The Anti-antibiotic Abuse

While people are constantly talking about the abuse of antibiotics, I see a trend in the abuse of anti-antibiotic measures.  I would like to draw the attention of the abusers and those being abused to this unhealthy trend.  The following is an analysis of the similarities and undesirability of the two abuses.

The use 

Antibiotics are very useful in treating bacterial infections.  Since their invention, lethal bacterial infections and epidemics are much better controlled.  Once, antibiotics were regarded magic bullets.  However, even magic bullets have their limitations.  You need to properly aim your targets before the bullets can hit them.  And, if your targets are wearing magic-bullet-proof vests, antibiotics lose their halos.

To guard against blind-shooting and the development of antibiotic resistance, measures against the abuse of antibiotics are very important.  These measures are multi-faceted.  You can increase the knowledge of the public and the medical profession.  You can modify the practice of antibiotic uses through legislation such as classifying antibiotics controlled medicine, or through education such as launching campaigns.  Since the awareness of the need to control the abuse of antibiotics, most antibiotics are still very effective against common infections.     

The abuse 

Because of one reason or another, doctors began to abuse antibiotics.  Abuse is the use when there is no indication, or when the harmful effects outweigh the desirable effects.

It is true that over 80% of upper respiratory tract infections do not need antibiotics.  However, it is also true that over 80% of doctors do not need to be reminded of this fact.  As in the use of antibiotics, we need to consider the indications, the spectrum, the doses, the durations and the side-effects when instilling measures against antibiotic abuses.  Targeting all doctors with over-potent and too-board-spectrum measures is obviously an abuse.  Asking patients to take pictures of all medications for all consultations so as to guard against antibiotic abuse is obviously worse than prescribing antibiotics to all patients, no matter they come for upper respiratory tract infections, or for consultation of mood disorders.  

The lethal side-effect 

One of the major reasons for the need of justified use of antibiotics is to prevent undesirable effects, among which is the disturbance of the normal flora of the body.  Abuse of anti-antibiotic measures will not kill the patient, nor the doctor; but they will kill the important trust between the patient and the doctor.  Undermining the trustworthiness of doctors in their prescriptions will naturally prompt patients to query the diagnoses and the management.  Without trust, how can the doctor convince the remaining 20% of the “URTI patients” who suffer from scarlet fever, Streptococcal pharyngitis and pneumonia to take antibiotics? 

Just like antibiotic resistance, there might also be group effect for mistrust.  Instead of rendering the individual advice on antibiotic use for upper respiratory tract infection useless, mistrust can affect other decisions on the use of antibiotics.  Alarmingly, mistrust, like antibiotic resistance, is also communicable among patients. 

Another serious side-effect for antibiotics is drug allergy.  We cannot accurately predict which individual will develop drug allergy towards which antibiotic.  However, a significant percentage of individuals will have drug allergy is a certainty.  10% of the population is sensitive towards penicillin.  Actually, people can have adverse reactions towards measures against antibiotic abuse.  In the anti-antibiotic campaign, it is interesting that seeming no one has addressed this hypersensitivity issue.  There are individuals who over-react to the anti-antibiotic messages and see antibiotics as evil.  Hypersensitive parents might put their children at risks of fatal bacterial infections. 

Evidence-based practice

Some, if not most, cases of antibiotic abuse are out of good will.  It is just that the doctor does not know that antibiotics do not help.  Clinical judgments on the causative agents of infection might not be accurate.  Even some bacterial infections, such as otitis media, might not need antibiotics.  These are the reasons that evidence-based practice is important.  Epidemiology tells us the prevalence of viral pharyngitis.  Clinical trials tell us that antibiotics might not be useful for cough. 

The appeals for judicial use of antibiotics are out of good wills.  However, chanting the mantra of antibiotic abuse is only self-serving the chanters.  Calling for outrageous actions will have no effect apart from side-effects.  Behavioral modification is the biggest challenge in community medicine and family medicine.  It needs expertise and it needs skillful means.  It is time to go back to evidence-based practice in the control of antibiotic abuse. 

The Abuse by others 

Doctors are not the only contributors for antibiotic abuse.  Despite being controlled medicine, antibiotics can easily be purchased by patients without prescription in Hong Kong.  In agriculture and fisheries, antibiotics are abused to a much greater scale.  Tons of antibiotics are routinely used in the hope of preventing diseases.  It is important to behave ourselves.  But it would be irresponsible if we ignore the big picture and never mention the other sources of antibiotic abuse.  In doing so would divert the public attention, scapegoat the doctors, and at the same time would not solve the problem. 

The relation between the medical profession and the public has also been undermined by various other sources.  Some attack doctors for not being able to treat the root causes of diseases.  Some claim that their treatments are better as they are without side effects.  Some claim that doctors are poisoning their patients with all kinds of drugs.  Some are manipulating patients’ spines to treat rhinitis and irritable bowel.  Some say that they are natural and thus superior. 

Facing all these frivolous, yet appealing, claims, it is important to avoid acts that would further undermine the trust on our profession.  The anti-antibiotic abuse needs to be stopped.

 

(Source: HKMA News December 2017)

You're working too hard.

(Source: HKMA News November 2017)

The Remains of the Day

“What do you think dignity’s all about?” 

“It’s rather a hard thing to explain in a few words, sir.  But I suspect it comes down to not to removing one’s clothing in public.” 

This was what Mr. Stevens, the butler of Darlington Hall, thought about dignity.  Interestingly, nowadays, people are a bit too eager to stripe openly.  It is not sure whether there are different interpretations of dignity, or different moral values. 

Mr. Stevens 

Mr. Stevens was the story teller.  Actually the story was plain recall of the remains of the days while our butler was preparing and then driving from Oxfordshire to Weymouth in his 6-day-trip.  He had been the butler of Lord Darlington since before the First World War, until 3 years after the death of Lord Darlington, which was shortly after the Second World War.  The huge Darlington Hall was sold to an American, Mr. Farraday.  The staff team was then instructed to be reduced from 18 to a mere 4.  In the name of a precious holiday offered by the new owner, Stevens drove to visit the Housekeeper, Miss Kenton, who had left some 20 years ago when she got married.  He received a letter from her hinting that she was not happy and was still fond of the old days while she was working in Darlington Hall.  He was in the hope that she could join his team again. 

Stevens was a reserved, subtle and strictly business person.  He valued his career and took pride in his professionalism.  He saw the core value of a great Butler to be his dignity.  “Dignity has to do crucially with a butler’s ability not to abandon the professional being he inhabits.  Lesser butlers will abandon their professional being for the private one at the least provocation….  The great butlers are great by virtue of their ability to inhabit their professional role and inhabit it to the utmost; they will not be shaken out by external events, however surprising, alarming or vexing.  They wear their professionalism as a decent gentleman will wear his suit; he will not let ruffians or circumstance tear it off him in the public gaze.” 

But Stevens was described as taken his role too far, to the extent that he was constantly wearing his masks and not just his suit.  He overlooked his father’s old age and continued to prescribed him much labor works as an under-butler.  W hen his father died of stroke in his tiny room in Darlington Hall, Stevens was busy attending an important function held by Lord Darlington concerning the post-First-World-War Germany.  When Miss Kenton tried to show her affection towards him, Steven just deflated it with criticism on her household work.  Finally, he met Kenton, who was then Mrs. Benn.  She confessed to him that she was actually in love with him and her agreeing to get married was just a gesture to annoy him.  However, after all these years, she had accepted her life as such and she had no intention to leave her husband and go back to work at the Darlington Hall again.  Stevens only showed the slightest regret, and decided to move on when he was watching the sun set. 

Mr. Kazuo Ishiguro 

Mr. Kazuo Ishiguro is the Nobel Prize-winning writer this year.  The Remains of the Days was written in 1989, the year I graduated.  It was awarded the Man Booker Prize for Fiction in the same year.  Ishiguro was not writing on the romance between Stevens and Kenton, as there was minimal.  Kenton’s role was to highlight the character of Stevens.  The writer wanted to reflect his worldview through the narration of Stevens, a rarity in the world.  He wanted to talk about dignity, about democracy, about universal suffrage, and about dictatorship in the background of the post World War II period. 

Here comes Lord Darlington, who questioned the democracy system of Britain.  “Democracy is something for a bygone era.  The world’s far too complicated a place now for universal suffrage and such like.  For endless members of parliament debating things to a standstill….  The present parliamentary system is compared to a committee of the mothers’ union attempting to organize a war campaign….  People are suffering.  Ordinary, decent working people are suffering terribly.  Germany and Italy have set their houses in order by acting.  And so have the wretched Bolsheviks in their own way, one supposes.  Even President Roosevelt, look at him, he’s not afraid to take a few bold steps on behalf of his people.  But look at us here, Stevens.  Year after year goes by, and nothing gets better.  All we do is argue and debate and procrastinate.  Any decent idea is amended to ineffectuality by the time it’s gone half-way through the various committees it’s obliged to pass through.  The few people qualified to know what’s what are talked to a standstill by ignorant people all around them.” 

Then, Ishiguro, through Stevens, said, “A butler’s duty is to provide good service.  It is not to meddle in the great affairs of the nation.  The fact is, such great affairs will always be beyond the understanding of those such as you and I, and those of us who wish to make our mark must realize that we best do so by concentrating on what is within our realm; that is to say, by devoting our attention to providing the best possible service to those great gentlemen in whose hands the destiny of civilization truly lies….  If a butler is to be of any worth to anything of anybody in life, there must surely come a time when he ceases his searching; a time when he must say to himself: ‘This employer embodies all that I find noble and admirable.  I will hereafter devote myself to serving him.’  This is loyalty intelligently bestowed.  What is there ‘undignified’ in this?  One is simply accepting an inescapable truth: that the likes of you and I will never be in a position to comprehend the great affairs of today’s world, and our best course will always be to put our trust in an employer we judge to be wise and honourable, and to devote our energies to the task of serving him to the best of our ability….  It is hardly my fault if his lordship’s life and work have turned out today to look, at best, a sad waste- and it is quite illogical that I should feel any regret or shame on my own account.” 

 

(Source: HKMA News October 2017)

How About Demand?

How About Demand?

My Question on the Strategic Review on Healthcare Manpower Planning and Professional Development Report 

Finally, the Steering Committee on Healthcare Manpower Planning and Professional Development, which was formed in 2012, has published its report (the Report) on the Strategic Review on Healthcare Manpower Planning and Professional Development (the Review) in June 2017.  The Review is very important.  As stated by the Chairman of the Steering Committee, Dr. KO Wing Man, “following the conclusion of the Review, Government will soon embark on an updating exercise on manpower projections in consultation with the relevant stakeholders and invite each and every of the Boards and Councils for healthcare professions to submit detailed and concrete proposals for implementing the recommendations of the Review taking into account the unique circumstances of individual professions.  We shall take all necessary steps to bring supply and demand of healthcare professionals into board equilibrium over time.”  This is in line with the aims of the Review, which are to make recommendations to: “cope with the anticipated demand for healthcare manpower; and facilitate professional development of healthcare professions.” 

I must confess that I am none the wiser after reading the Report.  I would like to share some of my observations and doubts with readers.  I shall concentrate on the parts concerning the manpower planning of doctors.  I shall make references to the content of the Report as much as possible. 

Training on evidence-based medicine teaches us that when reading a report, we need to study the methodology so as to appraise the validity of the results; to consider whether the findings support the conclusion drawn; and to be aware of the assumptions and limitations of the report. 

Basically, the approach of the Review is to calculate and to predict the demand and the supply of doctors in future years, and then “to quantify the difference between the projected demand for and supply of healthcare professionals i.e. projected manpower gap in terms of full time equivalents (FTEs).”  For the demand model, “historical utilization data and the Hong Kong demographic projections (2004-2015) were used to project age-, sex-specific utilization volumes.  These projected volumes were then converted into FTEs and subsequently further adjusted for externalities and policy interventions.”  “The supply model is a non-homogenous Markov Chain Model, where workforce systems are represented as ‘stocks and flows’.  These projected volumes were then converted into FTEs and subsequently further adjusted for externalities and policy interventions.” 

I would say that the model is beyond comprehension to all doctors.  This is because apart from the fact that the model is complex, there is no intention for the Report to explain to readers in any detail how the model works.  To me, the supply arm is relatively simple.  The majority of doctors come from the 2 Universities and the numbers are highly predictable.  For non-locally trained doctors, it is unlikely to have any substantial changes in number unless there are major policy changes.  The Report does not recommend any such major policy changes.  “The Steering Committee considers that while measures should be taken to facilitate experienced non-locally trained doctors to come and practice in Hong Kong, the quality and competency level of these doctors should not be compromised.  MCHK should continue to be entrusted to uphold the professional standards of doctors in order to safeguard patient safety and interest in Hong Kong.”  Recommendations to increase supply include increasing the number of UGC-funded training places, retaining doctors to work in HA, recruiting non-locally trained doctors through limited registration and established mechanism. 

For the demand part, “the projection for doctors takes into account the expected utilization rates of services drawn from HA and DH for the public sector, and those of private hospitals as well as the Thematic Household Survey conducted by the Census and Statistics Department for the private sector.  Demand from the academic, teaching and training sector has also been considered.  The projection has been adjusted for the impact of externalities such as the latest development of public and private hospitals and introduction of the Voluntary Health Insurance Scheme.”  That sounds comprehensive.  However, demand can be created.  Expectations of the public can be managed.  There can be no limit to the demand of healthcare services.  Therefore rationing is always important in the fair and effective distribution of limited supply and resources to meet theoretically unlimited demands.  In the Report, there is no mention of investigation into rationing of existing services, or how to manage expectation of the public in the future.  Facing a relatively predictable and stable supply of doctors, it is irrational to just try to recommend means to increase the supply of doctors without consideration of managing the increase in demand. 

From such model, it is predicted that for the best guestimate, the manpower gap in FTE would be at 285, 500, 755 and 1007 in the year 2016, 2020, 2025 and 2030 respectively.  However, the range for the 5^th and 95^th percentile would be 80 to 690, 320 to 989, 596 to 1296, and 829 to 1575 in the year 2016, 2020, 2025 and 2030 respectively.  These calculations are based on an important assumption.  “The manpower situation at the base year (i.e. 2015) is assumed to be at an equilibrium and the model takes into account known shortage in the public and subvented sectors for healthcare professionals as at end of 2015.”  So, to start with, it is assumed as a fact that there is shortage of manpower in the public and subvented sectors.  Against this important assumption, “the Steering Committee is mindful that the private sector is more flexible in adjusting productivity in response to market demand.  The Steering Committee also notes the observations of some that there remains spare capacity in the private sector and thus considers that the Government’s priority should be focused on filling the manpower gap in HA, which provides nearly 90% of all in-patient services and around 30% of primary care services in Hong Kong.”  Interestingly, there is no recommendation on how to make use of the flexible private sector with surplus of manpower. 

Last but not the least, let us look at the limitations of the Report.  “Healthcare manpower projection is an extremely complex mission.  There is no universal model for projecting healthcare manpower whether in the literature or among the jurisdictions surveyed.”  “The changes in the patterns of referral, sector of service delivery (public and private), technological advancement, scope of practice, feminization of the workforce, healthcare policy and service delivery regulation affect constantly the demand for healthcare service, while changing population demographics, inter-regional and inter-sectoral (public/private) movement of healthcare professional and patients as well as healthcare utilization patterns further complicate manpower projection.”  “Manpower projection is also a highly data-intensive activity.  Although public sector in-patient and outpatient data for manpower projection is readily available, a substantial proportion of patient care occurs in the private sector for medical and social care where utilization data are scattered, less complete, or not readily available.  The lack of normative standards defining productivity is also a major impediment to workload analysis.” 

Actually, the Report has stated clearly how the results should be used.  “Because of the nature of manpower projection and the inherent limitations of the model itself, the projection results should be viewed in perspective.  In interpreting the projection results, we should focus on the trend rather than the absolute gap.  The medium to long-term projection could change significantly if events unknown now happen in future.” 

 

(Source: HKMA News September 2017)

Peeling Small Potatoes

When I attended a cooking class on Chicken and Mushroom Fricassée (which was the French way of braising chicken pieces in white sauce), I was first given several potatoes.  The aim was to make some Pommes Parisiennes (which were potato balls fried in butter, again, in the French way).  The procedures were to peel the potatoes, to use a melon-baller to scoop out potato balls, to soak the balls in cold water, to put them in cold salted water and to bring it to a boil, to simmer, to drain and to dry the cooked balls on a kitchen towel, and then to fry them in a pan with clarified butter.  Then there were procedures for the chicken, for other side dishes and for the sauce.

Compared with the other students, I had no difficulty in remembering and following the procedures.  Doctors were good at memorizing funny words and protocols.  However, I got stuck with the first step: to peel the potatoes.  I was no newbie in cooking.  But I was also no expert in peeling potatoes.  Potatoes were not my choice for side dishes.  The theory of peeling potatoes was simple: just use a peeler and peel them.  However, in practice, there were many fine details to look after.  A fundamental difference was between peel inwards towards yourself or peeling outwards.  My observation was that Europeans tended to peel towards their own bodies; while Asians tended to peel away from their bodies.  I am Asian and I did not want to cut myself, so I used to peel and cut outwards.  That made me the odd one out.  Unfortunately, I was also the slowest one.

The potatoes I got were small.  They were not new potatoes, which were usually served unpeeled.  Small potatoes were actually more difficult to peel.  In the process, apart from the skin, you had to take care of the black spots on the potatoes.  You also had to decide whether that potato was usable.  When the potato was half-peeled, the starch made it very slippery and the chance of hurting your fingers increased.  Luckily the class was on a dish for family, and not for banquet.  Otherwise I would end up with just Pommes Parisiennes and nothing else; or might be a cut finger.

What I learnt was of course how to make Chicken and Mushroom Fricassée, well, with Pommes Parisiennes.  But the more important lesson was that things were not as simple as they appeared, and not as simple as you perceived.  Peeling a single small potato with unlimited time in a stress-free setting was totally different from what I was asked to do.  It was not just holding a peeler and peeling some skin off with every stroke.  The scale mattered.

This small-potato-lesson popped up in my mind when I read about the plan of asking retired doctors of all specialties and administrative staff to work at GOPCs and A&E departments to see patients in the recent summer influenza crisis.  The intention was good.  The move was straight-forward.  When there were too many patients, we increased working-hands and got more doctors.  However, the point was that seeing patients in outpatient settings might not be as simple as you perceived.

General practitioners are deemed, by some laymen and doctors alike, to be small potatoes in the profession.  However, seeing patients in outpatient clinics might be a bit more complicated than peeling small potatoes.  I had worked in an A&E department and have been a general practitioner for more than 20 years.  I still find it challenging in my routine work.  A patient does not come in and tell you that he has influenza.  Even if he does so, not too rarely he is wrong.  He might be suffering from Dengue, or lobar pneumonia, or lung cancer.  If he is right, he might have some underlying diseases that need to be taken care of, or that might complicate the diagnosis and treatment of his influenza.  Studies confirm that a patient always visits with multiple complaints.  While you have finished with the history taking and physical examination for the influenza part, he might tell you when he raises from the chair that he has per rectal bleeding for 3 months, or that he has episodic chest pain on exertion, or that his left third toe is itchy.

Whether to prescribe Tamiflu is the least difficult decision to make.  There are guidelines on that, though you might not have supply of Tamiflu.  If you want to give symptomatic treatments, you need to check all contraindications, warn about side effects, and take care of interactions with the patient’s own long term medications.  Prescription is only part of the management plan.  You have to answer at least 6 related and unrelated questions, ranging from a philosophical question of why he catches the flu and not his wife; to a practical question of quarantine from his 3 month old son and his 82 year old grandmother with diabetes and bronchiectasis.  And, do not forget to properly look at the itchy toe and to give a suitable cream for it.  At the end, when you warn the patient about red-flags just in case, he would probably dwell on the certainty of your diagnosis, and then throws out a legal jargon and labels your medications fruits of a poisoned tree.  At that time, you have to calm your furious mind.  You do not want to answer to the PIC of the Medical Council.  More importantly, anger might weaken your immune system, and anger might make you careless.  Doctors will also fall sick.  We will also suffer from influenza. If the doctor is over 65, or if he has chronic medical illnesses, he would be in the high risk group and himself needs Tamiflu, and himself runs the risks of serious complications from the infection.

If you are drawing a conclusion that seeing patients in the outpatient setting is complicated, you have missed my whole point.  You are still looking at one potato in your hand.  In the flu season, you are expected to see 30 to 60 patients in 4 hours.  You have to accomplish the above tasks 30 to 60 times in 4 hours, 2 times a day, 5 to 7 days a week.  Even if you received a gold medal in internal medicine 40 years ago, there is no time for you to peel and craft a master-piece potato.  You have to get your work done.

Peeling small potatoes is not simple.  That is what I learn in cooking class. 

 

(Source: HKMA News August 2017)

When Breath Becomes Air

When Breath Becomes Air

The Clouds are the Floating

The Flowers are the Blooming

When Breath Becomes Air is a book written by Paul Kalanithi, a neurosurgeon who died of non-small cell lung cancer (NSCLC) 22 months after the diagnosis at the age of 36.  His wife described the book as a cogent powerful tale of living with death.

“The Clouds are the Floating; The Flowers are the Blooming.” are two verses written by Thich Nhat Hanh, a master in Zen Buddhism, in his poem The Great Lion’s Roar.  They are mentioned in his new book The Art of Living, in which he explores the questions about life and death.  As always, he teaches mindful breathing, through which there is concentration and insight.  And there, lies the way.

Paul was born in New York, but he spent his teenage in Kingsman, a desert valley in Arizona, 100 miles south of Las Vegas.  His father was a cardiologist.  He moved the family to the desert town when Paul was 10 so as to establish a regional cardiology practice of his own.  Although his father and his uncle were doctors, Paul had made up his mind to study English literature and to become a writer.  He was the diligent and serious type of student.  He entered Stanford University and majored in English literature and biology.  As with many adolescents and great thinkers alike, Paul was haunted by the myth of live and death.  He wondered “where biology, morality, literature and philosophy intersected”.  He came to the conclusion that reading or writing alone would not give him an answer.  “Direct experience of life-and-death questions was essential to generating substantial moral opinions about them.”  After his first degree from Stanford and a degree in history and philosophy of science and medicine from Cambridge, he went to Yale for medical school.  He “was pursuing medicine to bear witness to the twinned mysteries of death, its experiential and biological manifestations: at once deeply personal and utterly impersonal.”

Ironically, during his years as a neurosurgical resident in Stanford, he was designated the chance to experience death directly, not as an observer or an intervener.  He was diagnosed to have NSCLC at the age of 36.  The chance of having lung cancer at 36 was 0.0012.  The cancer turned out to be EGFR positive and responded well to target therapy with Tarceva.  At that time, he started to write his book.  He diligently rehabilitated himself and was able to continue his neurosurgical residence work 18 months later.  Paul and his wife, Lucy, his medical school classmate and a physician, planned to have a baby.  With IVF, Lucy was soon pregnant.

Paul faced cancer and death head-on.  He realized that nothing had changed.  He was uncertain both before and after he had cancer when he would die.  At the same time, he was certain both before and after he had cancer that he would die.  As a doctor, he was trained to focus on the future.  But in reality, only the present day counted.

Paul did not finish his book, at least as the way he planned to.  The last chapter was written by Lucy.  Soon after he resumed his duty, the cancer got worse.  A new focus with no mutation gene (and thus not responsive to target treatment) appeared.  Chemotherapy failed because of intolerable side effects.  He was said to die in peace and satisfaction (despite leptomeningeal carcinomatosis and respiratory failure) with her 8 months old daughter in his lap.  He saw continuation in her.   

Thich Nhat Hanh coins the word “inter-being” to explain that one exists not as a self, but as an inseparable part of the whole universe.  There is continuation in our off-springs, in our siblings, in our spouses, in our ancestors, and in mankind.  He observed that when a cloud floats, the cloud and the floating are in fact inseparable.  The cloud is the floating.  He gives a profound view on death in his book: “People need to break free from 3 wrong views before they can be liberated from suffering.  The first wrong view is that we are a separate self cut off from the rest of the world.  This self is born at one moment and must die at another, and it is permanent during the time we are alive.  The second is that when we die, we cease to exist.  The third wrong view is that what we are looking for- whether it is happiness, heaven, or love- can be found only outside us in a distant future.”  Targeted to overcome these 3 wrong views, he introduces the practice of concentrations on emptiness, signlessness, aimlessness, impermanence, non-craving, letting go, and nirvana.  One of the ways to attain insight through such concentration practice is mindful breathing.  Thich Nhat Hanh has always been teaching mindful breathing.  The essence is to concentrate on in-breaths and out-breaths in relax and peaceful manner.

When Breath Becomes Air is not a pleasant book to read, especially for us doctors.  Paul had no choice but to face his cancer.  He described his life as sowing without reaping.  I do not know whether he finally got the answer to his questions about life and death.  He roamed into philosophical quotes before he could finish his book.  However, he did give first person experience on how to focus on the present moment bravely.  As a patient, he witnessed how important the doctors’ attitude and accurate but compassionate communication were.  “When the scalpel fails, the neurosurgeon is left with his words.”

I wonder how many readers would attain enlightenment after reading The Art of Living.  Non-self, impermanence and nirvana are said to be profound and beyond description.  Practicing mindful breathing might sound too simple, yet it might take your whole life time before you can bravely face inevitable sufferings that pop up now and then.  But at least, there are ways that might help, as it is advocated.  As the subtitle of the book says, the art of living is peace and freedom in the here and now.

Breathing in, I enjoy the harmony of my in-breath.  Breathing out, I enjoy the harmony of my out-breath.  When breath becomes air; the breath is the air. 

(Source: HKMA News July 2017)

1997 - 2017

 

July 1, 2017 marks the 20th anniversary of the return of Hong Kong to our Motherland and the establishment of the Hong Kong Special Administrative Region (HKSAR).  Since our return to the Motherland, the principles of "one country, two systems", "Hong Kong people administering Hong Kong" and a high degree of autonomy have been successfully implemented in Hong Kong.  With the staunch support of our country, the concerted efforts of all sectors of the Hong Kong community and the co-operation of the Mainland provinces and municipalities, Hong Kong has made good progress in its social and economic development.

The above is the first and second paragraphs of the foreword message from our Chief Executive C Y LEUNG in the Hong Kong SAR’s 20^th Anniversary website.  In 1997, I was in my early thirties and had been a general practitioner in private practice for a few years.  Memories of that year were unreliable, as the background was blurred, but some unimportant items were in distinct focus.  I had not begun my long journey of postgraduate learning.  I was playing computer games day and night.  Emails were seldom used.  There was no messaging or any other function except making phone calls with expensive and robust mobile phones.  Leon Lai was the best male singer from Commercial Radio.  Faye Wong was the best female singer.  The Best Film Award of the Hong Kong Film Awards went to Comrades: Almost a Love Story (甜蜜蜜).  The soap drama of TVB was Old Time Buddy (難兄難弟).  I had never come across the Medical Registration Ordinance.  I could barely distinguish between HKMA and HKMC.  Doctors seldom wore masks at consultations.  At that time, a newbie general practitioner could afford a small flat.

On July 1, 1997, I sat at home watching TV, as there was nowhere to go with the extremely heavy rain.  I even considered following urges from TV to sing together when the screen showed the song “Tomorrow will be better” in karaoke mode.  Then, 20 years went by.  Were tomorrow and the days after tomorrow really better?

Recently I heard officials putting up the increase in population in Hong Kong as evidence that Hong Kong had flourished.  I found this argument familiar and convincing.  I remembered listing this as the reason for one of the Ming emperors being considered a good guy in an examination in Chinese History and gained one mark for it.  There was no natural disaster.  People could make a living there and thus they did not flee and started to reproduce.  The population in Hong Kong in 1997 was 6.489 million.  It rises to 7.403 million in 2017.  The difference is 0.914 million.  However, immigration is another cause for a rise in population.  If we take into consideration the 150 people per day allowance, we have 150 x 15 x 365 + 150 x 366 x 5 = 1095750, which is roughly 1.096 million.  Whether the officials gained one mark for their illustration is up to readers to decide.

The Hang Seng Index reached its highest at 16673 on August 29, 1997.  It then dropped to its trough at 6660 on August 31, 1998.  The historical peak was at 31638 in October 2007.  The Hang Seng Index closed at 26030 on June 9, 2017.

The Centa-City Index (CCI) is an index created to reflect trends in the property market of Hong Kong.  It is a monthly index based on all transaction records as registered with the Land Registry to reflect property price movements in previous months.  It comprises a number of constituent estates.  July 1997 is used as the base period of the index. The index in the base period equals 100.  So, July 1997 was set as the reference point.  In July 1996, the CCI was 65.74.  In October 1998, the CCI dropped more than half from that of July 1997 to 47.94.  Then in July 2007, the CCI was 55.90.  In June 2017, the CCI reached historical high at 147.24.

The Gini coefficient is a measure of statistical dispersion intended to represent the income or wealth distribution of a nation's residents.  It is commonly used to measure inequality.  A Gini coefficient of zero expresses perfect equality, where all values are the same.  A Gini coefficient of 1 expresses maximal inequality among values.  The closer the Gini coefficient is to 1, the more inequality there is.  In Hong Kong, the Gini coefficient is announced every 5 years.  In 1996, the Gini coefficient was 0.518.  In 2016, the Gini coefficient was 0.539.

I am also not sure whether TV will put up the song “Tomorrow will be better” in karaoke version this year. But anyway, tomorrow is another day.

 

(Source: HKMA News June 2017)

Community Health Center

I read a proposal by the Primary Care Office on a pilot project of setting up a community health center.  Actually community health center is nothing new.  By definition, it is a health center in the community, though people nowadays would say that a health center needs to be multidisciplinary.  To me, I would consider the Sai Ying Pun Jockey Club Clinic, referred to by local people as the “Government Civic Hospital” and has been there for decades, is a community health center.  There are general out-patient clinic and different specialty clinics including maternal and child health center, dermatology and social hygiene clinic and chest clinic in a multi-storied building.  There are also X-ray and laboratory services.  If you think that there must be other healthcare disciplines other than medical doctors, then there is the David Trench Rehabilitation Center nearby.  There are physiotherapy, occupational therapy, psychogeriatric day care, psychiatric community nursing, general psychiatric day care and medical social services.

The Hospital Authority thought differently.  In 2012 it announced the opening of its first community health center in Tin Shiu Wai.  It was described as “the first health centre with design based on the Government's primary care development strategy and service model”.  And, “it is a one-stop centre where people receive comprehensive primary care services by multi-disciplinary primary care professionals in the community.  The general out-patient clinic on the first floor provides around 200 consultations per day.  Patients visiting the Tin Yip Road health centre are referred to the multi-disciplinary primary care professionals (including nurses, physiotherapists, occupational therapists, prosthetist-orthotists, dieticians and optometrists) located on the second floor to receive appropriate intervention and follow-up services.  The centre also collaborates with non-governmental organisations to provide health-care education and psychological counselling services”.

Let’s first skip the aims and objectives of setting up community health centers.  Although such objectives serve for navigation during the night, they are like stars that are difficult, if not impossible, to reach.  Afterall, it is how you communicate with Einstein and how you build the rockets that matter in your project to Mars.  We look at the operational aspects.  What are the differences between the Tin Shui Wai Community Health Center and the Government Civic Hospital?  Or how about adding a general out-patient clinic to the David Trench Rehabilitation Center? 

One obvious difference is that doctors from the general out-patient clinic can directly refer patients to services of other healthcare workers at the clinic.  However, putting all services spatially in the same building does not benefit patients.  Patients are unlikely to go directly from general out-patient to other clinics in the same day.  They have to wait for another appointment.  Unless patients are able to see the same doctor each time and more time is allowed for each consultation, the concept of family doctor and continuous primary care do not apply.  If just for direct referral from general out-patient clinic, this can easily be achieved by opening up the existing services to accept direct referrals.  Instantly, we have many community health centers. 

The pilot project of the Primary Care Office was different, as it said.  I summarized the differences from what I read as follows:

1. There is no medical doctor in the center.
2. It accepts referrals from doctors in private practice.
3. It targets more on prevention than cure.  Thus the scope of services includes risk assessment and chronic disease management; patient empowerment programmes; and health promotion services.
4. A case-coordinator, likely a senior nurse, will lead the primary healthcare team there.
5. The center will be led by a non-government organization.

Again, I am more interested in how it works, or how it is going to work.  All disciplines of healthcare workers exist in the private market already.  The opening of a community health center is unlikely to create more physiotherapists or podiatrists.  Instead, it employs its own healthcare workers and theoretically it will decrease the supply of workers in the private market.  This shortage also applies to senior nurses.  The concept of having a senior nurse as case-coordinator is adorable.  However, to fulfill the objective of continuous primary care, the same case-coordinator should follow-up his own patients.  The center will need to have many case-coordinators.  They are then overlapping the job of family doctors who are supposed to know their patients well and to lead a primary healthcare team. 

Preventive care does not come cheap.  High rents are eating away the major share of profits in the private market.  Charges for each visit for any healthcare worker are already higher than visiting family doctors.  In the community health center, there is the addition of a case-coordinator.  That will incur extra costs.  The case-manager is going to identify needs of patients and extra services are expected.  Why would building a community health center change the health seeking behavior of Hong Kong citizens?  How is the center to compete with other healthcare workers in the private market? 

The answer could not be found in the document I read.  So I asked.  The right question usually gives you the gist of the matter.  The community-health-center-to-be will be funded by the government (and thus you and me) and will be highly subsidized.  The intended charge for each visit is around $60, or in-line with other out-patient clinic charges.  It is always an ideal to provide comprehensive and continuous preventive care to all citizens.  However, ideals never work in real world.  Money is usually the limiting factor.  There is no need to go again into the healthcare system, budgeting and rationing.  The Primary Care Office might argue that the community health center targets high risk patients.  Nonetheless, that would include all patients with chronic illnesses, all smokers, all overweight people and all the elderly.  I guess that covers more than half of the population.  Another possible outcome is that the center turns out to be no different from other clinics run by the Hospital Authority where patients get routine healthcare services at an out-of-proportionally low cost.  In that case, the same effect can be achieved by just opening up the existing clinics to accept referrals from private medical practitioners.

I wish that this community health center will bring us to Mars, or will bring us one step nearer to Mars, or at least will point our way to Mars.  I hope it will not turn out to be trucks loading patients to watch movies on stories about Mars.

(Source: HKMA News May 2017)

As Simple as That

 

 

Eleven years ago, when I was a newbie in the Medical Council, I attended an inquiry.  The case was about a doctor found guilty of not keeping proper records of dangerous drugs in the magistrate court.  At that time, I was clear that I had to decide the case according to section 21(1)(a) of the Medical Registration Ordinance.  It was not about professional misconduct, which was covered by section 21(1)(b).  What puzzled me was the seemingly generally agreed comment among members that keeping an accurate dangerous drugs record was very easy.  It was simple mathematics and the doctor just needed to do the checking twice a day.  Thus, any mismatch should be condemned.

Of course those who maliciously sold dangerous drugs and those grossly neglected record-keeping should be sanctioned.  I also agreed that keeping a proper dangerous drugs record was important.  However, the point was that it was far from easy or simple to do so.  Ask an accountant, he would share with you that keeping an account balanced is not as simple.

Let us start with a single dangerous drug.  The best case is that everyone involved makes no mistake and the record is perfect.  You can secure it with auditing the record twice a day as suggested.  That needs counting the stock of that dangerous drug to match the balance in the record.  If it does not match, you need to go back to all the prescriptions of that session.  You might not find out where things went wrong because there might have been unnoticed mistakes in dispensing.  Even if you can find out where the mismatch comes from, you need to scratch your head before you can rectify it.  If you are using 20 dangerous drugs, you need to go through the above procedures 20 times.  Do not forget that human errors can occur in auditing also.  That might further complicate your daily exercise.

Time is another factor.  Dangerous drugs record keeping is important.  But there are many other issues that are as important, or even more important.  Checking expire dates of stocks is important.  Making sure investigation results are read and followed up is important.  Tracking drug compliance and follow-up appointments of patients with chronic illnesses is important.  Writing summaries for ten-year-old, five-inch-thick patient records is important.  Do not forget, maintaining the health of the doctor by enough rest and regular exercise is also important.

In real world, things are not as simple as your first impression.  I am not listing excuses for doctors to evade from proper record keeping.  Instead, you have to understand the nature of a task and to contemplate root causes for errors.  Further, knowing theories and methods is not the same as being able to carrying them out.  Otherwise, drug compliance or vaccine uptake rates would not bother us.  Smoking cessation would be as easy as snapping your fingers.

Another example of over-simplifying a problem and ignoring the role of other expertise is the use and abuse of antibiotics.  Recently there had been repeated open attacks on the abuse of antibiotics especially in treating upper respiratory tract infections by primary care doctors in the private sector.  This was said to contribute much to the development of antibiotic resistant bacteria.

Primary care is a branch in medicine no different from microbiology, or surgery, or oncology in the sense that it deals with a special aspect of patient care using specialized skills.  Primary care is not just treating upper respiratory tract infections with or without antibiotics.  Understanding health-seeking behaviors of patients, encouraging healthy living style, and modifying behaviors are but some of the challenges of primary care.  Overuse of antibiotics has been an all along existing problem.  As a family doctor who is practicing primary care and communicating with patients and colleagues every day, I can state with confidence that the situation is improving over the years rather than getting worse to the extent of out of control.  I do not have statistics to support me.  But neither did those who accused have any concrete evidence.  It is unfair to focus the spotlight at primary care doctors when antibiotics are used as food to feed live stocks and fishes, when you can buy antibiotics without prescriptions, and when most patients need to have intravenous antibiotics for most illnesses or non-illnesses in nearby areas.    

Despite facing a weak case, various strong measures were suggested and planned to spy on primary care doctors, to educate them, to regulate them, and to punish those who still choose to misbehave and endanger our Earth.  The usefulness of some of these measures was debatable.  For example, it was suggested that confirmation tests needed to be done before prescribing antibiotics.  How about sensitivity tests?  Do we need to monitor drug concentrations in blood?  Do we need to repeat the tests after treatment?  How about prophylactic antibiotics?  Longer term use of antibiotics poses more risk on the development of resistant strains.  Do dermatologists need to culture for bacteria and do sensitivity tests before treating acne?  Do gastroenterologists need to do sensitivity tests before treating H. pylori infection?  And, do they need to constantly monitor blood concentration?  Another example: the healthcare system in UK is different from our system.  They have registry for every prescription.  Thus statistics for antibiotic use is readily available.  It is unfair to compare two different healthcare systems and try to introduce large scale registry for antibiotics in Hong Kong.

But all the above are minor points in the argument.  An important element for primary care doctors to function is the trust between them and their patients.  Ruining this trust, the long term effects are disastrous.  Health education would be less effective, vaccination rates would drop, and investigation rates would shoot up.  Patients would turn to other healthcare workers who have all along promoting their without-side-effect-treatments and immeasurable holistic care.

Behavioral modification takes time and needs skill.  It is not as simple as that. 

(Source: HKMA News April 2017)