What is the big picture?

I have difficulty interpreting the Healthcare section of the Policy Address 2013 delivered by the Chief Executive of Hong Kong.  I cannot get the big picture.

The Policy Address is for the general public.  While most of them are laymen to healthcare policies, all of them are users of healthcare services.  The aim of the Policy Address is to tell the users what they will expect from the new government.  There is in fact no right or wrong healthcare policy.  There is even no absolute good or bad healthcare policy.  There is by no means a government can create and implement a perfect healthcare policy.  Afterall we all know that such policy does not exist.  There are always some stakeholders getting more than others, some getting less than what they expected, and some being neglected or even discriminated upon.  The government is entitled to identify problems and to set its own priorities.  But at least the government needs to tell us what its vision is, why it thinks so, and how it is going to achieve it.  I do not see these in the Policy Address.

The Policy Address states only one guiding principle.  The provision of quality and affordable healthcare services has been a proud achievement.  However, there exists a problem, which is the rise in medical costs due to different reasons.  The government needs to “tackle the root of the problem”.  So apparently it seems clear that the government identifies a problem and is going to tackle it in this year or in the coming five years.  However, it does not elaborate what the root of the problem is.  Obviously the problem is the rise in costs.  But what is the root of the problem?

Without identifying the root of the problem, we can still try to tackle a problem of rise in cost.  Theoretically, it is simple.  You can either cut the cost, or you can put in more money.  Of course you can do both, but there is always an inclination to either way.

Reading the Policy Address, injecting more money is in solid terms: “The Government allocated additional funding of about $2.5 billion to the HA last year, raising its annual recurrent subvention to $40.4 billion.  We will continue to set aside resources to strengthen our public healthcare system and enhance its service quality.”

  

Before we search for items to cut costs, I suggest looking into items that go the other way, that is, items that further raise the cost.  By cost I mean cost borne by the government but not cost paid directly from an individual citizen for medical expenses.  These policies, once implemented, will be unlikely to be “uninstalled” and will contribute to the rise in cost to the government.  The number of beds under HA hospitals will be raised.  New hospitals and clinics will be built.  Existing hospitals will be expanded.  The Drug Formulary will be expanded.  The waiting lists of specialist out-patient clinics will be optimized.  Waiting time for semi-urgent and non-urgent cases will be shortened by, again, injecting more resources.  The role of Chinese medicine and Chinese medicine practitioners in the public healthcare system will be expanded.  Chinese medicine in-patient services will be introduced.  (One point to note is that it is quite uncommon for Policy Address to specifically aim at “enhancing the status of Chinese medicine practitioners”.)  

While injecting money is relatively simple (theoretically, not practically), cutting cost is the talented part.  Let’s have a look at what the government has offered.  It is hinted that the private healthcare sector is a solution.  However, there is no commitment.  Public private partnership is mentioned.  Despite the cannot-be-considered-favorable comments from the Audit Commission on the few previous public private partnership pilot projects, the HA is just going to “study the feasibility of further service outsourcing”.  The section on private healthcare sector is then dominated by the eye-catching title of “Regulation of Private Hospitals”.  This is in-line with the all-too-often-heard comment that people prefer HA to the private healthcare sector mainly because of the relative lack of regulation.  The huge price differential of having a laparoscopic cholecystectomy with $50,000 in private versus $300 in HA is never a major factor except to the users.  Traditionally, regulation is never considered a kind of facilitation.  The Health Protection Scheme can be a mean to encourage patients going for the private sector and cut the cost of the government.  However, it is still in the going-to-be-consultation stage.  Whether it is helpful or not depends on the scale and details of the scheme.

The balance between the public and private sectors is the only strategy in cutting the cost.  Other proven and useful methods are not considered.  Preventive medicine and primary care have been practiced with success in many developed countries in cutting the cost of healthcare and in promoting the health of their citizens.  Preventive medicine and primary care were once the high-lighted healthcare policies in Hong Kong.  They have remained in the talking level, but then disappear completely in this Policy Address.

I scratch my head and think about what the root of the problem is.  I am thinking about drawing the conclusion that the government is going to tackle the problem of rise in cost by just injecting more money into the HA.  Then it comes the epilogue of the Policy Address.  I hear from the news that apart from what have been mentioned, there will be other policies.  They will be in the mode of 成熟一項推一項.  I do not know how to translate it, as I am not sure what it means.  Is it referring to the maturity of a policy from consultation and discussion?  Or is it referring to the right timing?  Or in fact the beauty is the ambiguity in meaning and the freedom from scrutiny?

So, the conclusion is that no conclusion is needed.  Let’s forget about the Policy Address in the meantime.

 

(Source: HKMA News February 2013)

Looking Back

(Source: HKMA News January 2013)

The personality paradox

I got lost this month.

My small-sized brain could not understand why prominent people and public figures kept talking nonsense.  Frank lies were thrown in our faces.  Public declarations that were affronts to common sense were made.  I would not consider them stupid.  Experience told me that it was usually those calling others stupid who were themselves stupid.  These prominent people and public figures were well known to be reliable and smart.  They were supported by people I respected.  Even for the nonsense, the people I respected kept their faith in those prominent people and public figures.

There must be reasons behind their behaviors.  Such reasons must be beyond my ability to comprehend.  I had thought about Buddhism.  Could it be collective karma?  This explanation did have some calming effects when you found lies thrown in your face.  But it did not offer much help in explaining individual behavior.  It was the same for my favorite Mappo Theory.  Well, if you are reading this Editorial, that means the world has not ended by December 21.

I turned to psychology to seek for hypotheses and theories to explain human behaviors.  I came across personality theories.  Personality could be defined as “psychological quantities that contribute to an individual’s enduring and distinctive patterns of feeling, thinking and behaving.”[1]  There had been constant searches and researches trying to classify, to understand, to predict and to change human behaviors.  In the recent hundred years, personality theories went in a circular fashion.  It went through biological theories, psychoanalytic theories, type theories, trait theories, social learning theories, the Big Five theories, and then returned to biological theories.  Yet, there was not a single unified and simple personality theory that could fulfill all these functions.  Among them, I found the Personal Construct Theory by George Kelly enlightening when applied to the above scenario.

George A Kelly (1905-1967) was a clinical psychologist engaged in the treatment of patients.  He found his standard Freudian psychoanalytic training inadequate when managing his patients.  He then developed a new theory in personality: the Personal Construct Theory.  Kelly started to explain his theory by assuming that people were like scientists in the sense that they would postulate theories, test them, and use them in their daily lives: “We started out with two notions: (1) that, viewed in the perspective of the centuries, man might be seen as an incipient scientist, and (2) that each individual man formulates in his own way constructs through which he views the world of events.  As a scientist, man seeks to predict, and thus control, the course of events.  It follows, then, that the constructs which he formulates are intended to aid him in his predictive efforts”.[2]  Here, the term “construct” was introduced and it stayed the key word for the theory.  He then stated out his Fundamental Postulate: “A person's processes are psychologically channelized by the ways in which he anticipates events.”[3]

I try to summarize the theory, in over simplified terms, into the following components:

1. Although both the external environment and thinking are in real existent, people perceive the external environment differently.  They construct the external environment in their minds according to their own experience and interpretations.
2. People behave in a way best to anticipate the future according to existing constructs, and to avoid conflicts with and contrast to their own constructs.
3. Stress and discomfort would develop if the outcome or anticipation of outcome does not conform to the person’s construct.
4. The process of construct formation and the constructs themselves are dynamic and modifiable.

So it was “construct” that mattered. While it took two to dance, it took three to form a construct.  When someone was saying that something was white, he was actually taking another two things as references.  One was similar to the object which he referred to as “white”, and another one as different from the two.  We could never know what exactly he meant without knowing what the two references were.  Nonsense that was an affront to our common sense might not be an affront to the liar’s common sense.  He was taking reference to something or someone else.  He did so in order to predict and to control the event in his own manner.

Of course he might have pathology in his construct formation.  Ironically, the treatment for defective construct system was Fixed-role therapy designed by Kelly.  In this therapy, the therapist worked out a new role with new sets of constructs for the patient to follow.  The patient would try to think and to behave as if he were the new person as prescribed.

Thus, the personality paradox I mentioned in the heading was several-folded.  First, I could not be sure whether I was the one having defective construct system.  Those prominent people and public figures with their supporters-whom-I-respected might have perfect constructs that guided them towards their brilliant future.  Second, they might be having pathological construct systems and thus they might benefit from treatment.  Third, they might be already undergoing treatment with the Fixed-role Therapy, but God knows who the therapist was.  Sadly, this paradox could not be elucidated as even post-mortem could not give an answer to psychological myths. 

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[1] P. 8, Personality Theory and Research 11^th Edition, Lawrence A Pervin 

[2] P. 12, The Psychology of Personal Constructs Volume One (1955), George A Kelly, Universal Digital Library 

[3] P. 46, The Psychology of Personal Constructs Volume One (1955), George A Kelly, Universal Digital Library

(Source: HKMA News December 2012)

The criminal charge of indecent assault and the disciplinary charge of misconduct in a professional respect

On November 4, 2012, a young doctor was found guilty of misconduct in a profession respect after a disciplinary inquiry held by the Medical Council.  The Inquiry Panel ordered that his name be removed from the General Register indefinitely.  The Inquiry Panel further ordered that the removal should take effect immediately upon its publication in the Gazette.  The Inquiry Panel also stated that the young doctor could not be a fit and proper person to practice as a doctor and that he could not be restored to the General Register at all.  The media referred the sentencing as the heaviest penalty ever imposed by the Medical Council.  Comparisons were also made to previous cases in which the defendant doctors were found guilty in criminal courts.  In contrast, this young doctor was found not guilty for the criminal charge of indecent assault, which aroused from a similar set of events leading to his removal from the General Register.  I shall analyze all these from a legal perspective.

In April 2010, the young doctor faced a criminal charge of indecent assault after he allegedly performed per vaginal examination on and took photographs from a female patient who consulted him for herpes zoster involving the lower body.  There were two major factors for his acquittal.  First, for the charge of indecent assault, there needed to be two components: actus reus (the act) and mens rea (the intention).  The act of touching the patient’s private part could constitute the act of indecent assault.  However, the prosecution also needed to prove that the defendant did it with an intention.  For example, if you waved at a taxi but accidental touched the breast of a lady walking from behind, it would unlikely be indecent assault.  In a medical setting, consent from the patient would be a legitimate reason for the act.  So the judge had to decide on whether there was consent, or implied consent, and the scope of the consent.

Second, for a criminal charge, the standard of proof was that the charge should be proved beyond reasonable doubt.  The jury or the judge had to be one hundred percent sure that the defendant had the intention to act indecently.  In this case, the judge, after taking all material facts and statements from witnesses into consideration, satisfied himself that there was a chance, maybe a very slim one, that the defendant doctor lacked the intent to act in a criminal way.  His acts, though stupid or inappropriate, might be accounted for by his relative lack of clinical experience.

For disciplinary inquiries by the Medical Council, things were different.  One should note that if this young doctor had been found guilty of his criminal charge, he would have been charged under section 21 (1)(a) of the Medical Registration Ordinance (MRO): that he had been convicted in Hong Kong or elsewhere of any offence punishable with imprisonment.  For this charge, he would have been judged by the inquiry panel mainly on the gravity of his offence.  And it would not have been a decision on professional misconduct.

In this actual case, an acquittal would not in itself lead to a disciplinary inquiry.  The inquiry was held because the case was referred by the Preliminary Investigation Committee (PIC) after investigating into a complaint or complaints received.  Section 21 (1)(b) of the MRO was invoked.  Basically, the young doctor was charged for conducting improper and unnecessary physical examinations; and improperly taking photographs and videos of several patients during consultations without consent.  The decision was whether he was guilty of misconduct in a professional respect.  The test for professional misconduct was set by the judge in the case of Koo Kwok Ho v the Medical Council of Hong Kong to be "whether the doctor's conduct has fallen short of the standard expected amongst doctors".  Note that there was no involvement of intention in the test.  Even when there was good intention, not to say malice ones, the doctor could be found guilty if his acts or behavior fell short of peer standards.

The standard of proof in disciplinary proceedings had been a focus of controversy.  Recently, it seemed to have been settled by a Court of Final Appeal case [Solicitor (24/07) and the Law Society of Hong Kong (2008) 11HKCFAR 117].  In para 116, it was stated that “the standard of proof for disciplinary proceedings in Hong Kong is a preponderance of probability under the Re H approach.  The more serious the act or omission alleged, the more inherently improbable must it be regarded.  And the more inherently improbable it is regarded, the more compelling will be the evidence needed to prove it on a preponderance of probability.  If that is properly appreciated and applied in a fair-minded manner, it will provide an appropriate approach to proof in disciplinary proceedings.  Such an approach will be duly conducive to serving the public interest by maintaining standards within the professions and the services while, at the same time, protecting their members from unjust condemnation.”  So, the standard of proof was not the criminal standard of beyond reasonable doubt, but the civil standard of a balance of probability with a somewhat circular logic built in.

After deciding that the defendant doctor had more probable than not fallen short of expected standards, the defendant doctor was found guilty of professional misconduct.  The Inquiry Panel ordered the removal of the name of the defendant doctor from the General Register in accordance with section 21 (1)(i) of the MRO.  This was in contrast to section 21 (1)(ii) where a time period was fixed for the removal.  Seemingly, removal without a fixed period was a heavier punishment as it appeared in the sequence in the Ordinance.  However, technically, the defendant doctor could apply for inclusion of his name in the General Register again as soon as the removal of his name was published in the Gazette.  So for a clearer message, both to the defendant doctor and to the general public, the Inquiry Panel also opined that there was practically no chance for his re-registration.

Another point to note was that the Inquiry Panel also ordered the removal to take effect immediately upon its publication in the Gazette in accordance with section 21 (1)(iva).  This meant that the Inquiry Panel satisfied that it was necessary to do so for the protection of the public.  This also added to the gravity of the sentencing as in normal circumstance, the removal order would not take effect if there was an appeal lodged.  

(Source: HKMA News November 2012)

Cogito Ergo Sum and Brain Washing

“Cogito Ergo Sum” can be translated as “I think, therefore I am.”  Many people take the words in their plain meaning literally and interpret the statement as encouraging people to think, and to think more so as to make their lives meaningful.  However, some regard “Cogito ergo sum” as the important conclusion of Descartes’ deep meditation to prove his own existence because of the fact and the action that he engaged in thinking.  His focus was on the “I”.  He satisfied himself that there was a thinker existing behind the act of thinking.  This seemingly obvious thinker/thinking paradox has haunted many philosophers.  Also through deep meditation, an opposite conclusion was reached by the Buddha.  He realized that there was no real existence of the person.  There was no thinker behind the act of thinking.  Rather, the thinker was an illusion made up to explain the act of thinking.

There are many philosophers and scientists who also doubt the obvious, particularly in the fields of the brain, the mind and thinking.  In late 1880s, psychologist William James came up with a new theory to explain the relation between our emotion and our behavior.  He proposed that our behavior was something instinctive, and our emotion only came after the behavior so as to rationalize it, or to explain for it as a habit of experience.  So, by his theory, our common sense was reversed.  People did not run from a bear because they were afraid of it.  Rather, they became afraid of bear because of the act that they ran from it.  Similarly, people did not smile because they were happy, but they felt happy because they were smiling.

Then in late 1960s, a young psychologist James Laird encountered William James theory and designed an ingenious experiment trying to verify it.  He succeeded in showing that people making happy facial expressions really felt happier; while those making angry facial expressions really felt angry.  Amazed by the results, other psychologists carried out various studies, in equally ingenious but different designs, and confirmed his findings.    

Also in the 1960s, another psychologist, Stanley Schachter, extended William James’ theory into bodily sensations.  At that time, it was known that different emotions were associated with different bodily sensations, such as change in heart rate, skin temperature and sweating.  However, there were obviously not enough parameters to account for the vast categories of emotions.  By a set of not-so-ethical experiments involving injecting adrenalin into participants, he was able to show that people tried to make sense of their increased heart rates by looking around them.  Thus people were much happier with increased heart rates from the adrenalin shots in a happy setting, and also angrier in an angry setting, than the controls with the saline shots.  So it was the bear that made you sweat, and then you looked around, saw the bear, and then began to feel afraid.

How about one step further?  Would the way we behave affect the way we think?  Can keep singing the national anthem make you more patriotic?  The book “The Wave” described how a 25-year-old history teacher and baseball coach created (too easily) a microcosm of Nazi Germany in his school.  In reality, in 1967, Ron Jones somehow unethically gradually modified his students’ behaviors to study the rise of Nazi Germany.  He lectured about the beauty of discipline, asked the students to sit in attention postures, and asked the class to repeatedly recite the phase “Strength through Community”.  He also created a class salute, gave memberships cards to students for the newly formed organization called the “Third Wave”, and encouraged students to report on anyone who openly expressed skepticism about the project.  The Third Wave grew by itself in days’ time and soon got out of control.  Ron had to call off the project in an assembly, and to explain to the students that how easily people’s behavior and belief could be manipulated.

You must have come across Zimbardo’s prison experiment about participants playing the roles of prisoners and guards.  Soon enough, participants fitted into their assigned roles.  The guards began to abuse the prisoners, while the prisoners tended to take such abuses reluctantly.  This was another strong illustration on how one’s behavior, in this case taking a certain role, would change one’s mindset.  You might not know that this experiment is required by law to be described in all books about the history of social psychology.  You might also not know that Zimbardo had himself adopted the role of the prison superintendent in his experiment.  He was astonished to find that his thinking had also been altered to the extent that he was unwilling to stop the experiment early when things got out of control.

When talking about brain washing, people tend to figure directly something to do with the brain.  However, in psychology, there is no crazy operation, flashing lights, white noise or injection of novel chemical to achieve this task.  Thinking is manipulated by modification of behavior in well proven experiments. 

(Source: HKMA News October 2012)

From the Editor

(Source: HKMA News September 2012)

Damn it! It is outrageous!

“If life gives you lemon, make lemonade.”

When you encounter something not-so-pleasant in life, try to make something meaningful and useful out of it.  This is a good and accurate description of what general practitioners in Hong Kong have been doing throughout all these years.  There are over two thousand general practitioners and family doctors serving the community.  Some of them have been working for decades.  They know people of their areas of service well.  They have been working for long hours, with average of ten to twelve hours per day.  A significant number of them even work seven days a week.  You can easily walk in a GP clinic and have quick and effective service in most of the public holidays including Lunar New Year.  However, there has been minimal support from anywhere.  The government has turned a blind eye to the snatching attitude of most landlords.  The government is supportive to the oppressive policy of the LINK towards general practitioners.  Apart from these, the contributions of general practitioners in the healthcare system in Hong Kong have never been recognized, not to say appreciated.  There have always been ungrounded and biased criticisms from government officials.  A recent example is the Healthcare Vouchers Scheme, in which general practitioners are the main service providers.  There are extra clerical and paper works with unrelated data input by doctors without any extra payment for the added service.  There has not been any complaint from the always-silent-group.  Bewilderingly, there are endless accusations of doctors over-charging the elderly.  

“If life gives you anything, just make lemonade.”

This is a new quote I invented to describe the behaviour of the government officials.  No matter what kind of project or new idea, they have the ability to turn it sour and ruin it.  The Healthcare Voucher Scheme is no exception.  Based on a single ambiguous result from an ill-designed survey, government officials have repeatedly said that there exist significant worries about healthcare providers raising their charges and thus cheating the elderly users and the government.  I have refuted such groundless and serious accusations openly and repeatedly in the past Editorials and in Ming Pao.  These can be retrieved in my blogs:  

http://cm-editorials.blogspot.hk/2011/02/doctors-were-framed-openly.html;  

http://cm-editorials.blogspot.hk/2011/03/take-it-or-beat-it.html;  

http://cm-editorials.blogspot.hk/2012/02/quirkology.html;  

http://chengchiman.blogspot.hk/2012/07/blog-post.html 

However, the following was reported in Ming Pao on July 18, 2012:

據了解，醫療券首階段檢討發現，70%長者用醫療券看傷風咳，有違政府推出計劃原意，即推廣長者使用私營預防性護理服務如體檢等。因此，政府擬在醫療券中期檢討研究如何將計劃扶入正軌，包括聘請兼職學生到私家診所實地蒐集醫生收費，從而探討如何防止私家醫生提高收費，變相將增加的醫療券金額袋入醫生口袋，預料明年會有檢討結果。

This is outrageous.  This affects the images of doctors seriously by treating some never verified accusations as facts.  I would like to remind anyone who stated such groundless accusations that there has never been any evidence to support them.  Have there been any complaints received?  Have there been any suspect doctors under investigation?  Has there been anyone arrested?  Has the government set up any hotline to receive complaints?  Since the accusation originated from a study, why don’t those so eager to pursue in this subject trace the participants in the interview and find out the bad doctors?

Again, this is outrageous.  The hidden official even took one step further and suggested to hire part-time students to spy on and to monitor doctors.  So, the clear message to the public was that the integrity of doctors was inferior to that of part-time students.  With minimal training and no accountability, part-time students should be given the power to go into records and charges of private doctors.  Based on the reports and findings of part-time students, a series of investigations should be initiated to look into any suspected doctor’s practice.  Should the students be officially called Red Guards?

Damn it!  It is outrageous!  I apologize for the use of language.  It is far too mild to express my anger and the absurdity of this matter. 

(Source: HKMA News August 2012)