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)
