Telemedicine

Recently there has been increased concern about telemedicine.  Some see it as a new opportunity for business.  More worry about the potential problems it creates.  Can doctors “see” patients using WhatsApp aided by photos and voice recordings?  How about live chats via computers?  Is physical examination dispensable in some cases?  How about spot diagnosis?  Can doctors prescribe without meeting the patients physically?

Actually, telemedicine is nothing new.  I read in novels that in the old days patients wrote long letters describing their symptoms to doctors.  And I think every doctor has answered telephone calls from patients.  Most of us would have given advice via the phone.  Some have placed phone orders to nurses.  While there are some features unique to telemedicine, I do not regard it a standalone process.  Rather, it is part of consultation.  Thus, rules for the normal consultation process apply.

It must be clear to both the doctor and the patient that it is, or it is not, a medical consultation.  This is very important but can easily be overlooked.  A patient might just send you some photos or questions.  While you consider them casual chats, he might take your answers seriously and rely totally on you.  In such cases, a doctor-patient relation is established.  The doctor is said to owe a duty of care to the patient.

Whether the doctor has discharged his duty of care to the patient would be judged by the standard of care, with reference to the standard of his peers.  Telemedicine is just part of the consultation process.  It is up to the doctor to justify how much he relies on the information he collected through telemedicine.  The doctor can always request the patient for a face to face history taking, followed by physical examination and investigations.  However, with the real-time live-chat technologies, there might not be much difference in the history taking part.  Telemedicine might even serve better as the patient is in his familiar environment and can be more at ease.  Sometimes, the patient might be able to show you some paroxysmal physical signs which can never be witnessed at the consultation room.

The aim of consultation is to arrive at a diagnosis, or to derive a management plan.  Some doctors regard telemedicine dangerous as it is difficult to adequately examine the patient physically.  However, it all depends on the condition of the patient.  Physical examination might not be necessary.  Or, telemedicine might serve as a temporary measure to handle the patient.  It is the clinical decision that matters.  Even during a normal face to face consultation, similar argument can apply.  Do we need to investigate every patient?  Physical examination has its limitations.  But obviously we would not say that a consultation is not complete without investigation.  Most consultations end with history taking and physical examination.  This applies to telemedicine also.  We need to know the limitations and the merits of telemedicine.  In rare occasions, it can stand alone.  In most occasions, it can help to diagnose and to manage.

It is prudent to build a safety net for yourself and for your patient.  Apart from the most probable diagnosis, we always need to rule out some differential diagnoses with serious implications, especially treatable ones.  I remember when I was working in the A&E Department, I always ran through the 10 treatable causes of sudden loss of consciousness, and I always carried a wide bore needle, just in case I encountered a patient with bilateral tension pneumothorax.  In telemedicine, it might be possible to send a from-the-lawyer disclaimer to every patient you see if you really love defensive medicine.  It is up-to-standard practice to alert patient on any red flags, explain the natural course of the illness, warn about the limitations of the consultation, and arrange for follow-ups.

Thus, telemedicine is not a new topic for doctors.  There are existing codes and laws governing its practice.  However, the real threat to patients is the lack of clear laws, and the failure in enforcing such laws, for non-medical parties.  They might sell health food, sell drugs, solicit patients to non-orthodox treatments through engaging with patients via telecommunication and advertisements.  We do not want to repeat the history of untrained “beauticians” doing whatever they choose to while doctors’ hands are tied. 

(Source: HKMA News April 2018)

Professionalism or Protectionism? Pragmatism or Dogmatism?

After our Financial Secretary announced the 2018-19 Budget, there was much criticism from law-makers and citizens alike.  His pro-government allies even openly asked him to redo his major piece of homework.  However, he was decent enough to spare his valuable time and energy to raise public concern on the issue of medical protectionism.  Again, he suggested that we should allow overseas doctors to practice in Hong Kong.  I assumed that he understood our medical system and knew that there is already the Licensing Examination as a route for a non-locally graduated doctor to get a license and practice in Hong Kong.  So, I took it that he was referring to by-passing the Licensing Examination. 

This is a highly controversial suggestion.  It involves a fundamental change to the Medical Registration Ordinance and there are numerous practical issues.  The Hong Kong Medical Association has been too dutiful and too diligent in directly tackling this problem with the aim of protecting the public and the profession.  However, the result was that parties taking the suggestion seriously were repeatedly labelled “protectionism”.  While we were talking about up-holding standards, official responses were that profits of private doctors would not be jeopardized.  Seemingly, blaming doctors serves as a good excuse to the apparent shortage of manpower in the public sector.  It was not us who did the obviously below standard manpower planning.  It was not us who raun the Hospital Authority and failed to tackle even a less-serious-than-average influenza surge.  And then, officials got indulged in this scapegoating game.  Whenever they mess up, they chant “protectionism” and pray to divert public attention at no cost. 

On the same day when our Financial Secretary smiled sheepishly and did his chanting, a group of construction workers went for a demonstration against the slow flow of funding from the government.  Not long ago, the same group of workers demonstrated to fight against importing foreign workers despite outcries from developers.  This was not labelled “protectionism”.  Actually, the government is practicing protectionism in various aspects without admitting it.  The government is adopting a tolerating, if not encouraging, stance towards minimally trained “cosmetic workers”.  There had been numerous blunders.  The medical profession had voiced out repeatedly.  The Consumer Council had openly advised on tightening controls.  Instead of protecting the public, the government chose to protect the income of these workers. 

I am not sure whether not importing workers to do dish-washing is protectionism.  But having mechanism in place for overseas doctors to take examination and get a license is surely not protectionism.  Some chanters commented that the passing rates of the Licensing Examination were too low.  Apart from reviewing the contents of the Examination, we might also need to consider whether Hong Kong can attract high-caliber overseas doctors.  We speak Cantonese dialect.  Most of us can only afford to dwell in ashamedly tiny cubicles.  We save every dime and send our kids to study abroad before their puberties.  Doctors are not allowed to advertise.  The dire working conditions of public hospitals hit newspaper headlines now and then.  Some of us fly regularly to Japan or Australia just to remind ourselves how a blue sky should look.  I do not think Hong Kong is the dream land for the cream of the cream, especially those married and with kids. 

Keeping the standard is important.  Examination is the most commonly recognized, though not perfect, way.  If exemptions from the Licensing Examination are granted, how are we going to maintain the standard?  Laymen’s matter-of-fact referral to “well-recognized” universities is but topics in WhatsApp group chats or amateur views from newspaper columnists.  To write it in the Medical Registration Ordinance, we need specific details that are reasonable and can stand from challenges.  Are we going to exempt all graduates from all universities from the United Kingdom?  Or just some selected universities?  How about graduates from other European countries?  How about those from the United States?  Or those from Mainland?

Does exempting an overseas doctor from the Licensing Examination mean exempting him from the internship?  In such case, we have practically surrender all controls on the entrance requirements.  Should the exempted doctors be allowed to practice under the employment of the Hospital Authority only?  The recent program of granting limited registrations to non-local doctors “to relieve manpower pressure and alleviate the workload pressure of frontline doctors” has stretched the Medical Registration Ordinance to a dangerous level.  Working posts with no training and no promotion prospect are provided to junior non-local doctors.  I doubt how job-satisfied those candidates will be.

Working is but one aspect of life.  Will qualified doctors become Hong Kong citizens?   Or will they be hailed back to their home countries if our Hospital Authority decides to end their contracts for one reason or another?  If non-local doctors who are exempted and granted licenses can stay in Hong Kong by starting their own private practice, it would create a loop-hole for some to just register their business and never practice medicine.  Hong Kong becomes a region with no border to medical graduates.

I have had enough.  I reiterate that I object to the talking-in-a-vacuum allowing foreign doctors to practice in Hong Kong without formal standard assessment.  I am not going to change my stance.  However, pragmatism might be a strategy against dogmatism.  I would like to urge the finger-pointers to forward a formal proposal to enlighten the profession and the public how they are going to solve the above problems.

I have all my dogmatic labels ready to throw at whoever speaks up.

(Source: HKMA News March 2018)

100% of the Time Is Easier Than 98% of the Time

 “It is easier to hold to your principles 100 percent of the time than it is to hold to them 98 percent of the time.” 

The above is a quote from Clayton Christensen in his book “How Will You Measure Your Life?”  Clayton is the Professor of Business Administration at the Harvard Business School of Harvard University.  The book was published in 2012, while he was 60.  As a professor at the Harvard Business School, he taught and discussed with many students every year about their career paths after they left the University.  After witnessing too many sad stories, he summarized his teachings into formulating answers and strategies to 3 fundamental questions:

1. How can I be sure that I will be successful and happy in my career? 
2. How can I be sure that my relationships with my spouse, my children, and my extended family and close friends become an enduring source of happiness? 
3. How can I be sure that I live a life of integrity- and stay out of jail?

He knew for sure that “none of those people (with sad stories) graduated with a deliberate strategy to get divorced or lose touch with their children- much less to end up in jail.  Yet this is the exact strategy that too many ended up implementing.”  He realized that it was strategies and theories that mattered.  “You might be tempted to try to make decisions in your life based on what you know has happened in the past or what has happened to other people….  But this doesn’t solve the fundamental challenge of what information and what advice you should accept, and which you should ignore as you embark into the future.  Instead, robust theory to predict what will happen has a much greater chance of success.”  What he did was to try to highlight theories that applied successful in business organizations, and to apply them in answering the above 3 questions. 

It is sure anti-climax to tell young Harvard graduates that their aim in life should be ensuring happiness by having a career that makes you happy (not about money or position), maintaining relationships, and keeping yourselves out of jail!  Since I am probably fixed in the first 2 aspects, I am more interested in how to keep myself out of jail.  Here comes Clayton’s famous quote: “It is easier to hold to your principles 100 percent of the time than it is to hold to them 98 percent of the time.”  He tried to explain why people deviated so much from their aspiration by the theory of “marginal costs”.  “Many of us have convinced ourselves that we are able to break our own personal rules ‘just this once.’  In our minds, we can justify these small choices.  None of those things, when they first happen, feels like a life-changing decision.  The marginal costs are almost always low.  But each of those decisions can roll up into a much bigger picture, turning you into the kind of person you never wanted to be.” 

He used 2 examples to illustrate that the actual cost implication would be much higher than the individual marginal cost.  The first was the story about Nick Leeson, the twenty-six-year-old trader who famously brought down British merchant bank Barings in 1995 after racking up $1.3 billion in trading losses before being detected.  That was not a planned action.  Everything started with a small error that Nick chose to cover up instead of admitting it.  The second was Clayton’s own story.  He joined the university basketball team when he was studying in England.  Once, he refused to take part in the champion game he had longed for, and that his coach insisted his attending, and his team-mates and friends begged him to.  The reason was that the game fell on a Sunday, and Clayton had made a personal commitment to God that he would never play ball on Sunday because it was their Sabbath.  It turned out that his team won despite his absence.  And he drew the conclusion that he had made the right choice and that sticking 100 percent to his principle saved him from crossing of the line repeatedly in the future.

At this point, I would like to tell my own story. When I was a houseman in a medical ward, my senior told me repeatedly that I should order a chest X-ray for an in-patient with COAD (chronic obstructive airway disease) if his condition deteriorated.  That was to make sure that there were no new complications such as pneumothorax.  Soon, I found that I had to order portable X-ray nearly everyday for half of the COAD patients.  By no means was I able to follow the instruction that my senior reiterated.  So I had to clinically distinguish who deteriorated more among those who deteriorated.  I came to the same conclusion that following guidelines and instructions 100 percent was much simpler.  However, there were various constrains in real life.  Furthermore, medicine is not exact science.  Doctors have to make decisions on which principle to apply, and more often, to justify deviation from the principle because of various real-life limitations such as resources, patient’s condition, patient’s preference.  Right from the start, we have chosen the hard way. 

It is still important to remember Clayton’s teaching.  I am not telling you to be a rigid, button-pressing, robotic doctor; though it might not be a bad choice for young doctors in the recent doctor-blaming, illogical, probability-ignorant environment.  What Clayton meant was that once you deviate from the principle, you lost your norm.  Your principle became “principle + 1”.  You got used to it, and next time, you deviated from your “principle + 1” and set the “principle + 2” as norm.  It would be tempting to do it again, and again. The result was that you moved away from the principle, which was set out with a sound reason, miles away.  My strategy to tackle this “deviation from strategy” dilemma is to be mindful.  Always remember and judge with respect to the original principle.  Each event is an individual event and does not affect the principle at large. 

Since we have chosen the hard way to uphold 98 % of the time, be aware of the difficulties and the implications.  Work out your own strategy to stay away from trouble, and jail. 

 (Source: HKMA News February 2018)  

 

恭賀新禧！

(Source: HKMA News January 2018) 

The Anti-antibiotic Abuse

While people are constantly talking about the abuse of antibiotics, I see a trend in the abuse of anti-antibiotic measures.  I would like to draw the attention of the abusers and those being abused to this unhealthy trend.  The following is an analysis of the similarities and undesirability of the two abuses.

The use 

Antibiotics are very useful in treating bacterial infections.  Since their invention, lethal bacterial infections and epidemics are much better controlled.  Once, antibiotics were regarded magic bullets.  However, even magic bullets have their limitations.  You need to properly aim your targets before the bullets can hit them.  And, if your targets are wearing magic-bullet-proof vests, antibiotics lose their halos.

To guard against blind-shooting and the development of antibiotic resistance, measures against the abuse of antibiotics are very important.  These measures are multi-faceted.  You can increase the knowledge of the public and the medical profession.  You can modify the practice of antibiotic uses through legislation such as classifying antibiotics controlled medicine, or through education such as launching campaigns.  Since the awareness of the need to control the abuse of antibiotics, most antibiotics are still very effective against common infections.     

The abuse 

Because of one reason or another, doctors began to abuse antibiotics.  Abuse is the use when there is no indication, or when the harmful effects outweigh the desirable effects.

It is true that over 80% of upper respiratory tract infections do not need antibiotics.  However, it is also true that over 80% of doctors do not need to be reminded of this fact.  As in the use of antibiotics, we need to consider the indications, the spectrum, the doses, the durations and the side-effects when instilling measures against antibiotic abuses.  Targeting all doctors with over-potent and too-board-spectrum measures is obviously an abuse.  Asking patients to take pictures of all medications for all consultations so as to guard against antibiotic abuse is obviously worse than prescribing antibiotics to all patients, no matter they come for upper respiratory tract infections, or for consultation of mood disorders.  

The lethal side-effect 

One of the major reasons for the need of justified use of antibiotics is to prevent undesirable effects, among which is the disturbance of the normal flora of the body.  Abuse of anti-antibiotic measures will not kill the patient, nor the doctor; but they will kill the important trust between the patient and the doctor.  Undermining the trustworthiness of doctors in their prescriptions will naturally prompt patients to query the diagnoses and the management.  Without trust, how can the doctor convince the remaining 20% of the “URTI patients” who suffer from scarlet fever, Streptococcal pharyngitis and pneumonia to take antibiotics? 

Just like antibiotic resistance, there might also be group effect for mistrust.  Instead of rendering the individual advice on antibiotic use for upper respiratory tract infection useless, mistrust can affect other decisions on the use of antibiotics.  Alarmingly, mistrust, like antibiotic resistance, is also communicable among patients. 

Another serious side-effect for antibiotics is drug allergy.  We cannot accurately predict which individual will develop drug allergy towards which antibiotic.  However, a significant percentage of individuals will have drug allergy is a certainty.  10% of the population is sensitive towards penicillin.  Actually, people can have adverse reactions towards measures against antibiotic abuse.  In the anti-antibiotic campaign, it is interesting that seeming no one has addressed this hypersensitivity issue.  There are individuals who over-react to the anti-antibiotic messages and see antibiotics as evil.  Hypersensitive parents might put their children at risks of fatal bacterial infections. 

Evidence-based practice

Some, if not most, cases of antibiotic abuse are out of good will.  It is just that the doctor does not know that antibiotics do not help.  Clinical judgments on the causative agents of infection might not be accurate.  Even some bacterial infections, such as otitis media, might not need antibiotics.  These are the reasons that evidence-based practice is important.  Epidemiology tells us the prevalence of viral pharyngitis.  Clinical trials tell us that antibiotics might not be useful for cough. 

The appeals for judicial use of antibiotics are out of good wills.  However, chanting the mantra of antibiotic abuse is only self-serving the chanters.  Calling for outrageous actions will have no effect apart from side-effects.  Behavioral modification is the biggest challenge in community medicine and family medicine.  It needs expertise and it needs skillful means.  It is time to go back to evidence-based practice in the control of antibiotic abuse. 

The Abuse by others 

Doctors are not the only contributors for antibiotic abuse.  Despite being controlled medicine, antibiotics can easily be purchased by patients without prescription in Hong Kong.  In agriculture and fisheries, antibiotics are abused to a much greater scale.  Tons of antibiotics are routinely used in the hope of preventing diseases.  It is important to behave ourselves.  But it would be irresponsible if we ignore the big picture and never mention the other sources of antibiotic abuse.  In doing so would divert the public attention, scapegoat the doctors, and at the same time would not solve the problem. 

The relation between the medical profession and the public has also been undermined by various other sources.  Some attack doctors for not being able to treat the root causes of diseases.  Some claim that their treatments are better as they are without side effects.  Some claim that doctors are poisoning their patients with all kinds of drugs.  Some are manipulating patients’ spines to treat rhinitis and irritable bowel.  Some say that they are natural and thus superior. 

Facing all these frivolous, yet appealing, claims, it is important to avoid acts that would further undermine the trust on our profession.  The anti-antibiotic abuse needs to be stopped.

 

(Source: HKMA News December 2017)

You're working too hard.

(Source: HKMA News November 2017)

The Remains of the Day

“What do you think dignity’s all about?” 

“It’s rather a hard thing to explain in a few words, sir.  But I suspect it comes down to not to removing one’s clothing in public.” 

This was what Mr. Stevens, the butler of Darlington Hall, thought about dignity.  Interestingly, nowadays, people are a bit too eager to stripe openly.  It is not sure whether there are different interpretations of dignity, or different moral values. 

Mr. Stevens 

Mr. Stevens was the story teller.  Actually the story was plain recall of the remains of the days while our butler was preparing and then driving from Oxfordshire to Weymouth in his 6-day-trip.  He had been the butler of Lord Darlington since before the First World War, until 3 years after the death of Lord Darlington, which was shortly after the Second World War.  The huge Darlington Hall was sold to an American, Mr. Farraday.  The staff team was then instructed to be reduced from 18 to a mere 4.  In the name of a precious holiday offered by the new owner, Stevens drove to visit the Housekeeper, Miss Kenton, who had left some 20 years ago when she got married.  He received a letter from her hinting that she was not happy and was still fond of the old days while she was working in Darlington Hall.  He was in the hope that she could join his team again. 

Stevens was a reserved, subtle and strictly business person.  He valued his career and took pride in his professionalism.  He saw the core value of a great Butler to be his dignity.  “Dignity has to do crucially with a butler’s ability not to abandon the professional being he inhabits.  Lesser butlers will abandon their professional being for the private one at the least provocation….  The great butlers are great by virtue of their ability to inhabit their professional role and inhabit it to the utmost; they will not be shaken out by external events, however surprising, alarming or vexing.  They wear their professionalism as a decent gentleman will wear his suit; he will not let ruffians or circumstance tear it off him in the public gaze.” 

But Stevens was described as taken his role too far, to the extent that he was constantly wearing his masks and not just his suit.  He overlooked his father’s old age and continued to prescribed him much labor works as an under-butler.  W hen his father died of stroke in his tiny room in Darlington Hall, Stevens was busy attending an important function held by Lord Darlington concerning the post-First-World-War Germany.  When Miss Kenton tried to show her affection towards him, Steven just deflated it with criticism on her household work.  Finally, he met Kenton, who was then Mrs. Benn.  She confessed to him that she was actually in love with him and her agreeing to get married was just a gesture to annoy him.  However, after all these years, she had accepted her life as such and she had no intention to leave her husband and go back to work at the Darlington Hall again.  Stevens only showed the slightest regret, and decided to move on when he was watching the sun set. 

Mr. Kazuo Ishiguro 

Mr. Kazuo Ishiguro is the Nobel Prize-winning writer this year.  The Remains of the Days was written in 1989, the year I graduated.  It was awarded the Man Booker Prize for Fiction in the same year.  Ishiguro was not writing on the romance between Stevens and Kenton, as there was minimal.  Kenton’s role was to highlight the character of Stevens.  The writer wanted to reflect his worldview through the narration of Stevens, a rarity in the world.  He wanted to talk about dignity, about democracy, about universal suffrage, and about dictatorship in the background of the post World War II period. 

Here comes Lord Darlington, who questioned the democracy system of Britain.  “Democracy is something for a bygone era.  The world’s far too complicated a place now for universal suffrage and such like.  For endless members of parliament debating things to a standstill….  The present parliamentary system is compared to a committee of the mothers’ union attempting to organize a war campaign….  People are suffering.  Ordinary, decent working people are suffering terribly.  Germany and Italy have set their houses in order by acting.  And so have the wretched Bolsheviks in their own way, one supposes.  Even President Roosevelt, look at him, he’s not afraid to take a few bold steps on behalf of his people.  But look at us here, Stevens.  Year after year goes by, and nothing gets better.  All we do is argue and debate and procrastinate.  Any decent idea is amended to ineffectuality by the time it’s gone half-way through the various committees it’s obliged to pass through.  The few people qualified to know what’s what are talked to a standstill by ignorant people all around them.” 

Then, Ishiguro, through Stevens, said, “A butler’s duty is to provide good service.  It is not to meddle in the great affairs of the nation.  The fact is, such great affairs will always be beyond the understanding of those such as you and I, and those of us who wish to make our mark must realize that we best do so by concentrating on what is within our realm; that is to say, by devoting our attention to providing the best possible service to those great gentlemen in whose hands the destiny of civilization truly lies….  If a butler is to be of any worth to anything of anybody in life, there must surely come a time when he ceases his searching; a time when he must say to himself: ‘This employer embodies all that I find noble and admirable.  I will hereafter devote myself to serving him.’  This is loyalty intelligently bestowed.  What is there ‘undignified’ in this?  One is simply accepting an inescapable truth: that the likes of you and I will never be in a position to comprehend the great affairs of today’s world, and our best course will always be to put our trust in an employer we judge to be wise and honourable, and to devote our energies to the task of serving him to the best of our ability….  It is hardly my fault if his lordship’s life and work have turned out today to look, at best, a sad waste- and it is quite illogical that I should feel any regret or shame on my own account.” 

 

(Source: HKMA News October 2017)