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) 

It Is Time to Revisit Sentencing by the Medical Council for DD Offences

Doctors need to handle dangerous drugs (DD) with care.  The storage and the use of dangerous drugs are regulated by the Dangerous Drugs Regulations (DDR).  Section 5 of the DDR specifies that a doctor has to keep a register for his dangerous drugs.  There are clear requirements spelt out in the section.  More than that, there is a Form of Register provided in Schedule 1 of the DDR, which is the format to follow.  Section 5 of the DDR states that any person who contravenes any of the provisions shall be guilty of an offence and shall be liable on conviction to a fine of $450,000 and to imprisonment for 3 years.  

Since it is an offence punishable with imprisonment, the doctor convicted by the district court of DD offences needs to report to the Medical Council.  According to Section 21(1)(a) of the Medical Registration Ordinance (MRO), the Preliminary Investigation Committee shall investigate the case and refer it to an inquiry panel if indicated.  After hearing the case, if the inquiry panel finds the doctor guilty, it can sentence according to the options spelt out in the same section of the MRO. 

In recent years, I have an impression that DD cases were sentenced differently from other cases by inquiry panels.  Even for much less serious offences, such as small discrepancies in DD stocks, the doctors were removed from the General Register (GR) for a month or more, some with suspended sentences.  Practice monitors were assigned to check on the doctors during the periods of suspended sentences.  As a result, many convicted doctors stated that they would stay away from using DDs altogether.  Some doctors used the avoidance of using DDs as a mitigation factor during inquiries.  Obviously, this is not healthy or desirable.   

It was mentioned repeatedly in judgments that “all cases of failing to comply with the statutory requirements to keep proper dangerous drugs registers have been dealt with by removal from the General Register, and in less serious cases the removal orders were suspended for a period with the condition of peer audit and supervision.” 

I went through judgments from inquiries and from the Court of Appeal, trying to figure out when and why this “board approach” came about.  In 1995, the Medical Council found Dr. Lai Chung Lim guilty of DD offences and ordered to remove him from the GR for 3 months.  In the judgment, it stated that: “The medical council is determined to send the clearest possible message to Dr. Lai and to other doctors who are breaking these rules: you can normally expect to receive a period of suspension from practice if you are found to be in breach of the dangerous drugs regulations.”  Dr. Lai appealed. The Court of Appeal upheld the decision of the Medical Council ([1996] HKCA 495). 

However, it did not mean that the Court of Appeal had agreed to or prescribed a starting point of removal from the GR for DD cases.  The Court of Appeal usually would not intervene with the decisions of the Medical Council as long as it “has not been guilty of some procedural impropriety or has not misunderstood any underlying legal principles.”  However, the judge did comment on this case that “it is a matter of regret that the Medical Council discounted the decision of another division of this court in the case of Ng Mei Sin v Medical Council.” 

In Ng Mei Sin [1995] HKCA 518 and before, such as in the case of Mao Chun Ting [1995] HKCA 530, the judge opined that the gravity of the offence needed to be considered.  He drew an inference that the appellant doctor acted out of ignorance.  He saw that “the courts have a tendency to treat offences of moral turpitude much more seriously than those of technical breaches of regulations.”  And, “it seems to me that the broad-brush approach of the medical council- treating in effect all offenders alike- is wrong in principle.”  In a more recent case of Lau Koon Leung [2006] HKCA 95, the judge suggested relevant factors to be considered in sentencing.  They included: the reason for not keeping proper record; the quantity of drugs; the nature of drugs and any evidence that the doctor was selling addictive drugs for profit.  He also pointed out that the list was not exhaustive and other factors might well be relevant in the circumstances of an individual case. 

Thus, Lai Chung Lim only serves as a precedent case on the inquiry level.  While it has to be considered, the distinguishing features of this case need to be noted:

1.  Large quantities of dangerous drugs were involved.
2. The council found the defendant doctor dishonourable.
3. The decision departed from its precedent cases.
4. The reason given by the council was that: “the problem of drugs getting into the wrong hands is becoming an increasingly serious problem in HK as time passes”, with emphasis put on the word increasingly.  The decision was made in 1995, which was 23 years ago.  The drug scene has much changed in recent years. 

Talking about precedents, actually there were at least 2 DD cases where the defendant doctors were sentenced much more leniently by inquiry panels after Lai Chun Lim.  In February 2002, the Inquiry Panel “accepted that the omission/commission of matters arose out of carelessness rather than a deliberate intention to contravene the Dangerous Drugs Ordinance” and served a warning letter to the defendant doctor without publishing the decision in the Gazette.  In February 2006, the Inquiry Panel “accept(s) that the discrepancy in quantity between the stock and the records of dangerous drugs is towards the lowest end of the scale in cases of similar nature.”  And “that this is a case of negligence rather than a case of inappropriate dealing with dangerous drugs.”  A warning letter was served.  Both cases were decided by senior members of the Medical Council in the relevant years. 

It is high time for the Medical Council to revisit its sentencing on DD cases.  The drug abuse scene has much changed in recent years as compared to 20 years ago.  It is undesirable for a doctor with technical breach of the DDR to be removed from the GR.  It is unhealthy to dissuade doctors from using DDs just because of the disproportionally heavy sentencing on DD offences. 

(Source: HKMA News Sep 2018) 

Do No Harm......

I was amused when I read in newspaper that not unlike previous years, top-scorers in the HKDSE chose to study medicine, and their reason was to be a good doctor and to help others.  Sooner or later, they will realize that it is not easy to become a good doctor.  More than that, there is no equal sign between a good doctor and helping others.

It is much easier to score high in an examination, or to be proficient in a certain skill.  There are always tricks to learn and ways to practice.  People seldom frown on a chef who is a fooling-around-foul-mouth-jerk.  They just remember his signature dish.  Magazines will interview him for his pigeon pithivier with French mushroom duxelles and foie gras.  He will never be threatened to have his name removed from the chef register by the “chef council” if it really exists.

You need more to be a good doctor.  Among other parameters, there are ethical considerations.  Our Red Book, the Code of Professional Conduct published by the Medical Council, provides some guidance on medical ethics.  In section C it reproduces the International Code of Medical Ethics adopted by the World Medical Association.  It spells out “Duties of Physicians in General”, under which there are 12 items; “Duties of Physicians to Patients”, under which there are 7 items; and “Duties of Physicians to Colleagues”, under which there are 3 items.  Section D refers us to the Declaration of Geneva, in which the doctor makes 10 pledges.

For easy memory, especially during viva examination, there is an ABCDE mnemonic for medical ethics: Autonomy; Beneficence; Confidentiality; Do no harm; Justice.  The most mentioned principle by laymen and doctors alike is the fourth one: Do no harm.  Many believe that it came from the Hippocratic Oath.  However, the exact Latin phase of “Primum non nocere” was likely to originate from another series written by Hippocrates called Epidemics.  (Epidemics means visits.  There were 7 books describing physicians’ visits to patients in different areas.)

Actually, “Primum non nocere” means: “First, do no harm”.  Some regard it the first principle in medical ethics.  Others see it as a practice guideline.  When facing an ethical dilemma, or when making a medical decision, check whether you might harm the patient by your intervention first.

If you construe the word “harm” in the narrowest sense, “Primum non nocere” becomes meaningless.  Every surgical procedure is harming the patient physically.  Even telling the patient what he is suffering from might harm his feeling.  Therefore, “harm” must be relative.  That is, taking everything together, there is more benefit than harm.  The question is: Who is to decide whether it is doing more harm than good?   

Evidence-based medicine is the cornerstone of modern medicine.  It can provide an objective measurement for medical interventions.  However, life is not that simple.  Liposuction is unlikely to improve life expectancy, but it is practiced every day.  There is a strong component of value judgment in which objective measurement alone does not help.  In the good old days, it was the doctor who made the call.  The doctor was relied on to choose for the patient with his knowledge and good intent.  As time moved on, and maybe as people realized that there existed bad doctors, patients wanted to have their says.  The ultimate decision was from the patient.  To help the patient to make the decision, the doctor’s responsibility became to inform the patient of every aspect of the medical interventions: different options, pros, cons and complications.  Nowadays, it is not enough just to inform the patient of each and every detail.  The doctor has to practically educate the patient from scratch, taking into consideration the patient’s background, mentality, religion, value, his obsession towards alternative medicine, and his position in the family and society.  Whether the doctor has discharged his responsibility would be judged not only by his own consciousness or the patient involved.  He is answerable to the Medical Council, the courts of law, the media, and the society at large.

If the above is not complicated enough, I remind you that we have been talking about one patient.  In a disaster scene, the doctor needs to decide on attending which patient first.  Working under our more-than-a-little-bit-far-from-satisfactory Hospital Authority, the doctor needs to see 50 patients in a morning outpatient session.  In real life where resources are limited, there is always the problem of rationing.    

Maybe that was the reason why the wise Hippocrates of Kos did not include “Primum non nocere” in his Oath.  Rather, he opted for the middle way: "I will apply, for the benefit of the sick, all measures that are required, avoiding those twin traps of overtreatment and therapeutic nihilism."

 
(Source: HKMA News Aug 2018)