Lack of manpower in Cardiothoracic Surgery Divison in Prince of Wales Hospital

Doctors manpower supply is always a sensitive question to politician and general public.There is no point of satisfaction. More doctors mean more comprehensive service and shift the balance of power to patient's side. For all types of treatment approach, patient will have no choice or no say if there is an insurmountable statement of lack of man power.

In Cardiothoracic Surgery, this is creme de la creme of all surgical specialties. Competition for training post is difficult and learning of skill is tedious and demanding.The talent of the trainee will in some form or the other affect the maturity of the surgeon. The character of the surgeon in this field must be perfectionist in surgical skill, diplomat in dealing with relatives and colleagues and decision maker for difficult situation.  Training usually span for more than 6 - 8 years.

Also, the higher the professional ladder , the higher demand of time ane energy in this field.

Not long ago, this specialty has suffered a manpower loss with shift of senior surgeons to private market.

However, there is no lack of new comers and young budding surgeon to take up the challange.

There is no complaint of lack of surgeon then.

In fact, there is complaint of lack of cases and referral from their medical colleagues.

So, why is there a sudden outcry of lack of resources? Lack of doctors? Lack of trainees and expert surgeon?

This boils down to the surgeons desire of easy life and competition for resources.

For all 3 centres in Hong Kong, to speak the truth, I would say it is never the Prince of Wales Hospital that is lacking resources.

Indeed, the climbing of number of heart cases is evident to that.

The reason of demanding more manpower is just a gesture to demand for reward for the volume of cases.

In Cardiothroacic field, usually one doctor is shouldering responsibility that the mean number of works hours is among the highest in all field.
We cannot judge the number of expert surgeon needed in a large centre. Only that there is pros and cons of more expert surgeon. First the experience is diluted. Second the competition and challange of the team to meet different surgeons demand is high. The surgeons may be in standby time more than actual service. The number of operations delegated to experienced trainees are much less.

Overall, more supporting doctors are needed instead of mature surgeon in a busy unit.
Maybe it is Prince of Wales Hospital CT Surgery Division wish to recruit more basic or higher surgical trainee instead of saying there is failure of retention of experienced staff.

Who would like to see their surgery postponed or waiting list lengthened from patients perspective.
But it is still an unknown black hole of crying for more resources.

(Back in the old days, when I was the only cardiothroacic first call surgeon, I and one experienced cardiothoracic surgeon manage the whole services with annual number of open heart surgery 60 - 80 per year and 300 throacic operations and average 2 - 3 major trauma consultations in the same setting of the teaching hosptial. I have not expressed of lacking manpower in year before the turn of millenium)

Need of Histological confirmation of Advanced staged Cancer

Cancer is a lethal disease. However, cancer seldom lead to immediate death.
For patient in acute care setting, infectious disease, trauma and vascular events account for nearly all emergency collapse or demise of previously healthy patient.

Nowadays, we talk about personalised treatment of cancer, we need to know the type and DNA of the cancer cells to formulate a treatment plan for the patient.
In patient when cancer presented with advanced stage of disease, should the medcial personnel insist of obtaining histological or pathological confirmation before proceeding for treatment.

There is usually a dilemma. To obtain biospy of tumour. If deep seating tumour, the risk is considerable. And if the tumour has spread to important oragnas such as brain or heart, to touch this area means major suffering.
So the chance of cure, if absent, should not warrant aggressive biopsy.
However some lesser invasive means if done under good techniques will help obtaining tissue for lung cancer.

They are:

Video assisted pleural biopsy of effusion drainage- targeted pleural biospy and effusion drainage

Bronchosocpic biopsy or transbronchial biopsy under sedation and locan anaesthetics

Endobronchial ultrasound transbronchial fine needle aspiration of paratracheal and carinal lymph nodes

Percutaneous fine needle imaging guided biospy of lung

By obtaining biopsy sample , the nature of cancer can be defined. The genetic and DNA studies of cancer cells can be pursued.

Personalised treatment and palliation of cancer can be achieved.

Yet, those method are however expensive.

Judicious choice of investigation will determine the success rate. Do need to seek specialist advise. For lung cancer, a cardiothoracic surgical specialist is essential.

To excise nodules directly or take in biopsy first - an issue of taking chance

In private sectors, not all patients come for treatment. They are just coming for second opinion. This is a hypothetical scenario to seek help from two soucess. If different, they would not jump on the treatment plan. If more or less the same or the reason given is the same, they can then opt for the original treatment plan. Rarely, they may accept the suggestion of treatment plan of the second doctor. And switch to the new care giver.

For me, as an experienced surgeon, the line of thinking of pursuing one investigation or other is more or less natural to me. Some nodules in the lung, I wound quickly advise surgery. Whether it is open or minimally invasive is not a major issue. The chance of missing lethal lung cancer is the main concern.
For some nodules with background of lot of disease, with chance of multiple metastases or just more likely a reactive change, I wound suggest observation or biopsy. Not always matter with the size. But to balance the chance of morbidity free surgery versus over - positive thinking.

Indeed, as advocated in my earlier blog, size if more than 9 mm should be annually re CT and excised once the possibility of benign lesion cannot be fully established.
Size less than 6 mm can be safely watched. Above 6 mm, can be watched for 3 or 4 years and left alone.
But there is always some exception. Sometime for over cautious patient, needle biopsy is essential though clinically likely Ca Lung is well suggested.

And the way to deal with negative biopsy has to be evaluated. If patient or doctors are totally insecure of leaving the nodule alone. Needle biopsy can be omitted.
For patients where non operative option is highly favorable, like bleeding tendency, very elderly, bread winner of family, needle biopsy at least clear some uncertainty in this occasion.

If patient  otherwise fit and healthy, Video assisted wedge biopsy is always justifiable if the lesion is regarded as suspicious.
For highly likely non malignant case, say with normal CEA, non smoker and calcified mass or very low PET SUV, needle biopsy is safe to document the non malignant nature in a way better than sitting on X ray comment alone.