The truth, the whole truth and nothing but truth?

Happy New Year!  Wish every reader tranquility in 2011.

In the first few days of 2011, I read an advertisement in the newspaper condemning how western medicine could not solve many medical problems.  In the same advertisement, the author claimed that he was able to do so by some methods invented by his good self.  It is now a trend that some individuals, without any formal medical training, be it western or any traditional, claim that they by some unknown reasons, or by self study, find out the reasons of many illnesses and how they can be treated and prevented.  Sometimes they have publications to support their claims, but most, if not all of them, are in the form of books or interviews not scrutinized by others.  The contents of such publications are mainly case reports and circular logics.

Appraisal of evidence needs training.  The public needs to be informed of and educated on these kinds of pseudo-evidence.  I am not saying which tradition of medicine is preferred.  It is the practitioners claiming superiority over others, but without any sound theory or evidence to support them, who are problematic.  Don’t think that many people know about evidence-based medicine and can put it into practice.  I had, in an occasion of a meeting, encountered a doctor who always claimed that he was evidenced-based oriented.  I challenged that the results of a study might not be valid, or at least not accounted for solely by one of the interventions, as there were multiple interventions involved.  To my astonishment, his counter-argument was the promotion of some sort of “black-box theory”.  He claimed that the interventions could be regarded as a black-box.  By all means, as long as it was effective, there was no need for us to bother what happened in between.  I stopped arguing back, as I found it meaningless.  If this “black-box theory” was promoted and preferred, we might be still at the stage of witch doctors.  We need to chant and dance together with our prescription or surgery as we are not sure what actually cause healing.

Sometimes, even the gold standard can be with fault and fraud.  In the January 5, 2011 issue of the British Medical Journal, the journalist Brian Deer wrote about the “MMR vaccine and autism” scam.  In the BMJ Blog, Deer compared this with the “Piltdown Man”: “On 21 November 1953, what is now Britain’s Natural History Museum stunned both science and the public by calling the fraud in the case of ‘Piltdown Man.’  Fragments of fossilized jaw, skull, and tooth, unearthed shortly before World War I from gravel beds, 45 miles south of London, were not, as had been believed, the remains of an aberrant part-human, part-ape ‘missing link.’  They were an elaborate, highly motivated hoax.”  The MMR scam began with a press conference in 1998 after the Lancet published a paper by Andrew Wakefield and colleagues describing 12 children with brain and bowel disease.  “Published in a five-page Lancet paper in February 1998, it triggered media campaigns which sent vaccination rates plummeting, and caused the most intractable health alarm in a generation.  The paper claimed that in two thirds of 12 consecutive child patients with ‘regressive developmental disorder’ and enterocolitis, attending one London hospital’s paediatric gastroentreology clinic, the ‘apparent precipitating event’ was a measles, mumps, and rubella vaccine, with a temporal link between shot and symptoms of 14 days.”  Deer cast doubt at the beginning: “Did the scientific community ever really believe that 12 families had turned up consecutively at one hospital, with no reputation for developmental disorders, and made the same highly specific allegations – with a time-link of just days – and that there was not something fishy going on?”  He looked into this matter with his critical mind and diligence.  In 2004, he published his investigation report in Sunday Times and that led to a GMC hearing of the doctors involved.  The hearing lasted 217 days from July 2007 to May 2010.

Deer spent seven years to investigate into Wakefield’s work.  It led to the UK General Medical Council’s longest ever fitness to practise hearing, after which Wakefield and his senior co-author, John Walker-Smith, were struck off the Register.  The paper was also retracted by Lancet.  After GMC published the hearing findings, Deer kept on looking into this matter.  He matched the subjects mentioned to that of the original paper and interviewed their parents.  He concluded that all data had been grossly modified or fabricated.  Apart from having no ground to link MMR vaccine with autism, the whole study was a scam to launch lawsuit against the vaccine manufacturers.  However, as Deer stated: “Wakefield, nevertheless, now apparently self-employed and professionally ruined, remains championed by a sad rump of disciples.”  That might reflect how the general public approaches evidence.

Talking about truth seeking, I would like to gladly introduce a new featured writer for the News.  She is Eve LAI and she starts a new regular section about food beginning this issue.  I would describe Eve as a doctor out of my imagination: Like Deer, she exercises her diligence in dissecting myths to expose the truth.  However, her scope only covers food and nothing else.  I am sure that she would present to you, in my opinions, fully biased self experience on food.

Talking about food and truth, I have the duty to report to members my bad (yes, bad; very bad) dining experience at our Central Club House.  I have to blame myself as I have forgotten that the contract of the chef is going to end.  I would advise and remind myself to think three times before choosing the Central Club House again, especially when there are guests and during these few months.  If Central is chosen because of the location, McDonald’s is definitely a better choice.

(Source: HKMA News January 2011)

Merry Christmas and Happy New Year!

 

This is the last issue of the News in 2010.  I hope that you will enjoy reading it during the holidays with the enriched content and beautiful photos, especially those of the Sports Day and the prize-winning photos of the Photographic Committee.  You will receive at about the same time a small gift – the HKMA pocket diary specially designed for our members.  You can find much useful information such as useful telephone numbers and advices from the Medical Protection Society.  Unique features are the HKMA events, functions and CME activities printed on the schedule.

It has become a habit to review the past year and maybe to plan for the coming year during the end of a year.  I notice that these kinds of reviews tend to focus more on negative events.  And it is a fact that negative events do leave more scars on our memories.  In this issue, I try to focus more on positive, enjoyable and encouraging events happened last year.  They may not be the most significant ones.  My choices will definitely be different from yours.  There are many personal memorable events, such as graduation, promotion, getting married, giving birth, or just a pleasurable chat with old friends.  Please don’t forget to bring them up in your review.  Buddhist teachings say that forms, names and concepts are all made up by our minds.  Events just happen as they are, and it is us who attach meanings to them.  The following are my medically related picks:

The HKMA 90^th Anniversary

• Congratulations to the HKMA.  There is a series of celebratory activities with the Charity Concert marking the beginning, and the Annual Ball at New Year’s Eve constituting a perfect ending.

Formation of the Beat Drugs Action Committee (BDAC)

• In response to the serious situation of youth drug abuse and the call from the Chief Executive, the HKMA BDAC was formed this year to coordinate and to promote beat drugs activities by doctors.

• Beat drugs action is one of the important themes of the HKMA 90^th Anniversary functions.  These include being the beneficiary of the Charity Concert and organizing Public Education Days.

Dr. CHOI Kin was elected the HKMA President

• This was the third time that Dr. CHOI was elected as President.

• His full cabinet also won the seats of Vice Presidents, Hon. Treasurer and Council Members.

Voluntary Medical Insurance Scheme (VMIS)

• The VMIS was endorsed by the Executive Council on September 28.

• The HKMA held a press conference and referred the Scheme as “poisonous pills in sugary coating”.

Human Swine Influenza

• Fortunately, the threat from pandemic Swine Flu did not actualize.

• On the day of writing this Editorial article, it was reported in the newspaper that there had been sporadic cases in England causing deaths from Swine Flu.

Human Swine Influenza Vaccination

• The HK Government was very pro-active in the issue of procurement of vaccines for Swine Flu.

• However, lay intelligence predominated and the response to vaccinate was poor.

• There were cases of Guillain Barre Syndrome suspected to be related to Swine Flu vaccination.  Among the victims, there was a doctor who luckily recovered fully. 

Public Private Partnership

• The Diabetic Share-care Program had been regarded as an important step towards public private partnership.

• It turned out that the response rate was poor.

• One reason identified for the poor outcome was that the small amount of subsidy which is out of proportion to the market price of diabetic care by general practitioners.

The confusing “Laboratory fees equal rebates in disguise” judgment from the Medical Council

• A decision from the Medical Council alleged that a doctor charging his patient more than the fee stated by the laboratory for performing laboratory tests was founded guilty of professional misconduct.

• Private doctors were much concerned about the issue, especially after a personal letter issued to all doctors from the Chairman of the Medical Council.

• It turned out that the letter was really personal as it did not reflect the decision nor the view of the Medical Council.

• This controversial and disturbing matter has not been clarified yet.  A knife is still hanging above everyone’s head.

The Medical Council stripped itself of the power to review decisions from inquiry panels

• From the “Laboratory Test” case, a review of the decision of the inquiry panel had been suggested according to power of the Medical Council stated in the Medical Registration Ordinance.

• Out of some inconceivable reasons, the Council stripped itself of this important power.

• This matter has not been clarified yet.

Dangerous precedents concerning the prescription of steroids

• It was decided in several inquiries of the Medical Council that before prescribing steroid to patients, the doctor had to voluntarily explain to the patients the proper name, the nature and the side-effects of steroids.  Otherwise it was professional misconduct.

• Many doctors do not agree to the decisions.  But these are precedents and doctors need to be aware of these cases.

Organ donations

• A Customs Officer injured his liver seriously during the execution of his duty.  His life was saved by a colleague who donated part of his liver to him.

• This piece of news was very heart-warming and encouraging.  It set a very good example in the promotion of organ donations.

(Source: HKMA News December 2010)

Happiness is here and now

As usual, there were many issues that trouble my mind in November.  Just to name a few: the scandal of repeated influenza vaccination due to greed, the strategies from candidates of Medical Council election and the Voluntary Medical Insurance Scheme.  But I am not going to trouble you with all these.  Happiness is here and now.  I am going to share with you my Zen retreat.

The retreat was organized by the Center of Buddhist Studies, the Plum Village Foundation Hong Kong and the Chinese Buddhism Cultural Center.  It was named “Zen Master Thich Nhat Hanh in Hong Kong 2010 – Awaken to Joy at Our Mindfulness Retreat”.  Thich Nhat Hanh is a great Zen Master.  He is a Vietnamese and was born in 1926.  He entered a Zen monastery at the age of 16, and was fully ordained as a monk in 1949.  He travelled to study at Princeton University in 1960.  During the Vietnam War in 1963, he returned to Vietnam and founded the School of Youth for Social Services which helped rebuilt bombed villages, set up schools, establish medical centers and resettle homeless.  Throughout the years, he heads his monastic and lay group, establishing monasteries all over the world (Vietnam, France, New York, Mississippi etc).  Since 2007, he has based at the Plum Village Monastery in the South of France, travelling internationally to offer talks and retreats.  He teaches Mindfulness trainings.  He has also written over 100 books. 

The five-day retreat was held at Wu Kwai Sha Youth Village from November 4 to November 8.  The theme of the event was “happiness is here and now”.  For this visit, Thay (Vietnamese: “teacher”) brought along 80 monks and nuns from the Plum Village.  There were approximately 1,400 people joining the retreat.  Practicing together allowed people to engage in a joyful, steady and supportive environment.  This retreat attracted people from various religious and spiritual backgrounds.  Yet, we all learnt and practiced mindfulness with an open mind and receptive heart.  

During the retreat, all of us were required to observe noble silence.  (There was no need to wear a “I’m in silence.” badge like what Julia Roberts did during a retreat in India in the movie “Eat Pray Love”.)  There was a timetable for both the residents and commuters.  Daily activities included sitting meditation, walking meditation, dharma talk, total relaxation, dharma sharing, yoga, qigong etc.  Everybody just did the same things as everyday life, except we learnt to do them with mindfulness.

So what is mindfulness?  According to Thay’s teachings, mindfulness is the energy of being aware of the present moment.  To be mindful is to be truly alive, present, and aware with those around you and what you are doing.  Are you aware of what you have and what you are doing at the present moment?  Are you distracted by memories of the past and worries of the future?

To practice mindful eating, we were required to appreciate the appearance and taste of the food; as well as to think of where the food came from.  After putting the food into the mouth, we were all requested to chew at least 30 times before swallowing the food.  And we were also requested to let the chopsticks and spoons take a rest during the chewing process.  The chewing process had to be enjoyable, thankful, and slow and relax.

Total relaxation was another amusing practice.  It aimed at removing our tension by breaking a day into several sections.  After lunch, we were all required to move to the main hall, lying down on the mat with a big towel on top.  Sister Chan Khong (a 72-year-old Buddhist nun, who followed Thay for 50 years) started guiding us to breathe in and out slowly and soothingly.  With the magic of her voice, I heard snoring around the hall very soon.  After a series of breathing exercise, sister then sang a number of lullabies to keep us relax (i.e. asleep).  There were over hundreds of people, lying in the same place, enjoying breathing and then sleeping together for an hour.  The hall was full of tranquility at the very beginning, followed by of a concerto of snoring.

I am not going to describe all the other exercises as space is limited in this column.  The one I certainly have to mention is also the most important one – mindful breathing.  During the retreat, the sound of a big bell was heard in a regular interval (even during dharma talk or eating).  Whenever the bell rang, everybody stopped still, stopped walking, stopped moving.  These were actually the bells of mindfulness.  They reminded us to relax, to stop whatever we were doing and to become aware of the present moment.  Attention was also paid to our breathing.  Thay teaches us that our breathing is always with us like a faithful friend.  When breathing, we feel the flow of air coming in and going out of our noses.  We feel how light and natural, how clam and peaceful our breathing functions.  Thus, whenever we feel heartrending, whenever we are sunken in a deep emotion, or whenever we are having fears or worries, we return to our breathing in order to anchor our mind.  Conscious breathing is the key to unifying body and mind.  It also brings the energy of mindfulness into every moment of our life.   

Accordingly, the mindfulness bells during the retreat brought our awareness to our breathing.  Whenever we heard the sound of the bell, we cited repeatedly, “breathing in, I know that I am breathing in; breathing out, I know that I am breathing out…“  With a couple of breaths we released our tensions and restored calm in our body and mind.  We returned to the peaceful source of life.

Happiness is here and now,

I have dropped my worries.

Nowhere to go, nothing to do,

no longer in a hurry.

Happiness is here and now,

I have dropped my worries.

Somewhere to go, something to do,

but I don’t need to hurry.

(Source: HKMA News November 2010)

Don’t call this public-private-partnership. Private doctors are not that stupid.

In September, I joined a trip to experience driving in the desert in Dunhuang.  Driving in the Gobi desert was definitely a new experience.  I had prepared to share with you in this issue the exciting trip and the new techniques I learned and practised to climb over a high sand dune of soft sand.  I had also extrapolated the philosophy behind these new techniques to our daily lives.  However, I changed my mind after attending a briefing session on public-private-partnership and reading the consultation document on Voluntary Medical Insurance Scheme.  There was an urge to write something else.

On September 28, the Voluntary Medical Insurance Scheme was endorsed by the Executive Council.  This Scheme was the result of the previous Healthcare Reform Consultation Document: Your Health Your Life. In Your Health Your Life, the scene was set that our healthcare system might not be sustainable because of the aging population, the increasing chronic illnesses and the rising medical costs.  A change in our healthcare system was needed.  It seemed that the Voluntary Medical Insurance Scheme was meant to be the change intended to solve the problems and to make our healthcare system sustainable.  However, as more details of the Scheme were disclosed, devils really crept out to get prepared to celebrate Halloween.  In a press release on October 11, the HKMA described the Scheme as “poisonous pills in sugary coating”.  I would leave the analysis of the Scheme to our President and other Council Members.  I am going to write about public-private-partnership.

Public-private-partnership had also been discussed in Your Health Your Life.  In Chapter 3, it stated that: “We believe that it is also worth pursuing in Hong Kong as it will not only help redress the mentioned imbalance between public and private healthcare services, but will, more importantly, result in an overall improvement in the quality of care for patients, make better use of the resources available in the community, and facilitate training and sharing of experience and expertise, thus helping to ensure sustainability of the healthcare system…”  So public-private-partnership had been described as promising as the Scheme to solve the healthcare system problems.  It was also a fact that the Hospital Authority had launched various public-private-partnership programmes, though of dubious results.  It might be of some predictive value on the attitude of the Government and the Hospital Authority towards the Scheme by looking into how it performed in public-private-partnership.

I was invited as a family doctor to attend a forum on the Community Health Call Center Service.  It turned out to be an occasion for the announcement of the launching of the Call Center.  It was because no matter what the attendants said or felt about it, the Call Center would be launched several days later.  The idea of the Call Center is to tag discharged patients who are over the age of 60 and who score over certain points in a scale of readmission risks.  Then there will be a community nurse from the Call Center to call the patients in regular intervals.  The patients, on the other hand, are encouraged to call the Call Center whenever they encounter problems.  There is no rolling out mechanism for tagged patients.

This Call Center Service obviously creates two problems.  First, since there is no rolling out mechanism, it is highly likely that eventually the Call Center will recruit all the old age people in that district under its care.  This is frankly going towards the opposite direction of Your Health Your Life, as well as putting a mechanism in place to make the Hospital Authority financially not stainable.

The second problem is that the Call Center in fact employs a community nurse to substitute the patients’ own family doctors.  Pilot results may be promising just because there will be more consultations for the studied patients.  Thus they tend to have more medical care free of charge.  Patients are “stolen” from their family doctors.  Instead of going back to their family doctors for follow up and management of whatever problems, patients are actively approached by a nurse on the phone, or asked to call the nurse when they encounter problems.  The nurse will provide twenty odd options for the patients, among which there are very attractive ones like home nursing and early appointments for GOPC and SOPC.  It is after all the screenings and among all options that the option of going back to the patient’s own family doctor is found.  There is no financial incentive, but just a reminder (may be for those patients with dementia) who their family doctors are.  The patients can always insist on other options.

The punch line is the emphasis on a “selling point” in this arrangement for family doctors.  It is referred to as support and back up.  In the rare occasions when patients are referred back to their family doctors and the doctors find that their patients need specialist care or admission, then the doctors could discuss with the community nurse and see if she would make such arrangement!  And of course the decisions lie with the nurse.  Sorry, no further comments.

For true partnership, there must be respect for family doctors.  A single nurse in a district could not replace the role of the patient’s own family doctor.  The Call Center is again using price differential to ruin family medicine.  Where is the relation that is emphasized in family medicine?  Where are the opportunities for screening?  Why should there be early appointments for GOPC and SOPC?  How could the patients’ family doctors have complete records of their patients?  What are the costs of Call Centers compared to private family doctors?  This wrong concept and arrangement should not be allowed to perish with the support of public money.  A simple version of this scheme is, instead of building another white elephant, just to give the financial incentive to patients and encourage them to have extra consultations with their family doctors.  

You can describe this scheme by any terms.  It could be true passion to help patients but with wrong and unskillful methods.  It could be expansion of public tertiary care to erode private primary care in disguise.  It could be just a fuss to spend public money.  However, whatever you call it, don’t call it public-private-partnership.  Private doctors are not that stupid.

(Source: HKMA News October 2010)

The tragedy

The Philippines Hostage Crisis on August 23, 2010 was a tragedy.  A former Philippines police officer caused eight deaths and himself being killed after eleven hours of holding hostage of fifteen Hong Kong tourists in Manila.  Part of the event had been broadcasted live and many Hong Kong citizens had watched in TV.  We were shocked by the drastic turn of the situation.  Our hearts were broken when we heard the gun shots.  We felt terribly sorry for the victims and their families.  Among these feelings, most of us also felt angry.  The actions of the Philippines police were nothing better than foul play.  That was a tragic demonstration of the Murphy’s Law, that anything capable of going wrong did go wrong.

I could feel the anger of many people while reading commentaries and responses from newspapers, magazines and the internet.  I looked into my angry feelings and tried to reason why I felt angry, as anger could be dangerous if it was not addressed properly.  The obvious reason was the unskillful rescue by the police.  It led us to the conclusion that they contributed to the failure of the rescue, and therefore death and injuries of so many people.  I did not expect the Philippines to be comparable to other advance countries like the United States.  They could be less well equipped and less well trained.  However, it was their performance which led me to the conclusion, without reasonable doubt, that they lacked the right attitude and the “heart” to save lives.  Their “didn’t care” attitude guided their actions.  So common sense was not applied, and consequences were not anticipated before each move.  Sadly, these seemed to apply to all levels in the Philippines team.  No one had the mind and intention to discharge even his basic duty of care that he owned the victims.  Via satellites, I could vividly feel the actualization of the unavoidable tragic ending because of the problematic attitudes.  I felt angry.

The above “attitude and common sense analysis” reminded me of two stories told by my patients.  (I think family doctors would share my experience of listening to stories, sometimes long-winded ones, from our patients.  It is interesting to note that many patients do come to tell their stories and forgetting about their chief complaints after the first two minutes of consultations.  It is more interesting to find that some patients come to give advice instead of receiving advice.  Anyway, these two stories were told by two young pretty ladies and I listened to them with great interest.)

The first lady complained about her bad experience after her eye check by an ophthalmologist for dry eyes.  Her contact lens were taken off and her pupils dilated while she told the nurse that she did not have any spare contact lens or glasses.  The consultation was uneventful and the diagnosis was dry eyes.  However, she had difficulty in locating the door when leaving the clinic and was luckily directed by the nurse to the door.  The rest of her trip home was less lucky and she asked me to surf through Youtube to see if there was any clip showing her wandering around in the corridor, in the lift lobby, in the MTR station and in some places unknown to her; and touching the walls and everything nearby.

That was not the end of the story.  What agitated her more was the experience in the following week.  She visited a beauty salon for what I called augmentation of eyelashes.  It is a process which practically sticks some artificial eyelashes to the original eyelashes, on a one-to-one basis, to make them look longer, and maybe thus prettier.  Her visit was for the removal of the previously augmented ones and then to have new ones someday afterwards.  The punch line was that after the removal of the fake eyelashes, the technician was really taken aback when my patient told her that she did not bring with her any make-up for the eyes.  She practically stopped my patient from leaving and tried hard to find some remedy for her.  No, it was not what you and I figured.  She was not selling any other product to my patient.

The next lady’s story was about her face allergy.  She was troubled by rashes on her face for several months.  She had seen various doctors including dermatologists.  Many tests had been done and important causes including immunological causes like SLE had been excluded.  The diagnosis was there: allergy; but not much could be done except local application of steroid cream.  Systemic steroid and oral anti-allergy medication had been tried but effects were only short-termed.  And of course traditional Chinese medical practitioners had been consulted and some magic ointments from neighbors and relatives had been applied and with no significant effect.

She was cured eventually. Her family doctor asked her to make a detailed diary of the appearance and subsiding of the rashes together with her daily activities and everything that came in contact with her face.  Upon careful analysis, it was found that the beginning of the appearance of the rash coincided with the partial tearing of her duvet bought in Shenzhen.  A breakage of the duvet cover led to the exposure of some fiber content that might cause irritation.  A changing of the duvet eliminated the rashes in a few days time.    

These two stories came to my memory because they both illustrated that knowledge, technique and training sometimes were not the most important ingredients during consultation.  With a caring attitude (the heart) and common sense, a girl who stuck eyelashes was more aware of consequences after operation.  A family doctor with training in dermatology incomparable to a dermatologist could use his time and patience (and common sense) to help his troubled patient.  These are the lessons that I regularly bring up to remind myself. 

(Source: HKMA News September 2010)

Important observations

Last month was a month for changes and for celebrations.  Two events, the HKMA 90^th Anniversary Charity Concert and the Public Education Day (Beat Drug Stars Brighten the Community) were successfully held.  Both events were beat drugs activities related to the new Beat Drugs Action Committee.  Another event was the Annual General Meeting with the announcement of results of the HKMA Council Election.  Dr. CHOI Kin was elected President (again).  Dr. CHAN Yee Shing and Dr. CHOW Pak Chin were elected Vice-Presidents (again).  Dr. LEUNG Chi Chiu was elected Honorary Treasurer (again).  The six elected Council Members were Dr. IP Wing Yuk, Dr. LO Chi Fung, Dr. SHEA Tat Ming, Dr. SHIH Tai Cho, Dr. WONG Yee Him and myself.  I have to thank everyone for their support so that I can continue to serve on the Council.  I was also appointed the Editor of the News again in the first Council Meeting.  (Dr. LEE Fook Kay was appointed Honorary Secretary.)  In this issue, I continue to share with you some important observations concerning decisions of the Medical Council.  It is about the use of steroid again.

Last month, a doctor was found professional misconduct “… in that he prescribed to the patient systemic corticosteroids without informing the patient of the nature, anticipated actions, and possible side effects of such medication.”  Another case decided early this year was looked upon as the precedent case.  The charge in that case was that “the doctor prescribed to the patient celestamine that contained steroid without informing the patient of the fact that celestamine contained steroid.”

In the recent case, the judgment stated that: “The Council has repeatedly emphasized that it is a duty upon all registered medical practitioners who prescribe steroids to inform patients of the nature and the side effects of the medication.”  The judgment was very strict and was very broad as it caught all steroids and not just systemic steroids, and the dosage or duration was not taken into consideration.  For example, the judgment also stated that: “By failing to inform the patient that Dexamethasone is a steroid, the Defendant’s conduct has fallen below the standard expected amongst registered medical practitioners.”  It was also ruled that the specific Chinese term 類固醇 had to be mentioned.  “The term 消炎、消腫藥 is too ambiguous as it can refer to many other drugs, and is not an acceptable substitute for類固醇.”

Naming it “properly” was not enough, the nature and side effects had to be explained.  In this case, “The Defendant only advised the patient of the potential side effect of gastro-intestinal upset.  No mention was made of other significant side effects of steroids, such as susceptibility to infection and mental disorder.  In this respect, the Defendant’s conduct has fallen below the standard expected amongst registered medical practitioners.”  It was debatable whether Dexamethasone 0.5mg QID for two days could cause these side effects.  Even for informed consent, failure to volunteer rare side effects might not render the doctor guilty.

The appropriate provision in the Code for warning patients about side effects of medications is Section 9.6.  It stipulates that: “Where a drug is commonly known to have serious side effects, the doctor has the responsibility to properly explain the side effects to the patient before prescribing the drug.”  The non-judicial use of steroids should be discouraged.  However it is neither a good law nor a good practice to make it necessary to have informed consent for the use of steroids disregard of the indication, the duration or the dosage.

Below is the summary of my observations and thoughts:

• Whenever steroid is use, the patient has to be informed.
• The doctor has to volunteer all the information.  He would be found guilty of misconduct if he does not do so.  It does not matter whether the patient asks about it or not.
• Steroids have to be referred to as 類固醇.
• Detailed potential side-effects have to be mentioned.
• This is not limited to systemic steroids.
• The indication, the dose and the duration are not taken into consideration.
• Strict liability has been introduced for the use of steroids.
• I still doubted that the prosecution had failed to prove that the use of a few days of low dose steroid could cause serious side effects to the extent that professional misconduct was involved.
• It is not clear whether this strict liability is limited to the use of steroids (and whether it is limited to systemic steroids) or to all drugs commonly known to have serious side effects.
• The strict requirement of informed consent for the prescription of a drug is more complicated than you can expect.  It can develop into the need to prove that there has been consent; that the patient understands the information given; that the patient agrees to the use of the medication with the specification of everything including the dose, the duration, the correct diagnosis and each and every details; and that there should be explanation of other options of treatment. 

(Source: HKMA News August 2010)

July 2010

One of the biggest events in the previous weeks was the 2010 FIFA World Cup.  The 19^th World Cup started on June 11.  For a whole month, the soccer fans were lacking sleep for sure.  I tried not to disturb my daily life by skipping the late night matches.  It was not until the quarter finals; I went to bed early and woke up in the middle of the night for the matches.  As for the venues, this year I had watched the matches at home, in bars, in karaoke, and even in conference rooms in Japan.  There were sixty four matches altogether.  What was the most exciting part of the event?  It was the unpredictability of the results of some of the matches.  I was actually writing this article at the very last minute so as to update readers on the latest results (and of course the hidden reason was that I had to support my team during these days).  The last game was just over.  I felt sorry for the orange; the bull won the championship at the end.    

Another imperative happening in this month was the HKMA Council Election.  As excited as the soccer matches, the candidates for different posts were very competitive.  Seeing that there were two candidates for the post of President, they had their cabinet nominees, who were fighting for the posts of Vice President, Honorary Treasurer and Council Member.  While door to door canvassing efforts and numbers of election campaigns had been scheduled within weeks, there was a growing tension between cabinets.  So who would be the next President finally?  We don’t need Paul the Octopus to tell.  By the time you receive the News, you should have known the answer. 

Just about that time, there comes another occasion.  The HKMA Annual Charity Concert will be held on July 31.  This year’s concert is an extraordinary one.  Why do I say so?  First of all, the year 2010 marks the 90^th Anniversary of the HKMA.  The Charity Concert would certainly be one of the celebration highlights.  The next exceptional thing is that the beneficiary of this charity event is not any benevolent organizations in Hong Kong.  It is the HKMA Beat Drugs Action Committee (BDAC). 

The BDAC was newly formed this year with the aim of promotion and coordination of beat drugs activities in the medical profession.  In reaction to the alarming statistics of ever rising numbers of young drug abusers and the leadership of the Chief Executive, there have been inputs and efforts from members of the society including doctors.  Both the HKMA and individual doctors have been organizing and taking part in various beat drugs activities with promising results.  However, beating drugs and helping drug abusers require long term coordinated work with constant review and input of resources.  It is under these backgrounds that the HKMA sees the need to form a new committee.  The BDAC will be looked after by designated staff to plan, organize, coordinate and review beat drugs activities involving doctors in order to strengthen the role of the medical professions in the team work of beating drugs.  Coming works of the BDAC include organizing more beat drugs courses for more attendants; organizing in-depth hand-on trainings; coordinating and evaluating the project between the Home Affairs Department and the HKMA Community Networks to help young drug abusers; piloting the use of group therapies in young drug abusers; and providing public educations.

Very soon we will be having the first HKMA Public Education Day.  The “Beat Drug Stars Brighten the Community” (抗毒之星耀社區) will be held on July 25, 2010 (Sunday) at Olympic City II.  As the organizer, we are grateful for having twenty co-organizing and supporting bodies (including hospital, school, NGOs, partent-teacher associations etc.).  There will be on stage performances (such as lion dance, singing, dancing, talk show, live band, martial arts etc.), medical booths and game booths.  Some of our members are performers or voluntary workers.  You are very welcome to come and support us.

It is appreciative that the HKMA and HKMA Charitable Foundation greatly support our Committee.  The donations raised for the Concert will be reserved for beat drugs activities organized by the BDAC.  The Committee will fully utilize its resources and efforts to tackle the youth drug abuses by encouraging doctor’s engagements.

To give a hand to the young drug abusers, please do support the BDAC.  It’s never too late.  Make a donation now! 

 (Source: HKMA News July 2010)