All Hell Broke Loose

All hell broke loose when the Medical Council announced the results of voting on the proposal for “exemption from internship assessment for non-locally trained doctors who have passed the Licensing Examination” after its policy meeting on April 3, 2019.  The results were that all 4 options from the proposal were voted down upon.

This mess could be traced back to June 2017, when the Steering Committee on Strategic Review on Healthcare Manpower Planning and Professional Development issued its review report.  In July 2018, the Food and Health Bureau invited the Medical Council to consider plans to take forward the recommendations in Chapter 5 of the review report.  One of the key recommendations was the “facilitation for qualified non-locally trained doctors in taking Licensing Examination and internship assessment”.  The Medical Council then set up a Task Force to look into these matters.

There was general agreement among the Task Force members that the internship assessment period could be shortened.  At present, the assessment period after a candidate passes the Licensing Examination is 12 months, after which he can get his full registration.  However, candidates can apply for exemption up to 6 months if he has a specialist qualification comparable to a Fellowship of the College of the Hong Kong Academy of Medicine.  So, practically we were talking about whether to shorten the assessment period of another 6 months only.

It was also agreed by Task Force members that candidates who applied for the exemption of the remaining 6 months should have worked for a certain period in institutions in Hong Kong.  This was in line with the principle for the requirement of internship.  After practicing in Hong Kong, the doctor should be familiar with the local scenarios including the healthcare system, epidemiology and culture.

There were 2 areas not in agreement:

1. The period that the candidate was required to work in Hong Kong.  This covered both the length of the period, and whether the candidate needed to work for a further fixed period after he passed the Licensing Examination. 
2. The institutions concerned.  The disagreement was whether it should only be the Hospital Authority, or it should cover all 4 institutions including the Hospital Authority, the 2 Universities and the Department of Health.

So, there came up with 4 options for the full Council to consider and to vote upon during the policy meeting on April 3, 2019.  Basically, all 4 options included that the candidate should have passed the Licensing Examination; and should hold a specialist qualification.  The differences were:

• A. A total of 3 years’ experience (including the period before he passed the Licensing Examination) in any of the 4 institutions under limited registration.
• B. After passing the Licensing Examination, he had to work for another 3 years in any of the 4 institutions under limited registration.
• C. A total of 3 years’ experience in the Hospital Authority under limited registration.
• D. After passing the Licensing Examination, he had to work for another 3 years in the Hospital Authority under limited registration.

Actually the 4 options were in pairs.  They differed mainly by the period of experience, and where the candidate was to work.  It was like an “chicken or egg first?” argument for the period to work before a candidate could apply for the further exemption.  Obviously 3 years might be enough to gain his local experience.  A shorter period might help to attract more candidates to apply.  However, he might leave the public institutions immediately when he got his full license.  That did not serve the purpose of alleviating the shortage of manpower in the public institutions.  For the same token, allowing the candidate to work in any of the 4 institutions might defect the purpose of attracting overseas doctors to work in the Hospital Authority.  It is common knowledge that the working environment in the Hospital Authority cannot be described as attractive compared to the other 3 institutions.

There had been diligent lobbying by government related persons, and among the Medical Council itself.  It was debatable whether one should concede when matters concerned important principles.  However, in this matter, the number at stake was estimated to be a handful of candidates a year.  It might not be a good time to drag on when there was so much sentiment orchestrated in the public.

Before the voting, there had already been common consensus reached.  Whichever of the 4 options came out, there was unlikely to be vigorous action of opposition.  However, it messed up.  It was described as “the worst show-hand” where the player messed up with the best cards he had ever got.  A new set of voting rules was used.  Although there was no problem with the set of rules, when applied in these particular conditions, all it did was to foul up.  The procedure of the meeting did not reflect the opinions of members present.  The voting did not aim at problem solving and decision making.  The consensus was ignored, and all 4 options were defected by the dividing of votes because of fine details.

After that, all hell broke loose.  There were press releases, there were finger-pointings, there were words of regret from the government, there were open accusations, there were open letters, there were demonstrations.  And of course, there were back-stabbing.  And there were more orchestrated sentiments.

The newest progress as on April 12, 2019 was another press release from the Medical Council Chairman.  It stated that “in view of the importance of the subject issue”, he was going to propose to suspend the operation of the Standing Order of the Medical Council “so that the Medical Council may reconsider and decide the various matters on exemption of internship assessment for non-locally trained doctors by a voting arrangement to be agreed.”

It was not common when consensus could be reached by all stack-holders, and an even rarer occasion that it then got all messed up. 

(Source: HKMA News Apr 2019)

What Most Private-Practicing Doctors have to do under the Private Healthcare Facilities Ordinance (Cap. 633)?

The Private Healthcare Facilities Ordinance (Cap. 633) is the new law passed to regulate private healthcare facilities which include private hospitals, day procedure centers and clinics.  Nearly all private practicing doctors will be affected. 

Dated back to 2012, there was concern over the safety of procedures done in private clinics.  In October 2012, the Steering Committee on Review of Regulation of Private Healthcare Facilities, chaired by the Secretary for Food and Health, was established.  It was followed by a consultation period from December 2014 to March 2015.  In April 2016, a consultation report was published.  In June 2017, the Private Healthcare Facilities Bill was introduced into Legislative Council.  The Bill was then passed by Legco and it was Gazettal on November 30, 2018.  From 2019 onwards, there will be phased implementation of the new regime.  

The mode of regulation is through licensing.  Health services establishments listed in Schedule 9 to the Ordinance are to be regulated.  These include private hospitals, day procedure centers and clinics.  Private hospitals are premises with lodging.  Day procedure centers are premises without lodging, and providing “scheduled medical procedures” as listed in Schedule 3.  Clinics are premises without lodging and not providing “scheduled medical procedures”. 

Most of the private practicing doctors in Hong Kong practice in clinics.  Under the new law, clinics need to be licensed.  However, exemption arrangement is available for eligible small practice clinics.  Although the doctor needs to apply to the Director of Health for a letter of exemption, the requirements are less stringent than those for applying for a license.  The criteria are:

1. The clinic is operated by at most 5 registered medical practitioners, who are not under limited registration, as sole proprietor, partners or director of a company.
2. The sole proprietor/partner(s)/company director(s) have exclusive right to use the premises.
3. Only the sole proprietor/ partner(s)/ company director(s) can practice in the clinic.
4. Locums are exceptions.  They can work for each sole proprietor/ partner/ company director for less than 60 days in a calendar year; and less than 180 days per clinic in a calendar year.
5. Each registered medical practitioner (not under limited registration) can operate at most 3 exempted clinics.

  

We have to note than exemption is not automatic.  A doctor has to apply for a letter of exemption by providing proof to all of the above criteria.  Exempted clinics will not be subjected to the code of practice applicable to licensed clinics under the new regime.  For a clinic without exemption, it needs to apply for a license.  The license needs to be renewed.  There will be regular inspection.  And there are other requirements to fulfill such as the requirement of a chief medical executive. 

There are different arrangements for doctors who are with limited registration under Promulgations No. 3 and 4 of the Medical Council since 1995 and 2001 respectively; and who are practicing in clinics registered under the Medical Clinics Ordinance (Cap. 343).  Since Cap 343 will be repealed under the new regime, these clinics will be registered as “scheduled clinics” under Cap. 633.  The license will be valid for one year or less.  And these clinics will be subjected to the same code of practice as other licensed clinics. 

For all other private healthcare facilities, application for licenses is required.  A licensee has to be wholly responsible for the private healthcare facility’s operation.  Also, he has to appoint a chief medical executive.  The chief medical executive has to take charge of the private healthcare facility’s day-to-day administration.  There are requirements set for the chief medical executive, which are different for different types of private healthcare facilities.  For all private medical facilities, the chief medical executive has to be a registered medical practitioner.  One interesting point to note is that there is no offence under the new ordinance that targets at the chief medical executive specifically.  It is the licensee who is ultimately responsible for the operation of a private healthcare facility. 

There are regulatory measures to tackle with breaches of the law and licensing requirements.  A private healthcare facility service can be suspended.  A license can be cancelled.  To deter serious and intentional non-compliance, a licensee can be subjected to sanctions for certain contraventions.  For example, the maximum penalty for operating a private healthcare facility that is not licensed or exempted is a fine of $5 million and imprisonment for 5 years.  So, when the time comes, remember to apply for a license or a letter of exemption (and I am going to tell you when).  Another example is that for failing to comply with a suspension order to suspend a private healthcare facility, the maximum penalty is a fine of $1 million and imprisonment for 2 years. 

It is also statutory requirements to have complaints management system in place.  A licensee has to set up a complaints handling procedure at source.  Unresolved complaints will be handled according to a centralized mechanism.  A committee on Complaints against Private Healthcare Facilities will be set up. 

The above-mentioned licensing procedures will be implemented in phases.  For private hospitals, applications will commence in mid-2019.  Regulations are anticipated to take effect in early 2021.  For day procedure centers, applications are anticipated to commence in 2020.  The first batch is anticipated to take effect in early 2021.  For clinics, applications for licenses and letters of exemptions are anticipated to commence in 2021 at the earliest.  The anticipated date for measures to take effect is to be announced later.  

(Source: HKMA News March 2019)

The Oracle Said So

 

I don’t know since when there has been a tradition that on the second day of the Lunar New Year, officials of the Hong Kong Government or VIPs will go to the Che Kung Temple in Shatin and draw a fortune stick for Hong Kong.  This year, stick number 86 was drawn.  The oracle read: 石田為業喜非常，畫餅將來未見香。怎曉田耕耘不得，那知餅食不充腸。

The oracles from the Che Kung Temple are user-friendly because, unlike oracles from other temples such as the Wong Tai Sin Temple, they are written in simple Chinese language.  They are not in parables.  You can try to interpret the oracles yourselves without any knowledge of ancient stories.  Metaphors, when used, are also often easily understood.

Literally, the oracle said that it was nothing joyable to own a field composed of stone.  Bread drawn on a piece of paper would not smell good.  These were because a stone field could not be cultivated to yield; and a picture of bread would never lead to satiety.  The VIP who drew this fortune stick extrapolated the oracle and urged Hong Kong citizens to support government policies.  An expert in oracle interpretation, however, explained that we should instead be skeptical in government policies and visions.

This incident was widely reported in news.  Interestingly, another piece of news was that the winter surge of influenza highlighted the shortage of doctors in Hong Kong, and the government was considering inviting overseas doctors to practice in Hong Kong with all sorts of exemptions.

It was nothing new that GOPCs, A&E departments, medical wards and pediatrics wards became war zones during influenza peak seasons.  Patients had to wait hours or even days to be seen.  Occupancies of wards reached statistically impossible data of over 100%.  Doctors and nurses were seriously over-worked.  These happened every year since I was old enough to read news, that was more than 45 years ago.  I guessed reporters could just copy and paste their reports from previous years.

An amateur’s knee-jerk reaction would be to increase manpower: If there were more doctors, everything would be okay.  However, upon second thought, one should realize that merely having more doctors would not solve the problem.  Would there be more GOPC sessions or more sites?  Could A&E departments increase their turnover?  How about medical wards?  Would more doctors mean more beds?

Healthcare management requires special knowledge and skills different from any medical specialties.  That was the reason Hong Kong had to pay much for management personnel of the Hospital Authority.  When we heard complaints of extremely heavy workloads from frontline doctors, we expected more than producing and disseminating “add-oil videos” from TV stars.  When we read complaints from frontline doctors on wasting time on paper works and meetings, it should be understood that they were not asking for snacks or fish balls.  When we saw fleeing of doctors from the HA, we knew that there were management problems.  

However, what we encountered were propaganda here and there and everywhere that increasing the number of doctors instantly from allowing overseas doctors to practice in Hong Kong would be the magic bullet.  Suggestions were many, some innovative, most impractical.  Loopholes were poked in the MRO.  The Medical Council was asked to cater for it through the route of Limited Registration.  Various exemptions were proposed to attract overseas doctors.  Even the Licentiate Examination was deemed exemptible.

Ignoring the root cause of management problems and focusing on increasing the number of doctors was exactly like ploughing a stone field.  No matter how hard you worked, it would yield no crop.  It was a waste of time and effort.  The harder you worked on it, the further away from fruitful results you were.

Promising the public that no more chaos would be encountered in future influenza peak seasons after overseas doctors were allowed to practice in Hong Kong was exactly like drawing bread on paper.  No matter how beautiful the vision was pictured, it would not smell good, nor would it be of any practical use.

Actually, I am not against overseas doctors working in Hong Kong.  This is not something new.  There are recognized and time-honored routes.  The Licentiate Examination and the application of Limited Registration are open and fair.  Of course, there can be discussion on how to modify such procedures.  However, over-emphasizing overseas doctors and forget about solving the real problem is obviously 耕耘石田 and 畫餅充腸.  It would just serve to out-focus the discussion.  Worst, it would jeopardize the standard of doctors in Hong Kong.

Doctors should have scientific minds and should be evidence-based.  It is no way that we are going to rely on fortune sticks and oracles to guide patient treatment and healthcare system management.  We are not the superstitious types.  However, chanting that overseas doctors can solve the coming influenza surge crisis is no better than fortune telling.

It might work to beat superstition by superstition.

So I preach: THE ORACLE SAID SO!

 

（Source：HKMA News Feb 2019）

新春大吉

(Source: HKMA News Jan 2019) 

From the Editor

(Source: HKMA News Dec 2018)

100th Anniversary

 

Last month, I stayed in Taipei for a few days.  Taipei is a city I don’t like too much.  While my friends went to shop for snacks that no body actually needed, I strolled around aimlessly, listening to once-upon-a-time pop songs in Mandarin via my Bluetooth noise-reduction earphones.

When I entered R79 Eslite Underground（誠品 R79 中山地下書街）, there was an exhibition showing paintings of vivid, soft and colorful images of children on huge light-boxes with annotations.  They were works by the famous Japanese children’s book illustrator Chihiro Iwasaki（岩崎知弘）.  She was born in 1918, and 2018 marks the centennial of her birth.  There were various celebration activities.  The National Museum of History in Taiwan cooperated with the Chihiro Art Museum in Japan and held an exhibition to present 100 pieces of her original work.  In this R79 Eslite Underground exhibition, several local writers pay tribute to Chihiro Iwasaki by choosing a few pieces of her work and wrote short stories accordingly.  This was the reverse of creating illustrations for story books, in which a story was written first.

Chihiro Iwasaki was born before her two sisters in 1918 to working parents in Fukui Prefecture.  She was raised in Tokyo and she was very active in painting and sports.  At age 14, she started to learn oil painting and sketch from Tokyo Art School professor and painter Saburosuke Okata.  When she was 18, she began to learn calligraphy.  The work I Can Do It All by Myself in 1956, in which she depicted her son, was her first picture book.  She then produced various picture books and illustrated for children’s books.  The Pretty Bird won the Graphic Prize Fiera di Bologna in 1971.  Children in the Flames of War won the bronze medal of the Leipzig International Book Fair in 1973.  Chihiro passed away because of liver cancer at the age of 55 in 1974.

The book that made Chihiro most well known was written after her death.  It was written by the Japanese actress and UNICEF Goodwill Ambassador, Tetsuko Kuroyanagi（黑柳徹子）, about her experience in the Tomoe Gakuen School where she attended as a little girl.  Tetsuko chose from the abundant works of Chihiro and was able to find a character that matched the dropped-out girl perfectly both in positions and expressions in her book Totto-Chan: The Little Girl at the Window.  The book made Japanese publishing history by selling more than 5 million before the end of 1982.  It was later translated into different languages.   

Around 1938, Tetsuko, addressed as Totto-Chan by her classmates, was kicked out soon after she entered school as first-grader.  Her form teacher complaint that she was naughty and disturbed the discipline of the class.  She talked too much.  She always stood at the window, called to the street musicians passing by and asked them to play a song.  She talked to every bird outside.  She repeatedly opened and shut the lid of her new desk.  Her mother was left with no choice but to bring her to an interview of a new school.  Totto-Chan was lucky to have a mother who was minded not to blame her, and to meet a kind educationalist headmaster who accepted her to his school after listening to her talking non-stop for 4 hours during her interview.  Her book was about those interesting stories while she learnt and grew in this warm and special school.

I liked this book, both the stories and the illustrations.  I shared the feelings of the author towards Chihiro: “Chihiro Iwasaki is such a genius to depict children.  I don’t think any other artist in the world can draw vivid and authentic children as such.  In her works, you can tell the difference even between six months old and nine months old, no matter what poses these children are.  I’ve always dreamed about using Iwasaki’s illustration in this book.  she loves children so much, and she is so willing to pray and give blessings to children.  What can be happier than fulfilling my dream?  As my story and Iwasaki’s works are so well coordinated, some readers assume these works are done in advance particularly for me.  This shows her works really portray different aspects of many children.”    

Why am I writing about Chihiro Iwasaki?  Apart from the fact that she was a great artist, it is the 100^th anniversary of her birth.  The HKMA will celebrate her 100^th birthday in 2020.  We are planning a series of celebration activities starting the forth season in 2019 through 2020.  There will be a kick-off cardiology symposium, followed by different sports and cultural activities.  The HKMA Orchestra and the HKMA Choir are already planning a grand concert in the forth season in 2020, followed by the Gala Dinner to mark the finale.

If you have any ideas on how to celebrate this important event meaningfully, please tell us.  And, prepare to hear from us on how and when you can join in one or more of the celebration activities.

(Source: HKMA News Nov 2018) 

Mandatory CME

Mandatory CME is on the way. 

I expect that half of our readers do not know what I am talking about.  In Hong Kong, there are around 14,000 registered doctors.  Among them, around 7,000 are on the Specialist Register.  Only doctors on the Specialist Register need to fulfill specified CME requirements to stay on the Specialist Register.  The word “mandatory” means “made necessary, usually by law or by some other rules”.  Section 20L of the Medical Registration Ordinance (MRO) specifies that: “A registered medical practitioner whose name is included in the Specialist Register shall undergo such continuing medical education relevant to the specialty under which his name is included in the Specialist Register as may be determined by the Academy of Medicine.”  Details of such requirements are provided in the “Principles and Guidelines on Continuing Medical Education and Continuous Professional Development (CME/CPD)” issued by the Academy of Medicine.  Basically, a doctor has to obtain a minimum of 90 points in a 3-year cycle. 

There is no such statutory requirement for non-specialist.  Instead, the Medical Council has implemented a “Voluntary CME Programme for Practising Doctors who are not taking CME for Specialists” since October 1, 2001.  It states that "the purpose of the Programme is to encourage pracitisng doctors to keep themselves up-to-date on current developments in medical practice so as to maintain a high professional standard.  Practising doctors who are not taking CME for specialists are invited to enroll in the Programme on a voluntary basis."  Doctors who have satisfied with the CME requirements (obtaining more than 90 points in a 3-year-cycle) are allowed to use the title "CME-Certified". 

In June 2017, the Steering Committee on Strategic Review on Healthcare Manpower Planning and Professional Development released a review report.  There is a chapter on “Continuing Professional Education and/or Development”.  It recommends that: “Boards and Councils should continue to upkeep the strong professional competency of healthcare professionals through, among others, making continuing professional education and/or continuing professional development a mandatory requirement.”  It points out clearly that: “Non-specialist doctors and non-specialist dentists may on their own volition voluntarily enrol in CPE/CPD administered by MCHK and DCHK respectively, but they do not have an obligation as that of their specialist counterparts to undertake and complete continuing professional education.”  “The Steering Committee considers that CPE/CPD should not be just option or confined to specialists, but should be widely promoted and ultimately become a mandatory requirement for healthcare professionals under statutory registration.” 

Recently, I heard repeatedly small talks (and big ones) on the implementation of mandatory CME for non-specialists.  I think there is no disagreement on the need for CME for all doctors, specialists and non-specialist alike.  However, making CME mandatory is another matter.  Before we debate on whether it should or should not be, I look at the hurdles.  The first one is about how to make CME mandatory.  There is no provision in the MRO on the requirement for and the sanction against not having CME for non-specialists.  To amend the MRO is no easy job and it takes much time. 

The Steering Committee has considered this also and states that “a possible route for implementing mandatory CPE/CPD – as an alternative to legislative amendments – is that Boards and Councils may determine and set out the CPE/CPD requirements as part and parcel of their professional standard requirements e.g. the code of professional conduct and establish a mechanism to oversee whether the healthcare professionals have satisfied the CPE/CPD requirement.”  What the Steering Committee suggests is to use the disciplinary procedures to penalize doctors who fail to satisfy CME requirements.  One way to do so is to put it in the Code of Conduct and deem non-complying doctors fallen below expected standards.  They would be found misconduct in a professional respect after going through the normal PIC and Inquiry procedures.  Whether this way is feasible or desirable will be the subject of much debate. 

The second hurdle would be the capacity to offer CME training.  For the self-study part, it is easier.  If the current voluntary requirements are kept, 20 points a year would be from self-study.  Another 10 points need to be obtained by attending seminars.  If we take 7,000 non-specialists, at least 70,000 hours/points a year would be in need.  This means that around 200 hours/points a day need to be provided.  If one seminar can provide one hour/point to 50 doctors, 4 such seminars need to be held every day. A big step forward in solving this resource problem is the recognition of on-line interactive seminars by the Medical Council. 

Other hurdles include acceptance by stakeholders, resource implications to doctors and to the Medical Council, legal implications and appeal mechanisms.  

It seems that the government has made up its mind on this mandatory CME issue.  It is stated clearly in the Review that “Once the relevant Board and Council has reached a view on how mandatory CPE/CPD should be achieved, it should draw up an implementation plan in consultation with the profession.”  I foresee that at the end of this year, we have to face such consultation.

 

(Source: HKMA News Oct 2018)