2012年9月14日 星期五

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.