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BEYOND the PRACTISE of MEDICINE

Mr. President

It is indeed an honour to be invited to deliver the Gerald Choa Memorial Lecture of the College of Physician of Hong Kong. It is an exception honour to me to have a chance as a surgeon to address the College of Physicians twice within a year - the McFadzean Oration in 2004 and now the prestigious Gerald Choa Memorial Lecture. Perhaps I should alter my mindset instead to think as an Honorary Fellow of your pristine College.

I accepted the invitation to deliver the lecture with trepidation. Firstly the late Professor Gerald Choa had contributed so much to Hong Kong that no amount of words can glorify his achievements. Secondly the giants of medicine who were my predecessors in this lecturership have imprinted such giant footsteps that I will never be able to match. It is more than David versus Goliath.

Gerald Choa was a physician par excellence in his times. He was the only physician, and his team the only physician team, that the University surgeons were willing to entrust. Yet at the height of his clinical career he move on to medical administration and policy formulation as the Director of Medical and Health Services. And, as this was still not enough to fulfill his insatiable vision, he founded the Medical School of the Chinese University of Hong Kong where up to today over 1000 - top rate doctors have been produced to serve the community.

It is on this aspiration of Gerald Choa, beyond the call of duty of a physician, beyond the challenge of the practise of medical that I would like to address you today namely :-

Beyond the Practise of Medicine, which includes :-

* To be engaged in treating the society rather than just the patients and their pathologies.

* To consecrate the culture of professionalism though proper medical education before and after graduation.

* To be able to predict social crisis and lead in crisis management.

These are no double the aspirations of the late Gerald Choa.

As a physician Gerald Choa is well aware of the scientific approach to medicine and that a complete doctor must thoroughly know the intricacy of the human body. He believed however that even this is not enough if a doctor wants to be an effective and efficient healer. He would have to know how the body interacts with the society at large. The effective health care providers will have to understand how the health care services interact with the society's need. More importantly, any leadership in the health care team will have to utilize the society's need to mould the health care service to achieve his ideal. Health care is a social issue, we as doctors therefore must learn more of the society at large to influence the society.

To us as doctors this would mean moving our management on patients in clinics and hospitals to managing the society in a political arena. This it should be for if we believe that the disharmony of the society could well be the root of all diseases, then we as healers of individuals cannot refrain from extending our role to heal the society. We must get ourselves to participate in the different tiers of Government, to make ourselves available to advise in formulation and execution of health and social related policies. We as doctors are in an advantageous role, for if our patients are willing to entrust their lives onto our hands they should also entrust their social needs into our confidence.

There is definite room to be a physician par excellence and be at the same time an effective politician and societal leader. Many in our ranks have taken or attempt to take this challenge, but we need more.

Medical educations extends much beyond the training of an trade or an occupation, it is the training of a profession. So too a medical school's role is to develop professionalism and inspire this culture into it graduands and the society. The difference between a trade or an occupation and a profession lies in the following characteristics.

Firstly professionalism is the promotion of altruism, engaging in a society and social services. It requires extensive special education training and more importantly a high degree of continuous improving knowledge. It also entails an ability and willingness to apply the knowledge and skill to a greater social good.

Professionalism is about the quest for autonomy, in the right to regulate, and, finally professionalism is the conformance to the development of a body of ethics.

A comparison of the core value of professionals and corporates will highlight the importance of professionalism to consecrate the very function of trust upon which our social contracts rest and upon which the public is assured that medicine is fulfilling its sacred obligation. The areas to highlight of course are that professionalism is for service and not for strict profit, for altruism and not for responsibility to stock holders and for humanism and not to consumerism. This is role of the medical schools and the Academy of medicine and all medical and health institutions who dares to stake a claim to represent the medical profession in any degree.

Crisis are inevitable, Gerald Choa had his share during his times. With rationale approaches good tactics most of these were properly managed if not averted. Today, crisis looms around the corner and leader of the medical profession must be alert and prepared to deal with the issue.

I like to share with you 5 real crisis that will befall on the medical profession and the society at large in the course of time. These are not exhaustive, nor am I "crying wolf" for the danger is lurking and the crisis are real :-

* Crisis of the aging population;
* Crisis of the collapses of the public medical service;
* Crisis of breaking down of doctor/patient relationship;
* Crisis of emerging or re-emergence of infectious; diseases; and
* Crisis of an immature democracy.

Let me elaborate.

The crisis of the Aging Population

The life expectancy of HK people and for that matter round the world is growing rapidly. In the 50's & 60's the average life expectancy is 50 - 60 years old. Today, the life expenditure of males is in the region of 78 years and females 84. Whilst it is good that we all living longer, the crust of the matter is that the ratio between the young and the elder is moving rapidly to the elderly. Today, one in seven people in HK is over 65 years old. In 20 years time one in 4 will be 65 years old.

What then is the crisis. It is obvious that, there will be more and more elderly and by comparison less and less young people - Looking at it bluntly there will a decrease in number of tax payers and increasing number of retirees.

The leaders of today must start to look at this problem of social imbalances and consider ways and means to first maintain the public financial position and secondly how to take care of this enlarging elderly group to assure that they are well looked after, well cared for, maintaining their health and perhaps provide opportunities for them to resume work and gainful employ to cater for the society.

The problem not only confronts the leadership of Government but each and everyone of us, be it in a Governmental sector or in the world of business.

To wit, we might have to consider the issue of widening our tax base to booster Government's public revenue. We might have to make alterations to our retirement age or at least make provisions for gainful employment for those beyond the set retirement age. In his address to the HA convention this year, your immediate past president has the vision to call for training more geriatricians.

Looking at it from a positive angle we may actually be employing people with experience at a low salary level. Secondly, as more and more people fall into the elderly bracket, there will be a greater need for elderly carers and for products that are catered for the elderlies, opening up thus a new career and a new business opportunity if not an entire new enterprise.

The crisis of the Collapse of the Public Medical System

HK has a public medical system that is second to none. For a $100/day or less if you are assesses to be in financial risk, you could have the best state of the art investigations and treatment. Many, even have this amount waived. This is to honour government motto "that nobody should be devoid of care because of lack of means".

Things are easy in bygone days when medical cost is cheap. Today medical cost is exorbitantly high drive by :-

Rapid rising cost of new medicine and new technology;

Aging populations (to wit over 40% of the HA beds are occupied by people over 65);

Demand of the patients and publics

So as medical cost soars, the public health care services will find itself difficult to make ends meet.

Figures shows that in 1990, about 85% of sick people who need hospitalization were admitted to the Hospital Authority. Today this figure stands at 95-97%. The Hospital Authority becomes a victim of its own success.

The end result is that the public medical service will collapse or at least the standards will drop for it would be impossible to maintain a high standard when one uses a finite budget to provide an infinite need and demand.

To avert such a crisis, leaders of today and tomorrow must look into way and means to remedy the situation either to enlarge the public budget for health care or make provisions for your staff and followers to take up medical insurance and seek private services to relieve the public service load.

It takes time to promote this culture but it needs to start now before it is too late. HK people deserve a high standard of medical services.

The crisis of breaking down of Doctor/Patients relationship
Medicine today is complicated by 2 areas. The spiraling cost of medicine has led to the search for more cost effective medical practices. Overnight medical practice has assumed a business mode. Patients are now labeled as "clients" and "customers" or "consumers". Overnight the "care and concern professional relationship" gave way to the courteous and cold "business relationship". The service providers explore different ways to reduce cost, while the consumer every means to ensure that he is getting his moneys' worth. Conflicts become inevitable.
Added to this is the fact that as coined by Peter Drycker the 21st Century is a "knowledge society" era - Knowledge obtained from Reader Digest, Time Magazines, Gossip Columns and the web. Armed with such, perhaps half baked, knowledge consumers start to demand - demand why certain investigations are not done; demand to know other alternative treatment modalities; and demand for an accurate projection of the degree of success and the percentage of side effects. In HK this is further accentuated by the process of semi-matured democracy. Overnight the public was given a vote which to them becomes a right - a right NOT to help improve the society but a right to demand. Fuelled by some politicians whose sole aim is to get votes, HK assume a "blame culture". Doctor are in the line of the firing squad.
To the ordinary doctors in the street the easiest thing to do is to succumb to whatever the patient demands, perhaps bend over backwards to do more and practise "defensive medicine". Overnight "opinion based physician led" medical service has given way to "patients demand" and "public led" health care services. The trust between a doctor and the patient is at all time low and the time honoured doctor - patient relationship shattered.

Regrettably the health care profession has to take some of the blame. The all too unnecessary political bickering within our ranks has resulted in the soar relationship between the Government and the profession, a chasm between the private and public sector, the specialists and the generalists, the doctors and the nurses, the seniors and the juniors creating a golden opportunity for the media to play Peter against Paul. All these does no help to promote the image of the profession in the eyes of the public. To wit the never ending internal squabble, that is now into the public arena, of doctors needing obligatory life long learning, call it CME/CPD if you will, not just to better ourselves but to show the public that we care, has made a laughing stock of the profession.

The Crisis of Return or reemergence of Infectious Disease

For some 50 years with the improvement of public health and better nutrition and sanitation in many parts of the world, it was thought that we can say goodbye to most infectious diseases. SARS has woke us up that we were wrong, for new infectious disease are always lurking round the corner.

In 1997 HK was struck by Bird Flu (Avian Flu). Fortunately it did not get of hands as we quickly kill all the chicken and yet Avian Flu is still very much with us. The recent discovery that the same virus was found in dead bodies the killed millions of people in the "flu" epidemic of 1918 only showed that old infectious are awaiting to make a come back.

Leaders in Government and those in public health must therefore be prepared not only to prevent a major disaster in HK but to be ready should HK be hard hit. Other leaders must be alert too. Sick employees produce deterioration of services or prediction standards. Whilst public health to a large extend is Government's responsibility, yet each one of us must do our part to be responsible for our own health and to ensure at all cost to prevent ourselves from getting sick. The culture that health is everyone business must be instill into the people.

Finally the Crisis of Immature development of democratization

When HK was under colonial British rule, there was no democracy. So when progressive democratization was introduced in the late 80's it was welcoming news.

Regrettably democratization in HK is still very much in a development stage and dare I saw immature. Yes, the ultimate of democracy is a right to vote. Yet this is a right more for one to vote to improve the society at large rather that a vote to promote your own demand. Similarly politicians are voted into the Governments system to help to shape the society and not to perform for the sake of getting votes again for the next election.

Such immaturity have thus slowed down government's decisions and progresses and dare I say many in private arena too. No, do not get me wrong, I am all for democracy, for transparency, for getting proper and adequate public opinions. Yet I strongly believe that leaders are there to lead - through good communication, open mindedness and through making difficult decisions rather then to stir up controversy for the sake of controversy.

Mr. President, Ladies and Gentlemen, in the last 20 minutes or so I have outline some of the imminent problems that faces the profession and the health care services and the society at large. These are pressing problems that need to be address and solve. This is perhaps the reason why the late Gerald Choa moved from being a pure physician to be a policy maker and then an educator.

I like to end by quoting to you a thought from Richard Gordon, the author of the "Doctor in the House" series, when in a serious mood he wrote :

"The potential of medicine is infinite, the demands on medicine must be unrestrained, but the resources for medicine is limited. Unless a fearless politician strikes a non political compromise between all three, the history of medicine may head for a disaster" Gerald Choa, I have no doubt will agree.