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)