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.

To get the most from public hospital

In previous blog, I have mentioned difference in public versus private medical care. As consumer who pays for medical service either by direct charge or indirect charge through taxation but time consming waiting list, one would seek the best means to obtain good and personalised service in public system

1. Stress on making appointment to new case clinic

Usually the new case clinic is seen by senior doctors or specialist directly. This help to prevent missing important ill patient who may not have correct diagnosis on referral. This is much better than going back to the old clinic with regular FU and reporting a new symptom or new disease. Stree on getting referral addressed to the new case time slot of the specialist clinic.

2. Ask politely for being interviewed by senior team member of the in charge physicians team.

So always allow for being interview at day time. At rush hours or non office hour, usually the front line doctors or even the on call doctors are available. There is absolutely minimal effect in asking question or challange the care mode when you are interviewed by person without authority.

3  Make a gesture of asking for well documented information but do not make threat to complain

Human nature make public servants sensitive to clients requiring thorrough documentation of every details. But never pose a threat to complain, This iwill destroy the original relationship with caregiver.

4. Make careful research on mode of treatment of your own disease. Make suggestion or pose rational queries on the selected mode of treatment.

5. Before committing to have operation in this or that hospital. Do research on number of similar cases handled in those cedntres.also some hospital has shorter operatoperation waiting list than other. Borrow other address if necessary

6. Trust your care givers and maintain harmonious relatioship by mutual respect.

For private care, word of mouth and transparency of charge is important and reflect the professionalism of individual specialist.

If the specialist refues to discuss the cost or fees before committment of care or hospitalisation, beware of that. If the care of the specialist are to be split among other profession, the client retain the right to know how the fee is splitted or on which ground.

I am Dr Chung Shiu Shek specialised in cardiac and thoracic surgery. Feel free to discuss your own or your family medcial need with me. I strive to give my best possible advice to any questioners. Phone: 3160 8865  E mail: chungss@ymail.com

Thank you

Medical checkup : A devil or an angel

Recently I came across previously healthy persons having major pahtology after medcial examination for relatively non urgent symptoms.  It dose reveal how life is so fragile and the relative inaccuracy of sense of being good as indicator of own health.

One relatively young middle aged women complaint of feeling mass in the abdomen. Being regarded as inexperienced person, self reporting of a mass in the abdomen is usually wrong. The possiblity may be nothing, fecal loaded colon or ballotable kidney or transmitted abdominal aorta pulsation.

Further enquiry about the symptom is none. There is no change of bowel habit and appetite and body weight is normal.  She has early menopause and otherwise healthy. Routine USG examination review nodule and echogenic shadow in the liver. Subsequent high power imaging showed multiple enlarged cystic and cavernous haemangioma in liver. Haemangioma is one of the most commonest benign tumour in liver. It is even more benigh than polycystic disease.  The pathology of haemangioma is not certain but autopsies study did reveal lot of people dying with asymptomatic large cavernous haemangioma. She was told to lead normal life until condition change. Of course, rupture of haemangioma will be fatal and under reported because they seldom arrive alive at Emergency department.

Another patient has chronic appetite loss. X ray show upper mediastinal mass. CT showed huge mediastinal cyst displaying the esophagus and abutting trachea.
Early surgery is advised even if the chance of malignancy is low. Patient is feeling unexpected diagnosis being serious blow to life.

Following previous blogs on asymptomatic lung cancer, early lung cancer is usually not detected and can be found normally by low dose CT screening.

Whether we should screen ourselve for common disease or not?  Some may prefer not to know seious potential disease. However, cure of disease is usually only possible for early diagnosed cancer. So screening is useful for individual person althought nor always cost effective for whole society. (Because extra resource is needed to diagnose or rule out asymptomatic and normal but looking suspicious area.

If one afford to do screening with time and money, I think occasional CXR say every 3 - 4 years, stool x occult blood and exercise test (simlified with only resting or stress ECG and saturation monitor may be all required for middle aged person. For female cervical smear, breast examination is useful.
For elderly male, PSA for prostate and USG for hepatitis carrier will be necessary.

For whole society, immunisation of Hepatitis B vaccine, and health education and policy to eliminate promotion of smoking, alcohol and bad fast food is useful.
A postive attitude to life and treasure of life is always good.

So precious moment seems to be gone if one did not make preparation of possible bad things.

I have help cure some individual who only got news of advanced cancer in screening procedure. Hope they grow strong after difficult therapy pathway.

My name is Dr SS Chung, andrew, My clinic no is 3160 8865, I welcome question and query on helath issue and I practice general medicine, heart disease, chest disease and chest surgery and minimally invasive heart and lung and aortic surgery.

To be or not to be: ON call 36 小時

I have briefed the internet surfer that to be a doctor, one needs to sacrifice own lifestyle and time. Further doctors are not much respected nowadays as they need to dealt with personal conflict with patients at front line. Stress in life decrease quality of life of care taker. But is it worthwhile?
To many young people who graduate recently from secondary school. They may have to decide early in their life whether to take up the profession or not.

As one of the specialist in this field, I have every capacity that I need to make statement of this. It is worth while and still much challanging. To make sacrifice requires strength and determination. It is worth the effort to endure until you finish the training. Training takes 6 to 8 years on top of medical school teaching and life long commitment for further education is also required,
But it is worth while to devote oneself to meaningful life. Further, the recreational aspect for doctors education is fun.

So young people, do go for the touch job as medical student and future challange is worthwhile.

On call 36 hours 小時

Doctors need to be on call for whole day and night and finish work only after the usual 8 or 12 hour daily schedule before going to bed. But this happen to be only apllicable for trainee. For specialist doctor or chief of service in each major specilaty involving emergency care and surgical operation. They are on call for life or on call 24 hours a day and 7 days a week.

Who pay them for the on call? None but the devotion to work and satisfaction in treating patients. Hospital authority would not compensate for that. Neither would the chief of service ask for the compensation like the hours counted in recent doctor- HA settlement on contract hours court case in Hong Kong High court.

The court or judge does sympathise on call doctors but the judge cynically approve for minimal or bare inevitable counting of hourly paid for Sunday "voluntary" or traditionally implied obligatory duty in Sunday or rest day ward round and coverage.

So private specialists doctor are on call everyday for their patient. Neither would they charge a standby fee. But they can choose to accept patient or not. So their call is not compulsory.

To be a doctor , think twice about that. You may need to study 18 hours a day to get finished the medical school. Work with on call 36 hours or at least 32 hours once every three or five days during training. Then on call every day practically for life.

Is it worthwhile, in future blog, I would explain to you that it is worth.

My name is Dr Chung Shiu Shek, specialist in cardiac and thoracic surgery. My clinic number is 3160 8865

The most live-able city in the world HONG KONG 香港最能活的城市

Despite all the bad comment on the future of Hong Kong, the Economist Magazine/News corporation has rated Hong Kong the best city to live in the world in year 2011.
I would not doubt about it but the ranking surpasses previous years of being rated the fourth to tenth comes so abruptly amidst the political turmoil of this place.

Hong Kong is my home and my birhplace. I have no hesitation to admit my citizenship as Chinese or Mainland china civilian but the tie to region HKSAR is more close to my blood and knowledge than ever. Before the 1997 change over, I have much reservation but a real practical issue to wirte down my nationality as Overseas British National with my HK passport. I would rather wirte down Chinese bracket BON (British overseas National) in Hong Kong rather than identifying myself as second class UK countryman but without any right of citizenship or residency.

How come other people recognise the strong points of living in Hong Kong but other people including most Hong Kong people thought the glory of the Jewels of the East has faded out more or less entirely. We are only one but not the most recogisable independent cities in Mainland China. We cannot surpass but to be surpasssed by cities like Beijing, Shanghai, Tianjin and Chongqing. Even the size of economy will be taken over soon by Shenzhen and then Guangdong or even Xiamen.

The one and probably more significant factor is the medical facility and accessibility in Hong Kong. I am proud of myself being one the medical supplier (specialist doctor in cardiac and lung surgery) in Hong Kong. I would not agree this is perfect but would say it is keeping on improving. But most Hong Kong majority would criticise the apparent self sufficiency of the medical system available in Hong Kong.  In prinicple, all public health care is  free but rationed. All specialist care are availabe at nominal charge and the care provided is up to international standard. However, this is far from the truth to see primary care is failing badly in preventive medicine aspect. Lots of people complaint the general satisfaction lacking in Hospital authority hospital.Thousands of hospital authority staff be in professional or allied health voted by foot to leave the system.

Yet , vaccination is nearly universally compliant, control of disease like SARS or swine flu is superb, major surgery like liver and heart transplant, sex change or conjoint twins operation are successfully done from time to time. For the problem of private medical care. It is not regulated and a lot of over charging is suspected. However, the success can be illustrated by the fact that lot of wealthy mainland people come to HK for medical consultation or even treatment and lots of wealthy businessman enjoyed good care by lot of private specialists.  Care in Hong Kong is good provided that there is no counting of cost of time in public HA service or no restriction of charge or resources for private market.

In Hong Kong, the proportion of national expenditure is only around 9 to 12 percent of GDP.  But the standard of care is good and doctors and nurses enjoyed good living support. If hong kong is so good in providing first class medical service at such an efficent expenditure. Then other countries should model their health system to simulate Hong Kong.  Everyone knows there is no free lunch in the world. So the local or insider would recognise a lot of hidden problem of heath care in Hong Kong. Thanks to the marketing or image controller persons in Hospital Authority. The drawback of the system is not exposed or shown to journalist who are only expatriate or visitor in Hong Kong.

If you ask one of British overseas worker or Philipino maid in Hong Kong. Are they enjoying good medical care system in Hong Kong. They would certainly point out that medical care in Hong Kong tends to be fragmented and haphazard and accessibility is far from simple or intuitive.  The specialists is availabe at high price and competition among health provider is not transparent and open.  A few giant specialists clinics or doctor dominate the private market and the fees they charge are ususally not afforable from general public.

I remember not long ago (actually availabe in Wikepedia) that one overseas Malaysian British citizen died of treatable disease in one of the public hospital in Hong Kong. Her Causcacian husband spent more than eight years to secure out of court settlement for the lack of care or even discriminative care availabe in public hospital system.
Although this isolated event has lot of overtone of cultural or racial difference, this illustrate the medical care in Hong Kong is like a cat and mouse game. Those who is familiar with the system can play the game well. thouse who do not or just take it for granted would not recieving expert care.

As an insider, I would expose the skill and trick to recieve good medical care in public system and private care to all. Hope everybody get the best care in Hong Kong.
Three cheers to the journalist who choose Hong Kong to be the best place to live because of an "excellent" medical care system.

My name is Dr Chung Shiu Shek who provide 24 hours emergency medical care to all enquirers and  I am specialist in cardiac, lung, chest surgery.
My clinic no is  3160 8865

Hyperthermia and Over sweating 多汗症

In Hong Kong, summer temperature is very high and city pollution and over-crowding create an ever increasing stress for out door activites or transit.  Human bodies have adaptive ability to extreme ambient environment.  Working under hight temperature would cause dehydration, heat stroke and cardiac complications.
Over sweating is the consequence of compensation in heat dissipation method in body
Over sweating in the palm and axilla cause embarassment in social life. Usually this begin in young adolescent and has incapacitating effect on social interaction of the youngster.
Both male and female are affected. It appear that male are affected more or they are willing to seek help more. For female, the problem is related more to odor than wetness. Armpit odor is more a problem for them in summer when less covered clothing is trendy then.

Treatment of oversweating or primary hyperhidrosis has long been used in society.

They include

1) self help method
2) Local anti-perspirant
3) removal of sweat gland by local ablation, surgery or injection
4) Botox injection
5) hormonal therapy or drug treatment
6) electophoresis - iontophoresis
7) surgical treatment of sympathectomy

The last method is most effective and durable.

But the drawback must be stated before surgical treatment.

They are:

1) over sweating in body
2) reduce facial flushing or red or lively color of face
3) small chance of failure
4) definite though small risk of sympathetic damage causing dropped eyelids (Horner 's syndrome) and small pupil

For educated patients with well thought of problem, surgery is usually fruitful. Stay in hospital is short and stay for post operative one or two days are common.
wound pain and anaesthetic problem is minimal
Decrease in sweating is permenant.