Take it or "Beat it"

This month’s breaking news must be the announcement of the Financial Budget by the Financial Secretary.  Started as an every-year-routine, Mr. John Tsang did manage to make a big fuss out of it.  Claimed to be a product of extensive consultations (which included opinions sorting from a large number of primary school students), the Budget faced loud voices of opposition from all walks of life.  The most controversial item was the injection of $6000 into each MPF account with the objective of soothing citizens from economic hardship.  Mr. Tsang was very firm at the beginning: "The budget has struck the right balance.  I think the budget was not bad.  I will continue to explain [it to the public] and hope more people will come to understand it" (February 25).  "We can't take this part out and that part out.  It is impossible.  It's difficult." (February 26)  However, this “take-it-or-beat-it” attitude made a sharp u-turn after the threat of mass demonstration was foreseen to have of a good chance of materializing.  So the proposed Budget was updated to give $6000 to each HK Permanent ID Card holder.  On top of that, there would be 75% salary tax rebate capping at $6000.

What I would like to discuss is the “take-it-or-beat-it” attitude in relation to the Healthcare Voucher (HCV) Scheme.  Yes, HCV again.

On January 17, an official openly accused doctors of cheating and raiding government subsidy money in the HCV Scheme.  The HKMA objected firmly.  Up to the date of writing this editorial, there was no explanation or apology whatsoever.  I would interpret that as the official and the government showing the “I really mean it!” gesture.  This was partially confirmed when I had the luxury to meet an official unofficially one fine afternoon.  I suspected that he was the arrogant official who framed doctors opened but there was no way to confirm.  He proudly presented to us his plan of imposing more conditions on the use of HCVs by doctors such as the filling of more detailed coding on-line and the amount of co-payment (why co-payment?) by patients.  He again emphasized the objective of the HCV Scheme as the encouragement of preventive medicine and health checks.  However, he could not provide an answer for why physiotherapists were included as providers as they obviously did not provide any preventive measures to the elderly.  I was interrupted when I tried to talk about the grievance of general practitioners on the extra work on HCVs and the adverse comments we received.  What I perceived subjectively (I have to be careful and fair to say this) was the “take-it-or-beat-it” attitude.  So my option was either to join the scheme or not to.  The terms were clear and pre-set.  They would not be changed for you.

This meeting reminded me of the Financial Secretary and the Budget: “Take it or beat-it, or show me your power.  I would not hesitate to call your bluff.”  However, our government and officials are more careful than Mr. John Tsang.  They had tested the limits of doctors before with some open humiliations and harsh accusations.  Seemingly, no too drastic actions were met.  So they can proceed.  This is what the Chinese saying of “testing with a clay-pot by the thief”.  Well, they might be correct.  Doctors including myself do not like marching on the street.  And general practitioners are used to looking after ourselves in a submissive, non-united manner.

After going through the whole matter again in my pessimistic mode, I in fact have to thank the “take-it-or-beat-it” offer.  This is not the worst scenario, although it is bad enough to have your own patient sold to you and then any official can openly call you a cheater and a liar (maybe it is worse to be a cheater and a liar to the elderly).  The worse to come is this: “Sorry, you are not eligible to join our scheme.”  Or maybe when you have twisted your practices and hopefully not your consciousness to join the scheme, one fine day you are told: “Sorry, you will be kicked out of the scheme unless you do so and so.”

Maybe I am pathologically cynical and pessimistic, but those senior (or old) enough should have witnessed the growth of HMOs.  With unequal contract terms that the doctors had never taken part in the negotiation, HMOs got the market share.  Then the terms are constantly changing to the benefit of the organizations.  Can you remember how many years haven’t the consultation fees been raised by HMOs?  How many times do you think they have raised their charges against their clients?  So what?  Take it or beat it.

Again, I would like to end with some advice to myself.  Stay healthy, both physically and financially.  Do some exercise and don’t overeat, or over invest, or over spend.  Always allow myself the option of saying no to the take-it-or-beat-it offer.  I don’t need to decide on the difficult question of whether to encourage or disallow my sons or daughters to become a doctor, as I don’t have any son or daughter I know of.  Continue looking after myself.  But if the situation is too bad (I am still thinking whether being accused openly while I am taking some pain to endure the unfair contract terms bad enough), maybe I shall go out and get united with the mass.  Maybe at that time, I shall get back my patients without having them sold to me.  Or maybe I shall get back my $6000 overcharged by the government.

(Source: HKMA News March 2011)

Doctors were framed openly

Kung Hei Fat Choy.  Wish everyone a prosperous year of Rabbit.

In previous months I suggested readers to focus on happy events of lives, and my new year wish was tranquility in 2011.  However, the beginning of the new year was disturbed by a piece of news appearing in several newspapers on January 17.  In short, the news was about the use of Healthcare Vouchers by Hong Kong citizens over 70 years old.  It quoted a government official (who remained anonymous throughout) saying that healthcare providers (mainly general practitioners and family doctors as I understood) cheated the aged by charging them more than the providers’ usual charges.  However, there was no evidence supporting this serious accusation.  The magnitude of the problem was also not assessed.  Whether there was one doctor (or even none, as the accusation was not supported by anything) or hundreds of doctors cheating the aged remained unclear.  The mysterious official also inferred from the “suspected to be fabricated” story and warned that further public money would go to doctors’ pockets without benefiting the aged.  He then concluded that a new mode of contracting the public money to organizations for checkups was needed.

What had happened was blatantly unacceptable.  The accusation was very serious.  It affected the accused doctors’ fitness to practice as it could be misconduct in a professional respect.  It damaged the image of the profession as a whole.  However, there was no way to try to discuss or to solve the problem.  The one who spoke and who raised the problem was anonymous.  He was not using any official channels to try to verify or to tackle the problem.  He just aired to some media in an irresponsible manner, adding his own inference and comments.  All these raised readers’ suspicion of malice intention behind this plot.

In view of the serious nature of this incident, the HKMA quickly held a press conference in respond to the ungrounded accusation.  As the Editor of the News, I also shoulder the responsibility of giving an account of this matter to readers with my analysis. 

The ungrounded accusations

The ungrounded accusations were found in four newspapers on January 17, 2011.  Below are the quotes:

Apple Daily:

『為免醫生繼續從中「掠水」，政府檢討後不會直接就醫療券加碼給長者，考慮明碼實價向醫療機構購買預防疾病的服務。』

『政府發現有醫生對使用醫療券的長者加價，甚至有人曾承認政府既然派錢，為何不從中得益。但由於沒有參與醫生以往的收費紀錄，政府難以調查多少醫生「抽水」。』

『政府認為，若未來調高醫療券金額，錢只會流入醫生口袋，長者不能受惠，加上長者只會繼續使用醫療券「睇傷風咳」；故當局不會直接在醫療券加碼，考慮直接向醫療機構購買預防護理或身體檢查等服務，供長者使用。政府擬預先定價，參與的醫療機構不能向長者額外收費，變相直接將錢給予長者。』

Ming Pao:

『政府調查發現，70%長者用醫療券看傷風咳，更發現有私家醫生藉詞「政府派錢，醫生可與病人對分」乘機加診金，因此，政府在醫療券加碼下，正研究為醫療券使用者設下只作健康檢查的條件，藉此提高長者預防疾病效益，同時也可防止私家醫生從醫療券「抽水」。』

『了解醫療券計劃的消息人士指出，當局更觀察到有私家醫生藉詞醫療券是「政府派錢，醫生可與病人對分」，將門診診金由150元提高至200元，並建議長者用2張共值100元的醫療券支付診金，令醫生多賺50元。』

HK Economic Journal:

『為免資助被侵吞，當局擬集體採購服務，讓長者不用額外付費，或要醫生報告額外收費。』

 

『現時長者如用醫療劵打流感針，因由醫生定價，用者需付餘額。政府消息直言，不傾向採用這模式，以免醫生「侵吞」資助，曾有醫生說：「政府派錢，我們分一點也很應該！」他舉例，流感針每劑 120 元，但疫苗計劃推出後，推高至 160 元，政府資助的 80 元，一半到了醫生口袋。』

SCMP:

“Health officials are alarmed by the abuse, which saw some doctors increasing medical charges for elderly patients enrolled in the scheme.  The Food and Health Bureau is working on new measures to curb the abuse.  One idea is to pay for primary care services directly from private doctors.” 

“’Some doctors have raised their fees on patients who use the vouchers,’ a person familiar with the scheme said.  ‘As a result, the elderly cannot fully benefit from the government subsidy ... the vouchers are effectively shared between the patients and doctors.’” 

It is common to have government officials to comment on reports or policies before their formal announcement.  However, there were some special features in this incident.  First, serious accusations were made on doctors and defamatory wordings were used.  Similar wordings were used by all the newspapers reflected that those wordings were likely to be said by the official.  Second, there was no proof at all and there was not the slightest intention to substantiate the claims.  It is obvious that the intention of making such accusations was not problem solving as there had not been any discussion with the profession or any action against the doctors accused.  Third, an important governmental policy involving public money in the magnitude of tens of millions was suggested to be made and be modified according to some hearsay or fabricated stories.

From the setting and context of the newspaper reports, it is natural for readers to come to an impression that the government official smeared the profession on purpose.  He was so desperate to sell his plan of channeling future public money to some organizations that he did not mind betraying his own profession.  However, this was done in an unskillful, or maybe arrogant, manner.  No one bothered to find proof for the accusations.  The ungrounded accusations were generalized to the whole profession.  The generalization was used to support some changes in the policy.  Come on!

Healthcare Vouchers

Healthcare Vouchers were introduced by the government in 2009 as subsidies for HK citizens over the age of 70.  Each year each elderly can have 5 electronic vouchers each having the value of $50.  It was said to be a pilot project when law makers criticized that the total value of $250 per year was grossly inadequate.  These vouchers can be looked upon as cash coupons in electronic form as they can be used equivalent to cash when visiting registered healthcare providers.

It is the cash equivalent nature of the Vouchers and the free choice of healthcare providers that rebut the accusation about doctors’ over-charging.  It is likely that each owner of the vouchers will value his own assets and will guard against abuse.  It doesn’t mean that there do not exist cases of doctors overcharging patients.  But the use of Healthcare Vouchers is unlikely to encourage overcharging.  Since the vouchers are to a certain extent equivalent to cash, a doctor can only cheat his patient once.  If he charges differently from his usual charge, his patient will know it and will be gone for good.  My own experience as a provider is that coherent elder patients are very alert of charges including how many vouchers are used and how many are remaining.

Another point to illustrate that the official was not telling the truth was about influenza vaccines.  Evidence shows that there are significantly increasing numbers of doctors charging less.  Many doctors now do not require the kids or the elderly to co-pay apart from the government subsidy.  What the profession facing is a race for fee cutting instead of the imaginary fee raising to raid the government or the elderly.  

Extra work for healthcare providers without extra gain

Concerning the use of Healthcare Vouchers, in fact much extra work has to be done by the provider doctor.  He or his staff has to register on-line for the patient, and to explain to the patient the number of vouchers used and the number remaining.  There have to be print-outs for the consent forms.  There are regular on site checking and audits by the government.  The consent forms have to be stored.  Any mistakes in the process will cause the doctor inability to have reimbursement.  In fact family doctors have helped the government to build up a data base of registered elderly and have smoothed out many handling and data input problems.  However, we are not acknowledged or paid.

The accepting of Healthcare Vouchers is in fact a contract between the healthcare provider and the government.  However, the terms of the contract have never been negotiated.  Many doctors do have grievance in taking the extra works.  Some of us accepted the unfair terms mainly because the scheme was promoted as a pilot project.  So it was worth to give it a trial without caring too much about the details.  Moreover, it is always easily got blamed when elderly are involved.  How can doctors chase for a few bugs and hinder the long-awaited subsidy scheme for the elderly? 

The arrogant official may argue that doctors do benefit from the scheme as extra money is injected into the market.  My own experience (still case reporting, but at least you can trace me for verification) is that I have been seeing my own patients who now use the vouchers to pay.  There are minimal extra consultations just because of the vouchers.  One of the reasons is the amount of the subsidy can only pay for one consultation per year.  It is likely that an average elderly patient needs more than one medical consultation with his family doctor in a year.  So it is natural for him to use the voucher to pay for one of the inevitable consultations.  

Design of data collection is problematic

I believe that there are actual statistics for the scheme because doctors are required to input extra data including the reason for each consultation before he can finish the cumbersome registration and reimbursement procedures.  However, the statistics may not be meaningful as there are faults in the design.  One of the faults is about the reason for consultation.  This was the main argument by the official to divert public money to some organizations.  Only one reason can be chosen for each consultation.  This ignores the fact that each consultation by the family doctor is multi-purpose.  Especially for the elderly, in order to save money, they usually go for a consultation when there are acute problems such as URTI.  During that consultation, they will raise all their problems for the doctor to solve.  For example, they might ask about their fear of lung cancer because of their recent cough.  The doctor can then educate them for cessation of smoking.  Then related topics of metabolic syndrome as related to smoking will be discussed and the patient’s body weight, BMI, blood pressure, and may be sugar and cholesterol levels measured.  Opportunistic screening and health education is the norm rather than the exception.  It is sad that while hidden agenda and family medicine are undergraduate stuff, these need to be taught to officials again.   

Preventive medicine and family doctors

Something has to be said about the ultimate intention of the hidden official.  Let us first suppress the inevitable suspicion of conflict of interest and hidden gains by him and concentrate on the discussions of rationales.  Is it good practice and is it beneficial to the health of the elderly when channeling them to health check centers instead of their family doctors?  Is it more cost effective and more beneficial to the elderly if he goes to an unfamiliar center to do blood tests for liver function and tumor markers than to see his own family doctor for opportunistic screening for early symptoms of cancers, cardiovascular diseases, renal diseases, eye problems and mood disorders?  Should consultations by doctors be replaced by routine profile tests?  Should the interpretation of test results be detached from the patient’s history and delivered by a staff unknown to him?  I guess it does not need a profession to answer the above questions.  It is another sad fact that while doctors have the duty to educate the public, the government is seemingly doing the opposite.

Important messages

• This kind of smearing action is harmful to the profession and is unacceptable.  It must be stopped.

• Based on this smearing, there was an intention of channeling public money to health check organizations.

• In response to the accusation and smearing, the HKMA has quickly held a press conference and sent a complaint letter to the Chief Executive and Food and Health Bureau.  There will be further actions if necessary.

• Your support and united actions are needed.

• Many family doctors have been penalized for the generosity, both in doing extra works for the government in the use of Healthcare Vouchers free of charge, and in providing free preventive medicine and counseling services to the aged.

• Ask yourselves: if you have practiced preventive medicine and provided advices and counseling in your consultations with the elder patients using Healthcare Vouchers, would you choose the options of “Preventive” and “Health Advice/Counseling” as the “Reason for visit” when handling Healthcare Vouchers?

(Source: HKMA News February 2011)

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)