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.

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.