Value of Life or Health - Perspective from health care helper

As doctors, most of the medical ailments are commonly known to us. We understand that most of the complaint about pain and ache or discomfort did not signify important illness. This is to be said with a caution such as coughing out blood, severe weight loss, depression with suicidal thought or severe spontaneous syncope.
Conversely, some severe life threatening disease may not have symptoms.

I have talked about screening in previous blog and stress that the benefit of screening for example in lung cancer is not to be down played. However, there is a need for mentality and financial resource for proper screening. Acutally the drive is more important than money in such cases.

But when it come to important illness such as severe pneumonia, renal failure, severe trauma or stroke, medical personnels are the least to cope with this. Their knowledge would bring some advantage but add worry to the treatment course.

To me, the loss of life turn out to be some daily events. More eye cathing are victims in natural disaster, violence such as rape or terrorism or medical mishap or early cancer in young adults. Acutually, life is quite vulnerable. The possibility of serious blow to it is always there.

To treasure it is really necessary for us to rethink eveything. Our existence certaily would be transient in the history of time. If at one time and at one place, we can make our surrounding or family happy. Out existence will add meaning to us all.

For me, I would try my best to give the best possible treatment to them. I cannot change my patient's fate. At most, I hope to give them the best attiotude to face life and death. Treasure existing life but forget tommorrow trouble.

Dr Chung Shiu Shek tel of clinic: 31608865

Sino Japanese Relationship

As a medical professional, we like to talk about politics but seldom take it serious. With wide coverage and nearly daily report of riots in China, the tension between China (PRC) and Japan is on every news' front page.  We all know from the day of birth that Chinese and Japan are competing countries and seldom in good terms. But the value of peaceful coexistence is more than everything to avoid mutual terror at World War II.  As Chinese, the sense of being treated unfairly is especially sharp. From Japanese society, their education may be deviated towards self righeousness; but most japanese are well educated and also believe in peace rather than militarism.

Why do the approach of the subject create so many news and tension?  The answer should be timing. As Diaoyu island is an old problem, whehter you want or not, practically it is under the control of Japanese force.  As these problem has been years, and nearly no interest about it by Japanese governement. Why japanese want action or something to be done recently. Usually the target against another nation help stabilise force and create unity in home country in favour of the existing power. They are used by both government to consolidate  power. In China, the future of post HU Jianto governement has been clear but not fully established. To push aside discrepancy of opinion, the need of unity for different ages or different force within the central government is important. More than anything, the hate against japanese invasion can be used once again for Vice Premiere Xi to assume good central control of power.

To Japanese government, the power of democratic party has never been stable since take over of premiereship from opposing self democratic party. They are faced again by tragedy of nuclear incident. They need more fame and esteem to stay solid in control of Japan. To unify the parliament, the pride of owning Diaoyu island is brought in again. In fact Japan own this island for ages. is there any need for power or petroleum over there? I thnik no, the economic advantage is not great, The susceptibility of being invaded or destroyed by other force make investment risky. From recent report on Japaneses newsmedia, there is comment or criticism of current act of Japanese government. So not all japanese want War as depicted by chinese media.

Why the newspaper always focus on this? To sell more paper and be only source for news. In War times, newspaper sell. Remember 9/11, suddenly everyone want to grap newspaper as research by reporter attract more attention and bring satiety to news hunger in public.

So we would heard about riots , tension, demonstration against Japan in Chinese news. But not after the 18th NPC commitee. By then, every protest will be suppressed. Peaceful talk with Japan will begin. Concession for mutual benefit will be granted. Any civilian upset about government weakness will be gone. No news about Diayo island will be publicised. Like the control of internet, there would be information control as tight that even thought there is protest, it will not be reported or mentioned in any media.

As for the Japanese, the status of the island will remained the same. You can call it nationalisation. You can call is isolation. Thus, there is no real owners and no transaction of money ever to be made in the Bank for the ownership of the island. Japanese media has no interest and never want to be made use of by their polictian. The Diaoyu island cannot be anything of financially as one thousandth of Tokyo or even the nuclear accident town. They are just hyperbole of the news media.

Thank to the gift of life: on the recieving end

As medical professional, the preciousness of life make some of our patients extremely grateful to us. But is it our preference to have such feeling and reaction. Or is it the absence of such action make us uncomfortable or dissatisfied. From the patient point of view, will our action of grafeful feedback secure better follow up service?

I recently read about the ICU dying patient news about recieving a generous cavdever organ donation. The news state that as an emotional reaction, the heart surgeon shed his or her tears saying that the patient should treasure this timely gift of life.  I usually feel uneasy about that emotional side of providing medical treatment. But the meaning of doctors act should however touches heart of most patient and people.

For doctor either recieving pay from public money or from paying patient 's pocket, they are suitably remunmerated with proportionally correct sum. The doctor has the de facto responsibility to carry out a good and technically right work.  Compliment to doctor success is thus an extra.  Having said that, doctors usually appreciate very much the thankfullness of their patient. Sometime these are driving force for doctors altruism.

Once I have the experience of being touched by my patient's word. He is a gentlemen and always thanks me for whatever procedure or treatment I provide him.  Once I talked casually to him. Do not be too courteous , you know you have paid me for my professional service. I owe you the trust. He responded calmly. Dr Chung, I know I have paid all the professional fee related to my treatment and I knowed I am entitled to high standard care. But regarding your service and careful adminstration of care, I still owe you a words of thank because of trueworthiness of your work. Our care and attention if acted from our heart are much valued by our patient.

Occasionally as private specialist, the care of long term disease bring much concern to financial burden.  So some of my patients will not return for follow up. This is reasonable as chronic disease can bear the burden of waiting list and these conditions can best be dealt with in public sectors. Anyway, I would not anticipate that all patient will be my faithful followers for life.  Sometimes, I heard complimentary words about my service but later default in follow up. I find it perplexing to understand. But In the real world, this is not uncommon.

In essence, I do feel good on the recieving end of thank and gratefullness. But do not take it too serious as your driving force. Some patients and most indeed has the concern of financial constraint.  They are entitled to develop way to secure best mode of care to them. So they would swarm between private and public care depending what fit them most.  However, I do feel satisfied after tough surgery or long operation, the patient or patient's relative say from their heart: You have done a great job. You have done a favour to them.

Surgeon with a heart: I am Dr Chung Shiu Shek specialist in Cardiothoracic Surgery, Clinic phone no: 3160 8865

Cancer: cure or control

Lung cancer is common and a fatal disease if not treated early and appropriately.  Quite a number of patient with lung cancer has physically normal lifestyle until the time of detection. The psychological trauma is no doubt great. With the improvement of drug and radiation treatment, more option is available on top of curative surgery. Are over treatment always produce good result and ensure good long term outcome?
This question has occurred more than couples of time for real cases.
Usually they are relatively young patient and locally advanced disease.

I personally would stick to traditional guide line but allow oncologist to have tailored made decision with different patients. Most oncologist has keeness for chemotherapy and less favor towards post operative RT. (of course they are exception)

So the cancer boil down to control or cure debate? Must all treatment be comprehensive to be exhaustive that near absolute cure is the best?  In fact life is in a cycle. No living organism is blessed with everlasting existence. Most persons are destined to have limited lifespan about 70 or 90 years.  If the treatment can restore our body to near normal life expectency, then probably this is already the best.  Say if the cancer recur at age of 90 or even 87, we would rather not treat but palliate the cancer. Cancer drug itself may be carcinogenic in long run. Too much treatment , if not necessary, may even do harm then good.

For a different group of cancer patients, they are elderly with moderately advanced disease. So the primary aim is opting for cure within the tolerance ability of the patient. Secondly, control of symptom will be more important than too aggressive treatment.  Minimally invasive surgery are therefore of most benefit to this group of patient.  I have done a few such cases with small wound for old patient. They all come around the surgery satisfactorily. In such group of patient, too aggressive chemotherapy may be of considerable side effect.

For terminal cases where palliation of symptom is most important. Control with oral anticancer or target drug is the best. Luckily, these drug are well tolerated even in elderly. However, the cost may be substantial. Recently I heard about interesting presentation stating thalidomide, metformin and some other old style drugs has anti cancer effect that their use can bring palliative symptom relief at low cost.

I am Dr SS Chung specialist in Cardiothoracic Surgery and expert in lung cancer treatment. My clinic no is 3160 8865

Need for more doctors in public sector

As a private medcial specialist, the public service is not my major concern. In fact one may eye public sector as direct competitor for patients.
However, as part of the medical community, the state of running of public sector has a lot to be in consideration.

Over 60% doctors registered in Hong Kong are in private practice. Less than 40% work in the public sector.  Over 90% of patient are attending public hospital or clinic services.  The demand is already under control by crowding or long waiting list or concern for delay aspect.  Also the public sector has to shelter the purpose of training, internship supervision and front line reseach and other continued medical training problem. Last but not least, there is a lot of public services such as the arena of East Asian games, preparation of disaster, SARS drill training and mangerial work.

So we need more working hands in public sector, as versus we want more doctors in community. As in many large corporation, retention of human resources or experienced worker is key to success of an institution. So we should look into individual institution and develop ways to retain experienced person. Every year, there is new graduate who would largely join the public services. Out of all these trainess,only one third of them are fully trained and worked satisfactorily in their position. Although, for healthy institution, some movement of manpower is inevitable. However, for particular field such as medical field in Tuen Mun Hospital, A/E department in various hospitals or anaesthesia field. Shortage is constant.

So why did doctors move to private practice despite advantages of stable salary in public sector.
In fact, it is a competition to be retained inside the research based institution in oversea medical field.

Constraint of medical practice and overwork is keypoint for dissatisfaction.
Human resources control is another factor.

The burden of public doctors in senior role is always higher than their private counterpart.

Hierachy in pulbic service is also the reason for stress,

For example, every newly qualified specialist has to shoulder the clinical burden fo patient complaint or untoward event or even to unjustified complaint. However, the doctor has the right to choose his patient, call pattern or working subspecialty.

The clinical hierachy has been two tiered, resident and specialist.

However, the managerial hiearchy is long. HCE - COS - Team Head - Senor specialist - specialist - resident. So there is high likelihood that the senior guys choose the gem of the department and leave the tough and donkey work to the lower tier. Even worse, the reporting mechanism in HA is causing constraint of whistle blower, the poor performance of the senior is never reported and will be penalised. The senior control the promotion and yearly assessment of lower class workers.

Further more, the competence of junior doctors is largely reliance on altruistic sacrifice of the senior person. If the senior person would not teach his helpers for skill and training, the junior will foreever will be untrained unskilled doctor that see no satifaction of job. With such situation there is no way to ensure the senior doctor to do their job. They claim to provide consultant level to all patients by depriving the less experienced training opportunity.

For health care administrator, the over dominence of COS or department team head make job satisfaction ot lower class doctor impossible to be achieved.

Therefore the proposal of two tier system and the non-involved third party for specialist consultation or assessment must be implemented to eliminate such problem.
So as clinical duty is two tier, the managerial or reporting duty should also be two tier. An non involved committee is created to assess the capability and performance the two tiers. For junior specialist,they should care for less number of patient and be remnumerated less. As their performance justify more patient, more patient load is directed to him and more salary is given to the two tier team.

This is a preliminary thinking of how we should improve our public care system. Will discuss more in future.
Thank for reading. I am Dr SS Chung
Chung Shiu Shek Specialist in Cardiothroacic Surgery

Reward to doctor

I am discussing the satisfying experience as a specialist doctor. In fact, although there is everyday news of mis management and medico legal incidence. The number of successful medcial treatment far outweigh the complaint case.
Also for chronic disease, the compliance of the patient is partly the success of communication skill delivered by his care givers.

Peolple usually measure the amount of gratefulness by the amount of fee they are paying their doctors.  However, the art of charging medical treament professional fee is the skill of making compromise.  No same doctors charge same amount. No same cases are charged same amount. I think the customer would anticipate variation of service fee. Of course, in free market, there is no rule to set the price limit. The affordability is a guide. The supply and demand of the doctor's time is a factor. But as doctors are deriving their satifsfaction from successfully treating one disease, the amount they charge should be reasonable to induce patient to turn to private sector for more efficient and personalised care.

Recently I have performed two operations for two patients with severe retrosternal mass causing aerodigestive compression. The courses of the medical treatment is challenging and difficult. One patient required temporary tracheostomy for prevention of repeated aspiration because of temporary paralysis of the vocal cord. She made satisfactory but testing recovery from her operation. Although she has some loss of confidence in her own physical ability and treatment progress, she is overall compliant of necessary step for rehabilitation. Deep in her mind, she has felt relief of potential hazard of airway compromise and dysphagia she had for long years. I was impressed by her stamina and honest trust and doubt on the course of treatment. She paid for the medical cost out of her savings without complaint.

For the second patient, he has airway compromise and rapidly desaturation after induction of anaesthesia. Though previously without any symptom of breathing difficulty, the weight of the mass and relaxation of muslce tone cause compression of airway deep down on the bifurcation of windpipe. Forutnately the anaesthetist has placed the long enough breathing tube (an endobronchial ventilation plastic tube) to the right main bronchus, maintaining good oxygen supply to the body despite lack of air to the L side.  With time constraint and possible disastrous outcome of irreversible hypoxia, I  with two experieneced surgeons' help expeditiously removed the compressing mass with tedious but careful steps. Airway patency was achieved after the mass was delivered out of the wound. She made rapid and uneventful recovery. She was grateful to the surgeons and their team.  Even without being told exactly the challenging moment of the perioperative difficulty, she understood the complexity and the risk of the operation involved. She revealed her fear when other physicians describe how difficult and risky will be an attempt on the operation.

As an experienced specialist thoracic surgeon, I did not underestimate the risk of the operation. With good preoperative planning and prepartion (including to solicit good assitant surgeons help and anaesthesia and last but no least nursing team), the risk was minimised as much as possible. Preop counselling and education to prevent sputum retention, wound complication and post operative deep vein thrombosis were done. Post operative ICU care and prepartion to standby for any unexpected deleterious outcome was pre arranged.  With confidence and knowledgable communication, the patient was inspired to think positively and to overcome the fear.
Good cooperation helps the perfect outcome.

I did not ask for high financial reward for difficult operation. The trust and willingness to put their life to me is the highest honour the patient would give. Like the second case, I would anticipate the market price for such operation would be double the fee I collected. Given the dangerous and stressful situation, the operation is very demanding. A reward proportional to risk and preoperative planning skill is not unreasonable. But the happiness in seeing a fruiful outcome is immensely rewarding.

Lastly I mention two situations when I was in public hospital to make contrast with private health care.

First, for the very first heart transplant patient in Hong Kong dating back to 1992, I witnessed the harvesting surgery as I was assisting the harvest of the liver on the same donor in public hospital late in the night. After 21 year, the patient appears in the media for celebration of the Hong Kong University heart transplant team anniversary, most surgeon appears cheerful and delighted. I am also impressed the satisfaction derived from minor role I take part for this patient.

Shortly before I left my previous public surgical unit, I encountered two patients with late presentation of thymic tumour invading through pericardium into heart. In one patient I peformed debulking with thymectomy and pericardectomy and shaving of most tumour from R ventricular surface. Before operation I mentioned to the patient that the operation result was not guaranteed as remaining tumour would persist and rendered the operation unsuccessful. The patient told me that she put her life and hope on my hands without hesistation. Not suprisingly I found out that in more than two occasions, she was refused surgical treatment in private market. Eventually she was referred by private surgeon to oncology unit of public hospital that eventually channeled to surgical department once again for second opinion. I did not know the final outcome of this patient after she recovered and left hospital. But I achieved at least in prolonging her hope for life. I felt satisfied and rewarded.

The second patient with similar findings of extensive mediastinal tumour invading the root of left lung. Major surgery with resection and simultaneously L pneumonectomy through midline incision and exposure is needed.  As the patient is elderly (>70) female, and there is a chance of incomplete resection. No operation was proposed until I met her in out patient follow up for lung function studies as preparation for pneumonectomy. I proposed early surgery without delay as the chance of unresctability grew with time. I explained briefly the risk and possible operative death. The patient instead of the accompanying relatives strongly accepted the surgical plan. She had "blind trust" on me and had possibly encountered too much controversial or in-decisive doctors. Operation went well though difficult and I had only sacrifice the upper lobe vein with intrapericardial left upper lobectomy en bloc with the tumour. The patient recovered uneventfully and was sent for further radiotherapy despite clear resection margin. My satisfaction was more than anything financially or compliment from family.

Patient recovery is greatest reward to doctors.