.  At that time, it was known that different emotions were associated with different bodily sensations, such as change in heart rate, skin temperature and sweating.  However, there were obviously not enough parameters to account for the vast categories of emotions.  By a set of not-so-ethical experiments involving injecting adrenalin into participants, he was able to show that people tried to make sense of their increased heart rates by looking around them.  Thus people were much happier with increased heart rates from the adrenalin shots in a happy setting, and also angrier in an angry setting, than the controls with the saline shots.  So it was the bear that made you sweat, and then you looked around, saw the bear, and then began to feel afraid.

How about one step further?  Would the way we behave affect the way we think?  Can keep singing the national anthem make you more patriotic?  The book “The Wave” described how a 25-year-old history teacher and baseball coach created (too easily) a microcosm of Nazi Germany in his school.  In reality, in 1967, Ron Jones somehow unethically gradually modified his students’ behaviors to study the rise of Nazi Germany.  He lectured about the beauty of discipline, asked the students to sit in attention postures, and asked the class to repeatedly recite the phase “Strength through Community”.  He also created a class salute, gave memberships cards to students for the newly formed organization called the “Third Wave”, and encouraged students to report on anyone who openly expressed skepticism about the project.  The Third Wave grew by itself in days’ time and soon got out of control.  Ron had to call off the project in an assembly, and to explain to the students that how easily people’s behavior and belief could be manipulated.

You must have come across Zimbardo’s prison experiment about participants playing the roles of prisoners and guards.  Soon enough, participants fitted into their assigned roles.  The guards began to abuse the prisoners, while the prisoners tended to take such abuses reluctantly.  This was another strong illustration on how one’s behavior, in this case taking a certain role, would change one’s mindset.  You might not know that this experiment is required by law to be described in all books about the history of social psychology.  You might also not know that Zimbardo had himself adopted the role of the prison superintendent in his experiment.  He was astonished to find that his thinking had also been altered to the extent that he was unwilling to stop the experiment early when things got out of control.

When talking about brain washing, people tend to figure directly something to do with the brain.  However, in psychology, there is no crazy operation, flashing lights, white noise or injection of novel chemical to achieve this task.  Thinking is manipulated by modification of behavior in well proven experiments. 

(Source: HKMA News October 2012)

From the Editor

(Source: HKMA News September 2012)

Damn it! It is outrageous!

“If life gives you lemon, make lemonade.”

When you encounter something not-so-pleasant in life, try to make something meaningful and useful out of it.  This is a good and accurate description of what general practitioners in Hong Kong have been doing throughout all these years.  There are over two thousand general practitioners and family doctors serving the community.  Some of them have been working for decades.  They know people of their areas of service well.  They have been working for long hours, with average of ten to twelve hours per day.  A significant number of them even work seven days a week.  You can easily walk in a GP clinic and have quick and effective service in most of the public holidays including Lunar New Year.  However, there has been minimal support from anywhere.  The government has turned a blind eye to the snatching attitude of most landlords.  The government is supportive to the oppressive policy of the LINK towards general practitioners.  Apart from these, the contributions of general practitioners in the healthcare system in Hong Kong have never been recognized, not to say appreciated.  There have always been ungrounded and biased criticisms from government officials.  A recent example is the Healthcare Vouchers Scheme, in which general practitioners are the main service providers.  There are extra clerical and paper works with unrelated data input by doctors without any extra payment for the added service.  There has not been any complaint from the always-silent-group.  Bewilderingly, there are endless accusations of doctors over-charging the elderly.  

“If life gives you anything, just make lemonade.”

This is a new quote I invented to describe the behaviour of the government officials.  No matter what kind of project or new idea, they have the ability to turn it sour and ruin it.  The Healthcare Voucher Scheme is no exception.  Based on a single ambiguous result from an ill-designed survey, government officials have repeatedly said that there exist significant worries about healthcare providers raising their charges and thus cheating the elderly users and the government.  I have refuted such groundless and serious accusations openly and repeatedly in the past Editorials and in Ming Pao.  These can be retrieved in my blogs:  

http://cm-editorials.blogspot.hk/2011/02/doctors-were-framed-openly.html;  

http://cm-editorials.blogspot.hk/2011/03/take-it-or-beat-it.html;  

http://cm-editorials.blogspot.hk/2012/02/quirkology.html;  

http://chengchiman.blogspot.hk/2012/07/blog-post.html 

However, the following was reported in Ming Pao on July 18, 2012:

據了解，醫療券首階段檢討發現，70%長者用醫療券看傷風咳，有違政府推出計劃原意，即推廣長者使用私營預防性護理服務如體檢等。因此，政府擬在醫療券中期檢討研究如何將計劃扶入正軌，包括聘請兼職學生到私家診所實地蒐集醫生收費，從而探討如何防止私家醫生提高收費，變相將增加的醫療券金額袋入醫生口袋，預料明年會有檢討結果。

This is outrageous.  This affects the images of doctors seriously by treating some never verified accusations as facts.  I would like to remind anyone who stated such groundless accusations that there has never been any evidence to support them.  Have there been any complaints received?  Have there been any suspect doctors under investigation?  Has there been anyone arrested?  Has the government set up any hotline to receive complaints?  Since the accusation originated from a study, why don’t those so eager to pursue in this subject trace the participants in the interview and find out the bad doctors?

Again, this is outrageous.  The hidden official even took one step further and suggested to hire part-time students to spy on and to monitor doctors.  So, the clear message to the public was that the integrity of doctors was inferior to that of part-time students.  With minimal training and no accountability, part-time students should be given the power to go into records and charges of private doctors.  Based on the reports and findings of part-time students, a series of investigations should be initiated to look into any suspected doctor’s practice.  Should the students be officially called Red Guards?

Damn it!  It is outrageous!  I apologize for the use of language.  It is far too mild to express my anger and the absurdity of this matter. 

(Source: HKMA News August 2012)

Behind the "Largest Healthcare Fraud Settlement in US History"

 

In July, it was reported in newspapers and TV news that GlaxoSmithKline LLC (GSK) agreed to plead guilty and to pay $3 billion to resolve its criminal and civil liability arising from the company’s unlawful promotion of certain prescription drugs including Paxil and Welbutrin, its failure to report certain safety data about Avandia, and its civil liability for alleged false price reporting practices.  The resolution is the largest health care fraud settlement in U.S. history and the largest payment ever by a drug company.  Among the unlawful promotion activities were providing hunting trips and Madonna concert tickets for doctors.

In fact the GSK guilty plead was only one of such settlement cases.  What was special was the escalating amount paid setting a new record of $3 billion.  In January 2009, Eli Lilly and Company paid 1.4 billion for the criminal charges and civil liabilities of the off-label marketing of the drug Zyprexa.  In September 2009, Pfizer pleaded guilty to a felony violation of the Food, Drug and Cosmetic Act for misbranding Bextra with the intent to defraud or mislead.  Then $2.3 billion was paid to for the criminal offences and the civil settlement.  In April 2012, Johnson & Johnson agreed to paid $1.2 billion for minimizing or concealing the dangers associated with Risperdal.  In May 2012, Abbott Laboratories Inc. pleaded guilty and agreed to pay $1.5 billion to resolve its criminal and civil liability arising from the company’s unlawful promotion of the prescription drug Depakote for uses not approved as safe and effective by the Food and Drug Administration (FDA).

What had happened to these drug giants?  What were the unique features of these cases?  Would these cases affect our practices?  The following are my observations:

1. There were criminal charges.  It was the government against drug firms and there were vast investigatory power and resources.  In May 2009, the Health Care Fraud Prevention and Enforcement Action Team (HEAT) initiative was announced.  The GSK case, for example, was investigated by agents from the Office of Inspector General of the U.S. Department of Health & Human Services (HHS-OIG), the FDA’s Office of Criminal Investigations, the Defense Criminal Investigative Service of the Department of Defense, the Office of the Inspector General for the Office of Personnel Management, the Department of Veterans Affairs, the Department of Labor, TRICARE Program Integrity, the Office of Inspector General for the U.S. Postal Service and the FBI.
2. For the criminal charges, apart from fines, the drug firms had to enter into Corporate Integrity Agreements to “behave themselves” and the directors would be held responsible for further offences.
3. Of course there were civil claims.  Because of the contingency fee arrangement and the availability of class actions, product liability and personal injury cases were big money in the US.  Fascinating stories had been written by John Grisham on those lawyers with private jets launching advertisements to recruit clients.  For the current cases, there had been a new frontier of attack.  Under the qui tam provisions of the False Claims Act, private citizens are allowed to bring civil actions on behalf of the United States and share in any recovery.  The purpose is to encourage individuals to come forward and identify companies and individuals that defraud the government.  For example, in the Eli Lilly case, the whistle blowers were its former sales representatives and they shared in 18%, or $78,870,877, of the federal share of the (civil) settlement.
4. For your information, The Law Reform Commission published a report on 28 May 2012, proposing that a mechanism for class actions should be adopted in Hong Kong.  The proposal was put forward after the Commission’s consultation paper in 2009.
5. Although in these cases, it was admitted that free lunches and all kinds of benefits were provided to doctors to “encourage” them to prescribe those drugs in an off-label manner, the blame did not fall on the medical profession too much.  The main reason was that drug firms with money, assets and insurance coverage were targeted.  Doctors did not have deep enough pockets.  Moreover, doctors were also cheated as the drug firms admitted withholding important research results and information, and at the same time falsifying data of researches.
6. However, the images of doctors were affected.  At least they were not independent professionals putting patients’ safety and well being as the first priority.  Also, their abilities in critically appraising studies and evidence were doubted.  For a lay citizen, it was easy to figure out a doctor prescribing just according to a casual chat from a drug representative who provided free lunches and Madonna concert tickets.
7. All the cases were more or less on the off-label use of medicines.  By definition, any use outside those approved by the FDA is off-label use.  It can be about the indications, the dosages, the duration of use, and the use in specific groups of patients such as children and pregnant women.
8. With these cases and judgments, doctors might need to be more careful on the off-label use of medicines.  It does not mean that all off-label use of medicine should be prohibited or avoided.  In fact off-label use of medicine is very common.  However, certain points need to be remembered.  First, the doctor needs to know that he is using the medicine in an off-label manner.  Second, he has to be able to justify the use.  He can either support it with data or studies.  Exhaustion of available treatments may be another justification.  Third, he should try to communicate with patients about the off-label use and to keep records of such communication.  Of course, all these are easily said than done.  At least, we should have the word “justification” in mind.  

(Source: HKMA News July 2012)

Fifty Shades of Grey

I am not talking about the best-seller “Fifty Shades of Grey” in which Mr. Grey indulges in sadistic-masochistic behaviours, though I am looking forward to its appearing as movies, either in its original, or in its “modified” versions by Hong Kong film-makers.  It just appears to me that June 2012 is a month of different shades of grey.  Patient A worries about her daughter’s primary two examinations.  Patient B is desperate to get rid of his renal stone.  Patient C wonders whether Netherlands can enter the final of UEFA European Championship.  Patient D is counting his final days from terminal liver cancer.  Patient E has a relapse of depression from the European sovereign debt crisis.  Patient F is saving every penny for his 300 square feet dream flat and defaults follow-up for hypertension…  Last but not the least, Patient Z is worrying about global warming.

I am sure that June 2012 is no different from any June, or in fact any other months in 2012 or other years.  What is different is only my perception.  Somehow I had picked up more negative messages and feelings from my patients.  The Buddha teaches us that life is suffering.  Although he also points out the ways to the cessation of sufferings, they are more easily said than done.  However, I got a little bit enlightened after I paid a visit to Siu Chi.

Since 2007, I have been sponsoring a little girl, whom I named Siu Chi from her original name, in one of the charitable organizations.  I first met Siu Chi when she was a four-year-old in kindergarten.  She was adorably cute with pretty round face and short haircut fringe bang.  When the little one first met me in the playroom, she was terribly nervous and withdrawn.  For thereafter visits, I tried to “bribe” her by bringing her little gifts like toys, books, soft drinks, candies, and fries.  As most of the children did, she loved junk food from McDonald’s very much.  It took several months’ time and we became friends. 

Even as young as four, she was already a clever and practical child.  Whenever I appeared outside her classroom, she smiled and ran to me.  After having a quick glance towards my hands, she would ask me sweetly, “What are you bringing for me today?”, “Is it a box of colour pencils?”, “Is it a book this time?”…  And if she saw the paper bag of McDonald’s, she would scream happily, “McDonald’s!”

I became busier at work and studies, thus I stopped visiting her for a period of time.  It was months ago that I decided to re-visit her again.  Time flied.  I no longer picked her from the prep school building; instead, it was the big kids’ schoolroom in the main building.  When she was called by the staff, she put down a book she was reading.  We had not seen each other for one year and a half, and she was then a grown-up kid.  She was still having her short haircut, but no more flat fringe.  And she was wearing glasses!  Unlike when she was little, she threw a glance at my hands without saying a word about the gift.  I handed her the little gift and she happily held it in her hand.  I was curious why she did not do the unwrapping as she used to do.  I suggested her to unwrap the gift and see if she liked it, she answered in a charm look, “it is impolite to unwrap the gift immediately before you.” 

I was watching her playing happily with friends in the playground when a staff approached her.  I heard murmur of their conversations and then Siu Chi quietly sat next to me.  I asked if there was any problem and she replied, “The nurse said you thoughtfully come and visit me, so perhaps I should better chat with you instead of play with friends.”  I felt a bit uneasy while highly praising her for being a very good and polite girl.  I suggested buying her favourite fries for her next time.  She grinned. 

Now and then, to arrange a visiting time slot was a challenging issue for us.  Siu Chi was a primary school child, and she had her busy life.  She had tutorials and prep times after school every Monday, Tuesday, Thursday and Friday.  She attended drawing lessons on Saturday afternoons.  And for Sundays and public holidays, there were always group activities like visits or tours.  It was not until a few weeks later that we found another time to meet.  The staff called to confirm the meeting while I suggested buying fries for Siu Chi.  It was actually a rule for all sponsors to get approval from the staff before bringing any food to the children just in case they had food allergies or other physical problems.  The answer was surprisingly a “NO” this time.  The staff revealed that it was no good to have fries after her proper meal.  That was the only “NO” I got throughout the years since I had sponsored her.  Siu Chi was disappointed.  She whispered, “What if I eat the fries after my stomach digests the dinner food?” 

While we were worrying about the fries, I noticed that kids were brought in constantly by policemen.  Siu Chi seemed not disturbed by such scenes.  She said that she had got used to new friends coming and old friends going.  Was she worrying about her future?  Her mother was in rehabilitation center and her father in prison.  She had grown up and gained unnecessary social skills in two years.  What would be the road ahead of her?

Well, what I knew at that time was that I could paint some colours on the background of grey by smuggling some fries for her.  To Siu Chi, she practiced “the power of now” nicely.  Afterall, it is perception that matters.  

(Source: HKMA News June 2012)

The road to pubic-private partnership becomes more winding

The road to public-private partnership (PPP) between the Hospital Authority and private medical practitioners becomes longer and more winding.  This is my impression after going through the Director of Audit's Report No. 58 (Chapter 3), “Hospital Authority: Public-private partnership (PPP) programmes”, published on March 28, 2012.  While the Audit Commission focuses on performance indicators and cost-effectiveness of the programmes, I look more into the culture, attitude and intention of the Hospital Authority behind these programmes.

In 2008, the PPP was recommended as a means to solve the manpower and resources problem of the Hospital Authority.  Since then, all we have got are several pilot projects.  These pilots were implemented “to meet service gaps” identified.  After four years, these gaps are instead filled by increased services from the Hospital Authority.  So these pilots can be conveniently shelved.  These are mentioned in paras 2.8 and 2.9 of the Audit Report: “Over the years, the HA had made arrangements with the FHB to extend the operation of the Cataract Surgeries Programme and the General Out-patient Clinic PPP Programme beyond their original pilot periods.  As at December 2011, the two programmes were entering the fourth year of operation.  The HA did not have any plan for rolling them out as ongoing services.  Audit noted that the HA commissioned two new cataract centres in December 2009 and May 2011, and that a new clinic was opened in Tin Shui Wai North in February 2012.  It can be seen from paragraph 2.8 that the two pilot PPP programmes have been used as stop-gap measures to address service gaps identified.  According to the HA, such measures have short-term usefulness and objectives that will benefit many patients.  Audit considers that while the measures have contributed to the strategic objective of managing growing service demand, they may not be conducive to the long-term development of PPP in healthcare.”

There is no evidence of any intention of setting up sustainable PPP programmes.  The Audit Report concluded in para 2.23 that “Four years have elapsed since the HA launched its first PPP programme (i.e. Cataract Surgeries Programme) in February 2008.  Audit considers it timely for the HA to devise such a mechanism to take stock of the overall development of PPP, consolidate the experience (including good practices identified and lessons learnt) and map out the future strategy for the further development of PPP in healthcare.”

There is even no evidence of any intention of studying or developing workable modes of PPP.  The amount of subsidy from the government is obviously a key factor in PPP programmes.  However, there seems no interest from the Hospital Authority to investigate into this factor.  One example is the Share-care Programme in which the $1200 subsidy is far below market price.  This is described in para 2.11: “As noted in paragraph 2.6(c), an objective of launching the pilot PPP programmes was to test the market and public acceptance.  This could help the HA design better PPP programmes in the future.  So far, the HA has varied the eligibility criteria for some of its PPP programmes, but it has not changed other key parameters (e.g. levels of government subsidy and patients’ co-payment) of its PPP programmes since they were launched.”

So what happen to these pilots?  They are either extended to be never ending pilots, or they would be ended with pending evaluations, and the participating patients are going back to the Hospital Authority as if nothing has happened in between.  Para 2.13 describes an interesting hidden exit plan: “Audit noted that the HA had not explicitly laid down any exit plans for its pilot PPP programmes.  Upon enquiry, the HA informed Audit in February 2012 that, while not laid down, its exit planning was based on the HA’s fundamental responsibility of providing healthcare for all Hong Kong residents.  According to such exit planning, should a PPP programme be terminated, the HA was ready to take back all affected patients.”

With such attitude and intention, the Hospital Authority is likely to implement all other recommendations from the Audit Commission, leaving the above mentioned “minor” parts.  Thus it is supposed to “step up efforts in promoting the charitable arrangements offered by participating ophthalmologists of the Cataract Surgeries Programme; and in launching other PPP programmes, examine the desirability of implementing similar charitable arrangements.”  The responsibility of the government and the Hospital Authority will be shifted to private doctors.  Apart from that, private doctors are expected to “include the HA as a co-insured party in their insurance policies for the PPP programmes.”  The private “partners” should be monitored more closely and be paid according to their performance.  The Hospital Authority is recommended to “review the effectiveness of performance-based payments; and consider adopting performance-based payments for PPP programmes in future.”  Also, it should “step up the monitoring of healthcare providers’ service delivery; and remind healthcare providers to give due consideration to the service protocols.”

The conclusion is that the title of this article is wrong.  There has not been any road to public-private partnership.  There might or might not be a road to public-private partnership.  If there is going to be one, it will be long and winding.

(Source: HKMA News May 2012)