System Failure, Below Standard, and Misconduct

I felt obliged to share with readers my thoughts after I read the judgment of an inquiry of the Medical Council of Hong Kong held in June 2013.  A gynaecologist was found guilty of misconduct in a professional respect for prescribing Amoxil to a patient who was known to be sensitive to Penicillin.

The judgment stated that: “Wrongful prescription of drugs which a patient is known to be allergic to can easily be prevented (my emphasis) by checking the medical record and checking with the patient.”  And then: “in view of the fact that there are cases in which the responsibility is plainly overlooked, we must send a message to the medical profession that the matter will be dealt with seriously in sentencing in future cases if patient’s known allergy is blatantly overlooked.”

It also commented unfavorably on whether further action needed to be taken by the Education and Accreditation Committee (EAC) in respect of her specialist registration: “We are of the view that to exercise proper care in prescribing medicine is a fundamental responsibility of all doctors.”  Although the doctor was ordered to be removed from the General Register for 1 month with the order suspended for 12 months, the EAC later removed her name from the Specialist Register permanently.  Of course she can appeal and/or apply to be included in the Specialist Register again.  Practically this meant that even though she got a suspended sentence in the inquiry, she was still unable to practice as a gynaecologist for a considerable period of time.

I fully agreed that the doctor had done something wrong.  In this case, the patient did suffer allergic reactions and was admitted to a private hospital for a few days.  The doctor actually owed the patient an apology.  The guilty verdict was a redress to the patient.  The sentencing also served to alert doctors to be more careful with medical prescriptions.  However, a few questions arose in my mind.

1. Are prescription errors really easily preventable?
2. Do doctors really expect zero error in prescribing?
3. Falling short of expected standard is professional misconduct?
4. Can imposing harsher (and harsher) punishment help preventing prescription errors?

Are prescription errors easily preventable?

Prescription errors remain one of the leading causes of medical errors worldwide.  Various measures have been implemented at different levels in order to try tackling prescription errors.  Yet no one nation or any medical organization can claim that they can prevent all prescription errors.  It might not be difficult to achieve zero error on an individual basis for a certain period of time.  However, like other human errors, prescription errors are hard to eliminate in a system.  I don’t mean that we should do nothing on this important issue, nor that doctors are not to be blamed.  It is only through recognizing the difficulties in preventing prescription errors that we can elucidate the root causes of them.  Telling mothers to feed their children with nutritious food spoon by spoon is unlikely to solve the worldwide problem of malnutrition.  Similarly, educating industrial workers about the importance of fingers will not prevent them from chopping their fingers accidentally.  Sending victims of industrial accidents to jail will certainly not be useful in cutting accident rates.

Do doctors really expect zero error in prescribing?

Honestly, do you expect to encounter zero prescription error in the coming year in Hong Kong?  Of course the answer is “no”.  Do not fall into the pitfall of pinpointing an individual doctor facing a particular patient.  With hindsight, it is negligence to give penicillin-sensitive patient penicillin.  However, this does happen repeatedly in everyday lives when there is system failure.  Human errors are bound to happen when there are routine and repetitive actions.  A good system has built-in checkpoints to pick up such errors and to rectify them.  In the aforementioned case, in fact the doctor had implemented measures to check for errors.  There were cautionary note on the paper record and an allergy alert function in the computer system.  Sadly, both mechanisms failed in this case.  Ironically, the panel regarded the doctor even more blame-worthy with such safety mechanism in place, and implied that she had blatantly overlooked the known allergy.

How about a surgical procedure, such as colonoscopy?  We tend to be comfortable with the intrinsic risk of perforation of the colon.  When such risk materializes, the doctor seldom takes the blame.  If he has implemented mechanisms which can reduce the intrinsic risks, he is highly likely to receive credits for such actions.

Falling short of expected standard is professional misconduct?

The term “professional misconduct” carries quite a negative sense.  It is quite a serious matter when a doctor is labeled with misconduct.  However, from the decisions in the cases Koo Kwok Ho (1988) and To Chun Fung (2000), the Court of Appeal somehow equated misconduct as “conduct fallen short of the standard expected amongst doctors”.  Taking that to the strictest sense, misspelling a patient’s name can be professional misconduct.  It all depends on what is expected amongst doctors.  If the inquiry panel thought that prescription errors were easy to prevent, they would easily find the defendant doctor fallen below expected standard.  But, again, do doctors really expect zero error in prescribing?

“Professional misconduct” is now the only verdict from the disciplinary procedures.  The defendant doctor is either guilty or not guilty.  Apart from the differences in sentencing, there is no way to distinguish a doctor who maliciously harms his patient for his personal gain from a doctor who is herself a victim of system failure.  A review of the disciplinary procedures is seriously in need.

Can imposing harsher (and harsher) punishment help preventing prescription errors?

While removal from the General Register with suspended sentence was by no means lenient, it was difficult to think of harsher punishment than removal from the Specialist Register permanently.  With the deluded view that prescription errors were easily preventable, the doctor was regarded having done a grossly irresponsible act.  I totally agreed that in private practice, the doctor had to take sole responsibility in mishaps in the clinic.  However, she was a specialist in O&G, but not a specialist in system errors and risk management.  The inquiry panel had already agreed that the risk of committing the same mistake was low.  I wondered how she could further prove to EAC that she would be fit to be a specialist.

While all doctors should be alerted to the prevention of prescription errors, authorities should also understand the root causes of such errors.  Just as putting victims of industrial accidents to jail would not cut accident rates; imposing harsher punishment to doctors is unlikely to help decreasing prescription errors.  A realistic assessment of resources in private practices and facilitation of effective system management would be more promising solutions.

 

(Source: HKMA News August 2013)

Will a doctor be removed from the General Register if he takes part in Occupy Central?

This is an academic analysis from my personal opinions.  I have no intention to solicit doctors to take part, nor to deter doctors from taking part, in the Occupy Central movement.  Afterall, I do not believe that any doctor will decide to join, or refrain from joining, the movement just from the clarification on a remote chance of being removed from the General Register by the Medical Council of Hong Kong.  However, I decide to write this analysis because I hate official answers.  I sense that Occupy Central has become a taboo.  While various organizations are giving out opinions on matters such as biohazard and E. coli levels on sewage spillage, they divert members to the Medical Registration Ordinance (MRO) and the Medical Council for official answers to this important, but relatively simple question.  This is just like referring a patient with anaemic symptoms to the Harrison’s Principle of Internal Medicine and the British National Formulary.  I have served as Council Members in the Medical Council for several years and I have done a bit legal studies.  It will be helpful to consider my viewpoints on this matter.  Of course, you have to be aware that my personal opinions might be wrong, and that they are by no means complete.  At least, they are human, but not mechanical, nor official.

First, the disciplinary procedures of the Medical Council are event-triggered.  For example, they are triggered by a complaint received, or the fact that a doctor has been convicted of an offence punishable with imprisonment.  It is unlikely that the action of a doctor taking part in the movement per se will trigger the disciplinary procedures.  There has to be a complaint, or he has to be arrested, prosecuted, and then found guilty of an offence punishable with imprisonment.

Second, many people get s21A(1)(a) and s21A(1)(b) of the MRO mixed up.  Or most of them do not even know that there is such a sub-section (a).  S21A(1)(b) is about misconduct in any professional respect.  It is decided by the falling short of the standard expected amongst doctors.  S21A(1)(a) is not directly related to standard or misconduct.  It is about a doctor who has been convicted in Hong Kong or elsewhere of any offence punishable with imprisonment.  In the event of consequences from a doctor taking part in Occupy Central, we are more concerned about sub-section (a).

The rationale for a doctor who has been convicted with an offence punishable with imprisonment to go through the disciplinary procedures is for protection of the public.  When an offence is punishable with imprisonment, it means that it is of considerable gravity.  Although it does not automatically imply on the doctor’s fitness to practice, it serves as a signal to the disciplinary body to look into each individual case so as not to miss anything important.  The offence may reflect the character and conduct of the doctor.  For example, a doctor convicted of sexual offences with suspended sentence to imprisonment by the court can still practice.  S21A(1)(a) gives the disciplinary body power to look into whether this doctor will endanger his patients if he continues to practice.  We are expecting higher standard for a doctor than any lay person.

Third, it all depends on what the doctor who takes part in Occupy Central has done.  Or to be more precise, what he has actually been convicted of.  The Medical Council has dealt with different cases in very different manners.  For some “trivial” cases such as traffic offences (Yes, careless driving is punishable with imprisonment!), they are usually dismissed at the Preliminary Investigation Committee (PIC) level.  The doctor can stay at ease on the General Register.  However, for more serious offences, such as sexual offences, offences involving dangerous drugs, and offences concerning dishonesty, the Medical Council takes them much more seriously.  In the past, the Medical Council has removed doctors with the afore-mentioned offences from the General Register, ranging from a month to indefinitely.

If the doctor who takes part in the movement is convicted of offences without components of violence and endangering others, the disciplinary body might take the case more lenient.  However, there is no guarantee that the case would be dismissed at the PIC level.  The doctor might still need to go through inquiry and end up with consequences ranging from “not-guilty”, to a warning letter, to removal from the General Register.  On the other hand, if the doctor does something more drastic and ends up convicted of offences such as arson, or wounding and inflicting grievous bodily harm, an inquiry and removal from the General Register will be likely.  This is because adverse inference might be drawn on the doctor’s character with such convictions.

Fourth, life is full of uncertainties.  This point is very important.  Law suits have notoriously been unpredictable.  This is particularly true for jury trials.  In a Medical Council inquiry, it takes as few as 3 not-legally-trained panel members (out of the 5 members to form a quorum) to give a verdict.  There is no precedent case for offence related to civil disobedience.  Although I expect lenient verdicts, out-of-tune results will not be too unexpected.  More important, what is going to happen during the movement will also be unpredictable.  The doctor needs to make sure he is not involved in anything drastic.  Even so, while he is looking at charges like “unlawful assembly”, the prosecution might charge him with more serious charges like “riot”.

Last, but not the least: consequences.  As explained, if the participant is not convicted of any offence punishable with imprisonment, disciplinary procedures will unlikely be triggered.  If he is convicted with offences not regarded as endangering the public for him to continue to practice, I do not expect harsh verdicts.  Even in the rare case that he is removed from the General Register, he can usually be reinstated after he has spent his sentence.  However, his specialist registration (if any) might be affected.  And, important to some, but not so to most, doctors, maybe he will not be able to serve as a member in the Medical Council or the Hong Kong Medical Association.

However, there are other considerations.  The doctor needs to be emotionally stable and strong.  Even if everything goes in the expected direction, law suits and disciplinary procedures are stressful and disruptive to daily living.  He is likely to pay for his own legal costs as his medical insurance plan is unlikely to cover his actions unrelated to his medical practice.  If things go wrong, there will be more legal procedures, more financial burden and more stress.  If there is an out-of-tune judgment from an inquiry, the only thing the doctor can do is to lodge an appeal to the Court of Appeal (apart from taking the verdict as it is, of course).  He might, for the first time in life, realize the inequality in power in court when he faces a Queen’s Counsel instructed by the Medical Council, risking shouldered the costs if the appeal fails.  

(Source: HKMA News July 2013)

Election complex

Election is never simple, and has never been simple.

Looking back, I have been a Council Member of the Hong Kong Medical Association for 9 years.  It feels good to be in a Sangha, and I have learnt much from it.  Therefore I have long ago decided to fight for staying in the Council for another 3 years when my term ends in 2013.

The usual way to be a Council Member is to go through the general election held every year.  You have to be nominated by a full member of the HKMA and then seconded by another.  Votes would then be casted by all members via returning their ballots by post.  There are 18 Council Members and every year 6 of them finish their 3-year terms.  So every year there are 6 vacancies for Council Members.

The terms for Office Bearers are different.  For the President, the 2 Vice-presidents and the Honorary Treasurer, they serve 2 years.  Therefore, there would be an election which attracts much more attention with cabinets fighting for positions of Office Bearers and Council Members every alternate year.  For the years with just Council Members election, competition and noise is much less.

Of the 25 members of the Council, 3 of them do not need to undergo the afore-mentioned election process.  The Honorary Secretary is nominated by the President and appointed by the Council.  The Immediate Past President is an ex-officio member of the Council without election.  The Legislative Councilor of the Medical Functional Constituency can be invited to be a member by the Council.  In some occasions, a Council Member can also be appointed instead of being elected generally.  One example is when one of the serving Council Members is appointed Honorary Secretary; his vacancy can be filled by a full member appointed by the Council.

Another occasion when the Council can appoint a Council Member is after the removal of an existing Council Member before the expiration of his period of office.  This has to be done by extraordinary resolution.  However, it is important to note that under some specified conditions, the office of a member of the Council shall ipso facto be vacated.  One example is when “an order under Section 21 of the Medical Registration Ordinance (Cap. 161) has been made against him by the Medical Council of Hong Kong and such order has been published in Hong Kong Government Gazette under the provisions of Section 21 (5) of the Medical Registration Ordinance.”

2013 is not the year for Office Bearers election.  Minimal attention was attracted concerning election.  This made some of the Council Members who had determined to continue to serve in the Council nearly forget to submit their nomination forms.  The result turned out that all the 6 of us remembered to do so, but no others did.  So no voting is needed.  IP Wing Yuk, LO Chi Fung, SHEA Tat Ming, SHIH Tai Cho, WONG Yee Him and I will serve in the Council for another 3 years.

I was reminded about the election by a phone call from my colleague asking me to support him to go for the Presidency.  This, together with CHOI Kin’s article in the April issue of the HKMA News, confused me.  CHOI Kin commented on criteria he considered essential for the President.  Some members read between the lines and deciphered the article to be referring to potential candidates.  However, the confusion was that the election for President would be more than a year later!  I remembered clearly that the presidential election took place in 2012.  Several colleagues called to convey their intentions to be the President.  Mysteriously, TSE Hung Hing was again elected President ipso facto without being challenged.  So, how come the campaign started so early for the election in 2014?

One reason is that the role of the HKMA becomes more important as she steps more deeply in politics.  Her pride as kingmaker in 2012 was but one illustration.  2014 to 2016 are two important years for Hong Kong.  In 2014, the 5 Office Bearers’ term will expire.  They are: TSE Hung Hing, CHAN Yee Shing, CHOW Pak Chin, LEUNG Chi Chiu and LAM Tzit Yuen.  CHOI Kin’s term will also expire if TSE Hung Hing is not re-elected President.  The 6 Council Members eligible for re-election will be: CHAN Hau Ngai, CHAN Kit Sheung, HO Chung Ping, HO Hung Kwong, KONG Ming Hei and PONG Chiu Fai.  Who will go for President?  Will there be new faces?

A logical approach is first to ask whether the present President chooses re-election.  TSE Hung Hing will have been President for 4 years, but recent history has a President serving for 6 years.  The next focus will be on the 2 Vice-Presidents.  The Articles of Association state that any member who has served in the Council for more than 3 years is eligible for election to be the President.  There are other ex-Vice-Presidents.  Rumor has it that SHIH Tai Cho will go for President.  He has the advantage of remaining to be a Council Member till 2016 even if he fails the Presidency.  On the other hand, retiring Office Bearers and Council Members have to consider that they may have to leave the Council if they fail in the election.  Therefore they need to assess before choosing which posts to go for.  This is also the consideration for CHOI Kin.  He needs to go for election if he chooses to continue to contribute to the Council.  He may want to make another record of serving as President for 4 terms.  Or he may choose to fit in any other posts with confidence.  And of course he can be appointed Honorary Secretary and bypass the election.

Election is never simple, but I don’t have to face the complexity myself as I am quite satisfied with my current positions.  Election has never been simple.  Anyone would agree after witnessing the 2012 Chief Executive Election, before and after.

(Source: HKMA News June 2013)

Rubber Duck and Thich Nhat Hanh

 

On May 2, 2013, the day of Tin Hau Festival in the Lunar Calendar, a giant yellow rubber duck was found floating and swimming in the Victoria Harbor.  It was not a miracle done by the Chinese Goddess who oversees the oceans.  However, it did attract over 300,000 people crowding around Tsim Sha Tsui to worship it.  And more importantly, they had to take pictures of it and with it so as to post them on Facebook and to share via other social networking apps.  This giant rubber duck was created by a Dutch artist, Florentijn Hofman.  It was built to resemble the beloved yellow bath toy (which of course was not invented by him, as some people mistaken).  The act of a giant rubber duck appearing in the harbor was itself performance art.  The work had traversed global waters since 2007 and could be seen in St. Nazaire (France), Sao Paulo (Brazil), Auckland (New Zealand), Hasselt (Belgium), Osaka and Hiroshima (Japan), Sydney (Australia), Nürnberg (Germany), Amsterdam (Netherland) and more places.  This was a project to spread love.  According to Hofman, “the Rubber Duck knows no frontiers, it doesn't discriminate people and doesn't have a political connotation.  The friendly, floating Rubber Duck has healing properties: it can relieve mondial tensions as well as define them.  The rubber duck is soft, friendly and suitable for all ages.”  It sounded real miraculous.

Hofman did not elaborate on how the Rubber Duck was going to achieve its healing effects.  Maybe that was performance art.  One could only get influenced and enlightened by it when one felt it and saw it, but it could not be expressed in words.  This did happen before.  When Buddha showed his disciples a flower, Mahakassapa got the message and became enlightened.  When I saw the photos of the Rubber Duck in the harbor, I did feel some joy of childhood.  I had a small (and ugly) rubber duck when I was small.  I would like to see it floating on water, better be boundless water, but there was not always the chance.  A giant rubber duck at sea is funny and straight forward.

I wondered if I could have any healing effects from the Rubber Duck when I was surrounded by thousands of people in Tsim Sha Tsui.  I also wondered how many people could have sudden enlightenment on seeing it.  Luckily, the Buddha did not just teach by showing a flower.  He did leave vast amount of scriptures detailing his teachings.  He realized the Four Noble Truths concerning sufferings and the cessation of sufferings.  He explained that he himself was not the truth, and his teachings were not the truth.  Instead, he showed the ways to the truth (of how to put an end to sufferings).  An analogy was like pointing to the moon with a finger.  The finger showed the way to find the moon.

A present Zen master, Thich Nhat Hanh, points out ways to happiness in explicit and easily understandable practices.  He teaches that: “There is no way to happiness; happiness is the way.”  This is in-line with the findings of William James that behavior influences emotion (as mentioned in my previous editorial in October 2012: http://cm-editorials.blogspot.hk/2012/10/cogito-ergo-sum-and-brain-washing.html).  In the background of sufferings, he tries to reset our default mode of emotional functioning to happiness.

Thay (That’s what others call the Zen master) also teaches people to be mindful of the present moment.  Happiness is now and here.  We have to treat ourselves more nicely because life itself is full of miracles: “People usually consider walking on water or in thin air a miracle.  But I think the real miracle is not to walk either on water or in thin air, but to walk on earth.  Every day we are engaged in a miracle which we don't even recognize: a blue sky, white clouds, green leaves, the black, curious eyes of a child -- our own two eyes.  All is a miracle.” 

Thich Nhat Hanh and the Plum Village International Monastic Sangha will come to Hong Kong at the end of May.  For this teaching trip, Thay will givie two mindfulness practices, one for healthcare professionals and another for educators.  There will also be a four-day retreat and a public talk. 

If you are troubled by events like the H7N9 bird flu virus in Mainland, Boston marathon blast, explosion at Texas fertilizer plant, Yaan earthquake, ICAC being investigated, the dock strike, filibuster, Occupy Central, or personal sufferings, try to get some healings by visiting the Rubber Duck.  In fact, you do not need to go to Tsim Sha Tsui.  Like Signature Bear, he tries to be healed by his own rubber duck.  With mindful practice, everyday can be a good day, although life is suffering (First Noble Truth).   

(Source: HKMA News May 2013)

When It's Gonna Rain......

There is a much-quoted Chinese saying.  It says: 「天要下雨，娘要嫁人。」.  It carries the meaning that when something is going to happen, it will happen anyway.  You can do nothing about it.  Just like when it is going to rain, or when your mother is going to get you a step-father.  (Some people interpret the second half of the quote as when a young lady is going to get married instead of when a mother is going to get married.  They think that it would make more sense as it was not really common or natural for mothers to get married again in the old days.  Well, you can say that the quote implies no matter something is natural or strange, if it is going to happen, one can still do nothing about it.  Anyway, the passive and helpless meaning remains the same.)

Recently I hear this quote very often.  I hate this quote.  I hate this quote to the extent that I get agitated when I hear it.  Having gone through so much (or rather, so little) about psychology, mindfulness and Buddhist teachings, I try to analyze.  When I look into my emotion, I feel quite strange about it.  I am now practicing to be kind rather than to be right.  I learn this from Pat Peoples of The Silver Linings Playbook, hoping to have Jennifer Lawrence as the end result.  Moreover, although I am not to the extent of having negativistic personality disorder, I am most likely to be a Five in the Enneagram system of personality typing.  Learned helplessness is the central theme.  It should be me who is talking about “天要下雨，娘要嫁人; you can do nothing about it” and then get others agitated.  I should have jumped out and echoed with those who spelled out my motto.  How come the oppposite happens?  No, it is not self-denial.  I am confused.

The answer dawned on me one rainy day when I was at a meeting.  While the quote was mentioned again (and again), I received the Amber rainstorm warning signal from my smart phone.  I thought I was sudden enlightened.  The reason for my rage was that there existed a difference between an individual and an association.  I could not tolerate a type Five association.  If learned helplessness was to dominate, why would we waste time in meetings?  How was the association to answer to its members?  Why should the association exist?  When it is going to rain, the Hong Kong Observatory realizes that there are risks associated with heavy rain.  It has developed the rainstorm warning signal system to predict and to alert the citizens of the rainstorms.  The system is widely promulgated and there are user-friendly applications for quick and wide information dissemination.  Citizens even do not need to go to work when the Black signal is hoisted.  So, there are many things an association can do when it is going to rain.

But wait! Before we go into those harm-reduction actions, are we talking about raining?  Except some national actions to manipulate the weather with missiles, there is not much an association can do to stop raining.  However, there might be something that can be done when mother is going to marry someone (else).  I do read in novels that it is not uncommon for mothers to consult their sons and daughters before they plan to formalize their relations.  As for young ladies getting married, in the old TV series The Bund (Shanghai Tien), Hui Man Keung chose to interrupt the wedding ceremony of Fung Ching Ching.

It might be futile to stop something natural from happening.  However, policy of an authority, such as the Hospital Authority, is never something natural.  For example, I do not believe that we can do nothing to stop the Hospital Authority from launching a new programme, or we can do nothing to change an existing policy of the Hospital Authority.  If we identify that something dangerous is going to happen, we need to stand firm and fight against it.  We might not succeed, but our stance should be clear and firm.  We might fail, but we should have issued the warning signal and have contingency planning.

「天要下雨，娘要嫁人。」is not the worst quote.  There is often another saying to go with it.  It is: “If you can’t beat them, join them.”  When big principles are involved, these two quotes are not options.  An association cannot and should not defeat itself by classifying light-heartedly everything to be natural and unbeatable.  Members cannot afford to be sold by the association whom decides to join the fathomed unbeatable counterpart and counts money for it.

Recalling that I am now practicing to be kind rather than to be right, I should not be furious about others’ behaviors whatever the intention behind, be it self-interest or for the good of the majority.  However, please be diligent and innovative enough to bluff me with theories and analysis of pros and cons.  Don’t tell me that an association can do nothing when it’s gonna rain.

(Source: HKMA News April 2013)

March 2003

Ten years ago, in March 2003, the Hong Kong Special Administrative Region (HKSAR) suffered from the attack of a new deadly virus.  Around 1750 people contracted the disease.  Sadly, among them, about 300 patients died.  A significant proportion of the patients and the diseased were healthcare workers.  After a few months, the virus was identified to be a corona virus; and the disease named as Severe Acute Respiratory Syndrome, SARS, or the SAR Syndrome.

Now is March 2013, while we pay our respects and salute to the sufferers, we might want to review the tragedy.  Luckily SARS was unheard after 2003, though there are now sporadic cases of a new corona virus.  But can we handle another outbreak of severe infectious disease?

There have been quite a number of reviews in the media.  I have gone through some of them, and I have chatted with some colleagues.  On an individual level, since the causative agent is a virus, we do not have a magic bullet for it.  Ribavirin is out.  Steroid is for the immune response.  It is doubtful if the aged anti-SARS serum is effective.  We do have better supportive treatment now, such as better ventilators and Extra-corporeal Lung Support (ECLS).  On infection control level, we now have the quick screening test for SARS, allowing prompt identification of probable subjects.  We have better protective equipment, which is regularly used by healthcare professions.  We have better ward facilities such as negative pressure wards.  We have the precedent of quarantining a hotel during the swine flu period in 2009.  We have better action plans and we have trained people for strategy execution.

However, are we prepared psychologically for an outbreak?  For those who experienced SARS ten years ago, do you still remember how you felt at that time?  For those younger doctors, have you ever thought of the life as a doctor in the period of a disaster?  I try to recall my feelings ten years ago.  Although I was by no means in close contact with SARS patients, as a family doctor I was still a frontline worker.  Every patient with fever was a potent sufferer of SARS.  I had to wear protective gears.  I could not play with babies and kids and I could not hold them in my arms.  I did not eat at my clinic, and I dined alone in open areas during lunch.  I avoided lifts as far as possible.  I went straight for a bath when I reached home.  I heard story from patients about how their friends and relatives got infected.  I knew that some of my colleagues were affected.  I read in newspaper that the number of casualties increased every day.

I then realize that I would have to prepare to face “losses” if there were another outbreak.  In the worst case, I might lose my life.  More likely, I might lose my freedom, which includes the freedom to travel, the freedom of not being isolated, the freedom to meet and chat and dine with friends without worry.  Surely, I would lose the trust of breathing in without the filter of a mask, maybe at the same time losing the trust on my patients.  Others would suffer similar losses, to a greater or lesser extent.  Apart from physical and psychological aspects, the economy of Hong Kong, maybe the whole world, would be affected.

Reviewing the tragedy ten years ago, and contemplating what would happen if I were to face it again, a saying keeps ringing in my mind.  It says that the most delicious food is just dumplings; and that the most comfortable thing (to do) is just lying down.  最好吃不過是餃子；最舒服不過是躺下。 In some northern provinces of China, dumplings are the staple food, just like our rice or the Caucasians’ bread.  After experiencing major events, be they good or bad, one would likely come up with the conclusion that uneventful lives are most valued and longed for.  Just like a commercial advertisement of an airline years ago, after travelling around the world and tasting cuisines from different countries, what the traveler misses most is a bowl of rice.

It might be enlightening while you compare your troubles now and your anticipated losses if there were SARS again.  You might be troubled by the continuous rise in real estate prices, a fall of stock market, your rival getting promoted, failure to gain the love of the one you admired, and so on, and so forth.  But looking back at the list of losses you do not want to encounter, they are mostly mundane things that we have forgotten, or failed to notice.  They are: freedom, trust, or even the down-to-earth things as breathing and being able to live.

In March 2013, here I again pay tribute to the diseased and the sufferers from SARS.  I pray for Hong Kong that no tragedies will happen in the future.  I treasure the bowl of rice I am going to have for dinner, after which I would lie down, and sleep through the night.

(Source: HKMA News March 2013) 

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)