Dangerous precedents

“No more Medical Council!”  I had told myself when I wrote the Editorial last month that I should not write on the Medical Council anymore.  Summer is approaching and it should be time for fun.  As shown in the photo, my bear had refused to dress up for taking picture for illustration anymore.  When I caught him, he had got changed and was ready to play in the pool with his rubber duck.  (The photo was taken in a misty day, which by coincidence reflected the atmosphere and the environment of what I am going to discuss.)

However, I was also caught liked the bear.  It was only when the media approached us did we know that there had been a letter uploaded to the website of the Medical Council to all doctors from the Chairman of the Medical Council.  It was only when a letter from the Secretary of the Medical Council was put up for discussion in the HKMA Council meeting did we know that the HKMA was asked to publish that letter for the Chairman.  Members of the Medical Council confirmed that there had not been any discussion on the content of the letter nor any discussion on the letter itself.  Upon enquiry, the Chairman stated that it was only her personal opinions.  The HKMA thus decided to decline the request for publication of the “personal letter in the name of the Chairman of the Medical Council”.  Because of the irregularity and the attention stirred up in the media, I was asked to write something on this matter.

Everything started around September last year when a doctor was found professional misconduct because he charged an old-aged patient excessively for blood tests for sexually transmitted disease with the provisional diagnosis of zoster.  Most doctors might agree to the verdict of this straight forward case.  However, it was the reason for finding him guilty and the judgment that most doctors disagreed to and even found annoying.

The case and the judgment

Apparent facts

• A doctor charged a patient up to ten times the cost for blood tests.
• He marked the charge as laboratory tests in the receipt.
• He was then found professional misconduct for charging excessively.
• However, the reason given in the judgment for finding him guilty was that the item “laboratory charge” as stated in a receipt should be “the fees charged by the laboratories”.  Charging more than that was “a rebate in disguise” and was misconduct.

Impressions

• This was an extreme case with ten times excessive charge on a relatively old aged patient without thorough discussion and time for decision.
• The inquiry panel failed to address the uniqueness of this case and instead made a general finding on technicality.
• The reasoning was super artificial, if not wrong, and dwelled on the labeling of an item on a receipt.
• By the reasoning of the judgment, a doctor would be found misconduct if: he charged one dollar more than what the laboratory billed him and at the same time he wrote that amount on a receipt as laboratory test.
• The ruling disregarded the common practice of doctors and the ambiguity posed threat to many doctors.

Implications

• To avoid being caught by the ambiguity of the judgment, it might be wise to add a clause to explain every charge on the receipt to be interpreted as including, and not limited to, consultation, handling, professional judgment and advice, rental…, and virtually everything in the world.
• The judgment was so artificial that it took the convenience of targeting the bill from the laboratory because the charge was stated clearly.  This meant that when the cost could not be defined conveniently, the charge would not matter.  This encouraged doctors to perform more laboratory tests in their clinic, which might not be a desirable outcome.
• All the fuss might spread to “medication fees” in the receipt in a similar sense to “laboratory tests”.

The handling by the Medical Council Chairman

Apparent facts

• The doctor appealed to the Court of Appeal and lost.  His appeal was dismissed.
• The judgment from the Court of Appeal did not rule on the interpretation of “laboratory tests” or how the verdict was arrived at.
• The main focus of ruling was whether it was appropriate for the Legal Advisor of the Medical Council to give advice on the points of law and on facts during an inquiry.
• After the judgment was delivered, the Chairman of the Medical Council uploaded a personal letter addressing to all registered medical practitioners, stating that: “Arising from this case, the Medical Council wished to impress upon members of the profession that the doctor’s own fees for professional services should be clearly separated from the fees collected on behalf of laboratories for investigations.  If the doctor charges fees for his own services in connection with the investigations to be performed by the laboratories, the charge should be clearly set out and explained to the patient.”
• The content of the letter and the issuing of the letter had not gone through the normal procedure of discussion and endorsement by members of the Medical Council.
• What the Chairman wanted to “impress upon” doctors in the name of the Medical Council was more than that decided in the case.
• The artificial judgment in the case ruled that when a charge was stated as laboratory test, it equated the charge billed by the laboratory to the doctor.  Charging more than that stated was charging excessively (and rebate in disguise).
• However, what was stated in the letter posed a strict liability on doctors to explain charges to patients irrespective whether they were asked by patients or not.

Impressions

• The case concerned was an exceptional case with extreme charges.  It was a disaster for other doctors when a general judgment was given which would affect their common practice.
• It was more disastrous when this was seized as a chance to “impress upon members of the profession” with the involvement of the media.  This gave the public an impression that the exceptional case was not exceptional, but it was necessary to warn all doctors who might be behaving like the doctor concerned.
• The reason for the Medical Council to have representations from different sectors is for thorough discussion and collective decision making.  It should take into consideration of opinions and voices from different aspects.  Seemingly, this mechanism was not respected.

Implications

• The image of doctors was affected out of an extreme case of misconduct (in which the doctor was reprimanded only).
• New code of conduct or innovative interpretation of the code tended to arise from the inquiry level.
• Due process was not respected.

Ripples

• All these arose as ripples from the judgment of an extreme case of misconduct.
• There had been attempt to initial a review according to the Medical Registration Ordinance (MRO) so as to clarify any ambiguity and to address concerns from doctors.  However, the request was disallowed because of a strange interpretation (as least it was strange to me) of the MRO saying that the word “Council” in that provision meant the inquiry panel instead of the usual meaning of the Medical Council.
• So apart from missing the chance for discussion and stopping the ripples, the Medical Council was stripped of an important power to review a decided case.

All these are dangerous precedents.

 (Source: HKMA News May 2010)

As Time Goes By……

 

As time goes by, the year 2010 marks the 90^th Anniversary of the HK Medical Association.  There will be a series of activities to celebrate this big event.  The Charity Concert on July 31, 2010 will mark the beginning of these activities while the Annual Ball on December 31, 2010 will be the finale.  Other activities include sports events (the HKMA 90^th Anniversary Cup), singing contests, public education events, recreation and cultural activities, and the production of souvenirs.  It is my honour to be responsible for the production of the Commemorative Publication.  If you have any documents or photographs related to the history of the HKMA and would like to share with others, please kindly send them to the Secretariat (Ms. Candy YUEN).  Your precious memories might appear in the Publication.

As time goes by, this is the third year I have been serving on the Action Committee Against Narcotics (ACAN).  The medical profession and the HKMA have always been supportive in beat drugs activities.  In response to the need to consolidate beat drugs activities organized by the HK Medical Association, the Beat Drugs Action Committee (BDAC) was formed in March 2010.  It aims at strengthening the role of doctors in the team work of prevention and management of drug abuse problems in Hong Kong.  Activities organized by the BDAC include school talks, public education, CME lectures and workshops for doctor training, group therapy programme with drug abusers, and cooperation with other organizations and professions in the prevention, treatment and rehabilitation of drug abusers.  Another piece of good news was that the BDAC had successfully applied to be the beneficiary of the 90^th Anniversary Charity Concert.

As time goes by, it is becoming more and more difficult to be a doctor.  It is becoming more and more difficult for a doctor to realize, to understand, to accept and then to follow the decisions of the Medical Council so as not to find himself being charged misconduct in a professional respect.  The recent area of concern is the prescription of steroids.  In this issue of the News, the Special Feature section from JSM talks about the pitfalls in the use of steroids.  I think this article is in response to a recent decision of the Medical Council.  The agreed facts of the case were that a family doctor diagnosed an adult patient having acute bronchitis and gave him three days of celestamine (one tablet four times a day).  He was found professional misconduct not because of his failure to justify the use of steroid.  The charge was that he prescribed to the patient celestamine that contained steroid without informing the patient of the fact that celestamine contained steroid.

It was a strange charge.  It stated that if you gave steroid to a patient, you must tell him the fact that steroid was given.  It did not matter whether the patient asked for it or not.  You must volunteer this piece of information.  Otherwise, it was professional misconduct.  And this was exactly the case.  Apparently, the patient did not ask anything about the medication.  He just disappeared after receiving the medication and then complaint to the Medical Council.  Then the outcome was that the doctor was found professional misconduct.

Steroid is a potentially harmful medication.  There can be very serious side effects to the patient especially when used in high dose and in prolong use.  Doctors have the duty to explain clearly to the patient about the indication, the side-effects, the precautions and the alternatives to the use of long term steroid.  This is the respect of patients’ rights to choose and to have information before consenting to treatment.  This should apply to all kinds of treatment.  The more serious the side effects are, the more information should be given and more time should be spent on discussion.  The relevant provision in the Code is Section 9.6, which stipulates “Where a drug is commonly known to have serious side effects, the doctor has the responsibility to properly explain the side effects to the patient before prescribing the drug.”  

Having stressed the importance of patient protection and the respect of patients’ rights, one must also agree that misconduct in a professional respect is a very serious allegation to the doctor.  Being found professional misconduct would certainly affect the doctor’s good name.  The guilty doctor can also be removed from the general register and his livelihood being affected.  He might have difficulties in his application for restoration to the register.  He is not eligible for the election to be a council member of the Medical Council.  In this case, it should have been the duty of the Medical Council to prove that the use of three days of celestamine with the said dosage on an adult patient could cause serious side effects to the extent that the doctor was obliged to volunteer information concerning its use.  However, it seems to me that the judgment imposes a strict liability on doctors to volunteer information including side-effects on steroids whenever they are used irrespective of circumstances and justifications.  Naturally, many questions would arise in doctors’ mind.  Is this good development in the control of doctors’ practice and conduct?  What are the harmful effects of three days steroid on an adult?  How about other medications such as antibiotics, NSAIDs, hormones and symptomatic treatments?  Do doctors need to volunteer information on the use of these potentially harmful medications?  What make steroids single out in medications?  How about the omission of the use of steroids when there is an indication for their use?  Do doctors need to volunteer information for not using steroids?

As time goes by……

(Source: HKMA News April 2010)

Does it make sense?

It is spring time and Tiger Woods is back.  Let’s talk about golfing.  When reading golf magazines, there are always columns on quizzes and asking the pros.  So I throw out a question for you: When a professional golfer misses a half-foot putting, is he unprofessional?

What is unprofessional?  As doctors, we have been sensitized by the word “unprofessional” and are likely to link it automatically to professional misconduct.  Our approach to the question would be to ask if his act of missing a half-foot putting falls below the standard of his peers.  Someone would suggest asking the opinion of another pro in golfing.  Then there happens to have one pro telling you that it does happen for pros to miss short putting.  Evidence is ample if you watch TV.  Even Tiger Woods misses short putting once in a while.

If you, acting as the judge, stop at this point and are satisfied that the golfer involved is not unprofessional, then you are unprofessional to act as the judge.  The pro who gives his opinion is only a pro in golfing, but not a pro in judging.  The judge should analyze the context of the missed put.  Was the golfer aiming at the hole?  Had he done his routine preparatory work?  Was he distracted?  Had he done that putting in his usual manner?  The judge should be satisfied that all these things had been done properly and that it was only hard luck that the golfer missed the short-distance put.  He can then rule the golfer not unprofessional.  In some cases, even the lay audience can easily point out that the golfer has failed to aim at the hole.  The golfer can thus be regarded unprofessional without involvement of the expert witness.  That’s how common sense works.

The above is a parable told by me to explain the development of the approach by courts through the cases of Bolam and Bolitho regarding the decision of breaching of duty in clinical negligence.  They also bear some relation to the decision of professional misconduct.  The famous Bolam Test states that: “A doctor is not guilty of negligence if he has acted in accordance with a practice accepted as proper by a responsible body of medical men skilled in that particular art...  Putting it the other way round a doctor is not negligent, if he is acting in accordance with such a practice, merely because there is a body of opinion that takes a contrary view”.

However, courts are uneasy at this simplified, automatic approach.  In Hucks v Cole ([1993] 4 Med LR 393), Sachs LJ introduced the “insurance principle” into the Bolam Test.  Basically, he opined that if the price for precautions to prevent the actualization of a certain risk was small when compared to the risk involved, it was negligent to omit the precautions no matter what other doctors did.  He said (at page 397): “When the evidence shows that a lacuna exists by which risks of great danger are knowingly taken, then, however, small the risks, the courts must anxiously examine that lacuna - particularly, if the risks can be easily and inexpensively avoided.  If the court finds on an analysis of the reasons given for not taking the precautions that, in the light of current professional knowledge, there is no proper basis for the lacuna, and that it is definitely not reasonable that those risks should be taken, its function is to state that fact and where necessary to state that it constitutes negligence.  In such a case the practice will no doubt be altered to the benefit of patients.  On such occasions the fact that other practitioners would have done the same thing as the defendant practitioner is a very weighty matter to be put on the scales on his behalf; but it is not conclusive.”

Subsequently, the House of Lords seized the opportunity to re-explain the Bolam Test in Bolitho v City and Hackney H.A. ([1997] 4 All ER 1151).  They made some interesting observations on the status of the Bolam test.  They opined that it was not enough to solely rely on medical opinions.  The opinion itself “must have a logical basis”.  The court therefore must be satisfied that the experts in question had weighed up the risks and advantages associated with a particular procedure and had reached, in Lord Browne-Wilkinson’s words, “a defensible conclusion”.  I reframe the approach in one question: Does it make sense?

One sunny day, I had the privilege of discussing cases with some senior colleagues. One of the case scenarios described an adult patient who presented himself to an ENT specialist with several weeks’ history of one-sided ear block, ear discomfort and tinnitus, together with recurrent nose bleeding.  I opined that the patient actually presented with the cardinal symptoms of nasopharyngeal carcinoma.  Missing that diagnosis without further investigations put the doctor at risk of professional misconduct.  I was mocked at by a senior doctor.  He told me that I should not think that I processed better knowledge on NPC than a specialist in ENT.  Moreover, there happened to be another ENT specialist who believed that missing the diagnosis of NPC with repeated consultations on that patient was accepted practice in his expert opinion.  That was not a case of tricky NPC where repeated biopsies were negative on different occasions.  Apparently I doubted whether the EBV status or an endoscopic examination had been performed.  The patient was lucky to trust his lay knowledge and visited another ENT specialist, who diagnosed NPC right away and started treatment.

As a family doctor, I always remind myself and medical students about two separate lists of differential diagnoses.  One list involves common causes on which you will probably find the actual diagnosis to account for the patient’s signs and symptoms.  The other list includes important causes that a doctor cannot afford to miss.  They are serious illnesses particularly those that are treatable.  Missing the diagnosis means depriving the patient of an opportunity to have early treatment and sometimes it means depriving the patient of his life.  Nasopharyngeal carcinoma is common in Hong Kong and it is of good prognosis if identified and treated early.  The patient in the case scenario obviously went to see the specialist to rule out the risk of something serious.  Did evidence tell us that the doctor had thought of the diagnosis of NPC?  Had he ruled out the important diagnosis by assessing the risks of the patient?  Was he aware of the family history of NPC of the patient?  Had he checked the EBV status?  Had he done any further investigations including scanning or endoscopy?  Did the judge and the expert consider these questions that the patient wanted them to answer?  Did all these make sense?

(Source: HKMA News March 2010)

新年進步

(Source: HKMA News February 2010)

New Year Wishes

 

On 7 January 2010, the news of a doctor being admitted to Queen Mary Hospital set off the alarm for the safety of the Human Swine Influenza (HSI) vaccine.  It was announced by the Center for Health Protection, Department of Health, that “on 6 January 2010, the Centre for Health Protection (CHP) received report of a 58-year-old man who complained of lower limb weakness and was admitted to Queen Mary Hospital (QMH).  The patient developed sudden onset of bilateral calf pain and increasing lower limb weakness since 28 December 2009.  He was admitted to QMH on 2 January 2010.  He received human swine influenza (HSI) vaccine on 24 December 2009 in a government outpatient clinic.  Clinical examination revealed bilateral ascending lower limb weakness.  Currently his condition is listed as serious and his vital signs are stable.  The first nerve conduction test showed prolonged distal motor latency, which was compatible with early phase of GBS and other demyelinating diseases.  Magnetic resonance imaging (MRI) and cerebrospinal fluid (CSF) examination did not identify other cause for the symptoms.  Other investigations are ongoing to confirm the diagnosis.”

Guillain-Barre Syndrome (GBS) is a known adverse effect of HSI vaccination.  By statistics, we are bound to encounter one or more cases if we give HSI vaccines to a large population.  It is difficult to establish causal relationship between a single case of GBS and HSI vaccination.  Evidence shows that it is more beneficial for patients with chronic illnesses and citizens at age extremes to receive HSI vaccines.  Therefore the CHP maintained that the vaccination program continued and urged high risk groups to receive HSI vaccines promptly.  However, the public reacted with skepticism.  The number of people receiving vaccination dropped sharply with the announcement of the news.  This is understandable, especially when there have been debates on the efficacy and safety of the vaccines.  I also believe that it is sensible and logical to withhold vaccination for a short period of time (say one to two weeks) just to make sure that there is no more incident of related adverse effects.

I sincerely wish that the doctor will recover completely and uneventfully.

To mark the beginning of the year 2010, the HKMA Office Bearers and Council Members give their New Year wishes to our members in this issue.  My wish is that members can develop prajna (which is a Sanskrit term, meaning “wisdom” in Buddhism).  While attaining the wisdom of Buddha, we can “see things as they really are”.  Of course this term is a bit circular.  One can never be sure of things as they are “truly are”, since there is no recognized proof for it.  Moreover, even if we can see things are they truly are, whether we can accept these “facts” psychologically is another matter.

One of the applications of prajna is for meetings.  Meetings are intended for discussion of matters, and to come up with conclusions and solutions.  They serve the purpose of collective decision making and allow sharing of ideas and concerns from different stakeholders.  In these years I have attended many meetings in different occasions.  I must admit that I have learnt a lot through these meetings.  There are always new ideas and new angles of vision to the same matter from different stakeholders.  There are people who can analyze matters in a very logical manner.  There are ingenious ideas that I can never think of.  However, meetings can sometimes (hopefully not always) be boring and counter-productive.  Some are a waste of time and they challenge your temper and endurance.  One would particularly appreciate a Chinese saying that “those who have not investigated or looked into the subject matter do not have the right to speak”.  It is in these situations that prajna is most useful and important.  If the chairperson possesses prajna, he can then see things as they really are, both for the matters to be discussed and the reasons for the “copremesis” (a medical term referring to the vomiting of faecal matter) of the attending members.

For those who are unfortunate attending the disgusting meetings, prajna can be useful in seeing the true reasons for “copremesis” and thus time may pass more quickly.  Some intelligent people with prajna tell me that there are basically three causes for “copremesis”.  The first one is to argue for the sake of arguing, and to talk for the sake of talking.  Some people like arguing and they cannot accept the fact that there are different opinions.  Some people think that meetings are for talking and sharing all their personal feelings whether related or unrelated to matters discussed.  Yet, many people utter just for the sake of being recorded in the minutes so that their presence and their engagement in discussions are recorded.

The second reason is lack of technique. People with various hidden intentions need to lengthen the meetings, and if possible, to talk others out of it.  However, the lack of technique leads to “copremesis”.  There is no logical analysis or counter-arguments, but just repeated regurgitation of the prepared materials (the Human MP3) or the quoting of examples and throwing out of arguments totally out of scope.  The third reason is exactly the lack of prajna.  Some people uphold and insist on foolish believes and try their best to convince others.  They are blind to logic and counter arguments from other members.  This group of people is relatively more dangerous, as they may lead to heated arguments and even physical violence.  In rare occasions, they may lead to more drastic actions including demonstrations.

Again, I wish everyone success in the cultivation of prajna in a new year. 

 

(Source: HKMA News January 2010)

Sports Month

November was a month for sports games.  We had the Oxfam Trialwalker, 2^nd Guangdong Hong Kong and Macau Sports Meet, Family Sports Day and various Joint-Professional tournaments.

The Oxfam Tailwalker 2009 was held on 20-22 November 2009.  There were a total of 18 HKMA teams taking part in the event.  The weather was tremendously cold, dropping to 2°C with the Cold Weather Warning signal hoisted.  I sincerely show my appreciation to all the participants, especially those hurriedly joined the Guangdong sports trip the next day after the long march. 

The 2^nd Guangdong, Hong Kong & Macau Sports Meet was held on 21-22 November 2009 at Guangzhou.  Even though minor episodes like traffic jam and late arrival happened on the first day of the trip, nothing really affected the morale and performance of our athletes.  I also took part in the badminton competition.  There were 5 matches including 3 men’s double and 2 mixed double.  The arena was horrible (that was my description), with basketball and badminton matches playing together at the same area.  Lighting was real bad, with a mixture of dazzling spotlights and sunlight.  The shuttlecocks were of extraordinary slow speed, in contrast to those of slightly on the fast side used for HKMA competitions.  Despite all these, all of us did enjoy the games with both Macau and Guangdong teams.  We managed to beat Macau team with a tight 3:2, while we could hardly manage to excel against the professional performance of Guangdong team.  We were the 1^st runner up in this event.  For the overall results, Guangdong was the overall champion, Hong Kong came second and Macau came third.  Congratulations to all the winners!

The Family Sports Day was held on 28 November 2009 at Stanley Ho Sports Center.  We had doctors participating in exciting events like 400M, 800M and inter-professional relays.  We also had their kids participating in funny events like hop in bag and bean bag throw.  I always enjoyed taking snapshots in the playing field and listening to the cheers from kids while practising their 3-legged race.  I also made some suggestions to our President during the occasion so as to make the event more carnival-like.  It would be more fun and attractive if there were more activities like hotdog booth, marshmallow booth, balloon-twisting, blow-up sliding down etc.  And how about cheering competition with participants from high schools and halls?

By the time you receive this issue, it is almost Christmas.  It is also near the end of the year.  As a New Year gift for the year 2010, attached please find the HKMA pocket diary.  This is the second year we specially produce the diary, which records all planned CME activities for the whole year.  I hope all of you would make good use of the diary and therefore having pleasurable CME trainings all over the year.  

When writing this editorial, a number of events related to the medical profession in the year 2009 came across my mind.  This year, I didn’t have time to do a formal and organized review, as I had to hand in numerous essays and to prepare a written examination for my MBS study.  So the following presents list of event-based snapshots: 

• The introduction of the Elderly Health Care Voucher Scheme, with the need of computer use and on-line registration
• The outbreak of H1N1 Influenza, resulting in the quarantine of hotel residents
• Our President was expelled from the Medical Council and then reinstated
• Beat Drugs Campaigns in HK with the full cooperation of HKMA organizing the Certificate Course for Family doctors and Beat Drugs Schemes of our Community Network
• Pilot Scheme for School Based Voluntary Drug Testing
• 60^th Anniversary of the Founding of the People’s Republic of China
• The ruling of the Medical Council on “Rebate in disguise” and the questionable refusal for review of the case
• The H1N1 Flu Vaccination scheme
• The appointment of Professor SUNG Jao Yiu, Joseph as Vice-Chancellor of the Chinese University of Hong Kong from July 2010

They might not be the “big ten”, as different people would have different perception for the significance of different events.  What are your choices?

(Source: HKMA News December 2009)

Indecent Assault

 

On 6 November 2009, a 26-year-old (male) doctor, who was about to receive a qualification from the Royal College of Surgeons of Edinburgh, was convicted of indecent assault on a 15-year-old girl during his elective period in the A&E Department of Tuen Mun Hospital.  It was reported in newspaper that on 10 February 2009, the girl had stomach discomfort and was seen by the doctor.  She lifted up her dress to her rib area for the doctor to examine.  She asserted that the doctor pushed her dress and her bra up to her collarbone and touched her breasts without her consent.  The Magistrate found the doctor’s testimony not consistent with the statement given to the police and found him guilty of indecent assault.  The magistrate clearly pointed out that the offence constituted a breach of trust.  When passing sentence, the magistrate criticized him for taking advantage of a young and vulnerable girl, and that the doctor had shown no remorse.  He was sentenced to imprisonment for nine months.  After serving his sentence, the doctor needs to face a Medical Council inquiry because of the criminal conviction.  There is a high chance that he will be removed from the General Register for a certain period of time.

Although Glenn Beck in his new book “Arguing with Idiots: How to Stop Small Minds and Big Government” wrote that “opinions should end where facts begin”, the fact for the above case was that might be no one would know the fact.  Even the two people involved in the case might not know the whole particulars.  The doctor might be preoccupied by something in his mind and thus had done something not in his full consciousness.  The girl, on the other hand, might have mistaken some procedures and firmly believed that the act was a sexual assault.  At this point in time, the only fact was that the doctor was found guilty.

It is perception that matters.  Some doctors believe that the doctor was innocent and would like to help his appeal.  It is a fact that the judge would usually choose to believe in the patient rather than the doctor when there is contradicting evidence.  It is because it is hard for a doctor to remember every detail of one patient among hundreds of patients seen, but it is convincing for the patient to tell every detail of a single consultation in which she finds problems.  Frontline doctors might find them vulnerable especially in a busy environment in short of nurses to act as chaperons.

Another concern is rehabilitation of the doctor.  No matter the doctor had committed the crime or not, this event was a real trauma to his career and to him psychologically.  He needs help in terms of financial assistance, career counseling and psychological counseling.  I think the medical school where he graduated and the HKMA should take the initiative to offer assistance to him during his trial, during his appeal (if there is any), during his stay in prison, after his release, during the Medical Council inquiry and afterwards.

For the public, people might also perceive that they are vulnerable.  There had been cases of sex crimes including inappropriate sex relation of a doctor and his psychiatric patient, hidden camera installed in a private clinic and indecent assault committed by a medical student.  Doctors and patients are in an unequal position as doctors are the authority while patients are sick and anxious.  One must admit that there exists a real risk, no matter how small this risk is, that a doctor might abuse his power and position and do something harmful to the patient.  Therefore it is very important to make sure that doctors do not abuse their positions, and that there are clear mechanisms to show to the public that doctors will not abuse their power.

It is the role of the Medical Council “to assure and promote quality in the medical profession in order to protect patients, foster ethical conduct, and develop and maintain high professional standards”.  In the above mentioned case, apart from holding an inquiry according to the MRO after the doctor spends his imprisonment, the Medical Council should make sure that there is no latent period between his release from prison and the delivery of verdict from the inquiry.  It is because the doctor is still on the General Register and thus can still practice before there is any action from the Medical Council.  For public protection, the logistic of the inquiry should be carefully monitored and there should be an interim measure for suspension of doctors from practicing if there are criminal offences resulting in imprisonment especially sex crimes.

Buddhism looks at moral evils in three levels.  The first level is called anusaya, which means sleep.  At this level moral evil remains dormant in the form of latent tendencies.  The second level is called pariyutthana, which means arising all around.  At this level the latent tendencies are awaken and cause emotional turbulence and excited feelings.  The third level is called vitikkama, which means going beyond.  At this level our emotions manifest themselves in the form of vocal and physical actions.  The vitikkama is most dangerous but easiest to control.  This can be controlled by moral discipline (sila) such as Codes and Regulations.  Evil at pariyutthana level is controlled by concentration (samadhi).  I regard this as impulse control training, which should be introduced and reinforced both at undergraduate and postgraduate level.  Wisdom and insight (panna) is needed to uproot evil at anusaya level.  This involves personal development.  A good foundation at medical school is very important. 

(Source: HKMA News November 2009)