|
01 December 2001
Neurosurgeons Galore
Speech by Dr C H Leong
President of the Hong Kong Academy of Medicine
at the Annual Scientific Meeting of
The Hong Kong Neurosurgical Society
Thank you for the invitation to address your Society on this august occasion. As the President of the Hong Kong Academy of Medicine, I consider this both as an honour and a duty.
When your President issues the invitation, I was at a loss of what to say. It would be just too gloomy to talk on economy. Worse, I am personally an economic failure. It is definitely too negative to talk about health care reform. Government¡¦s procrastination and the profession shortsightedness have made any suggestions of health care reform into farce. Worse whilst the health care system will not improve under the current status, bickering within profession is aggravating, control of medical standards and practice will soon fall with the hands of the non-professional. Needless to say I cannot be completely absolve from blame. My twelve years of toiling the soil regrettably has managed only to sprout weeds. Yet as the saying goes there is always a silver lining amongst the cloud. We shall see!
What I would like to do tonight is therefore to alter the mood. Talk on something light, and together with you graze into the future.
Let me therefore begin by portraiting to you my perception of Neurosurgeons as a student of medicine; as a surgical trainee; and now as a Neurosurgeon¡¦s working partner.
In the late 50¡¦s and early 60¡¦s undergraduate neurosurgical teaching was scanty, if not, non-existent. You are taught extra dural haemorrhage, brain tumors and cranio-pharyngiomas. You are given the impression that only the best of the best can become neurosurgeons and even then most patients other than those with early diagnosis of extra dural haemorrhage die anyway. You are taught of the pioneers of neurosurgery, William Macewen, Victor Horsley, Ernst von Bergmann and Harvey Cushing and their eccentricity. Incidentally there were no lack of oddities in our local neurosurgeons then. There was this Englishman John Hunter, who would take 10-15 hours to do an operation. He wore a specially designed mask fitted with 3 pipes, one for sucking his excessive saliva, one to pump in oxygen, and one that is connected to a bottle of glucose water for him to replenish his energy. It was a taboo to ask but nobody was able to give me an answer whether he needs a catheter or was he operating with Paul¡¦s tube. Then there was H L Wen, perhaps the pioneer and doyan of Neuosurgery in Hong Kong who to most amaze, operate with acupuncture anesthetist by sticking needless around the scalp. He is a big size man by any standard, one wonder how he would perform the very refine craft of neurosurgery with his no. 8 size hands. Yet the excels!
My expression of Neurosurgery being a highly refined surgical craft was shattered as I took up surgical residency. My first encounter assisting a nerurosurgical operation was removing a brain tumor. I entered the ¡§arena¡¨ with great expectation but to my horror the whole operation was very much similar to the art of Chinese delicacy of sampling ¡§monkey brain¡¨. The head was cleanly shaven, perhaps the only refine part of the operation. The skull was virtually ¡§cracked¡¨ open with a hand drill, chisel and bone nibbler and amidst spurting blood the tumor was ¡§blindly¡¨ enucleated Haemostasis was attained, at least temporarily, by packing the hole with gelfoam. There was no single piece of skull bone to cover the bony defect. The scalp was thus quickly closed over pulsating and fungature brain.
My nightmare came on my first ¡§stand alone¡¨ craniotomy for suspected extra dural haemorrhage. Using a hand drill was not easy, you either do not drill deep enough or you are drilling the brain. The use of a gilly saw was an art by itself, it took me many ¡§burr holes¡¨ and numerous saw of the brain to figure out that there was a ¡§protector¡¨ and how to properly introduce it. Invariable in these cases the brain bulged out. It was then that I understood what a ¡§brain fungus¡¨ was all about. How then did you close up?
In desperation, you shave whatever bulges out, worse as you shave, more appear. Do not be alarm, many of these ¡§victims¡¨ actually survive the ordeal and has apparently very little post-operative disabilities. One wonders how much of the brain is really needed to be alive and functioning. For those who survive, they end up all blue and swollen in the head for weeks to come. It was then that one starts to realize the wisdom of Sir John Erichson who some 130 years ago said ¡§the abdomen, the chest and the brain be forever shut from the intrusion of the wise and humane surgeon".
The true neurosurgeons of today are of course an entire different breed, having passed through a good period of general surgical training, you enter into one of the most lengthy and intricate training programmes before being able to become a Fellow of the Academy of Medicine in Surgery and registrable in neurosurgery as a specialty. And so it should be. For whilst you may take a ¡§non chalant¡¨ attitude in the brain because you are so accustom with this organ, the public, the semi-professional still consider the brain as sacred and untouchable. Working sometimes next door to neurosurgeons, realizing the work of colleagues in different neurosurgical units, I began to admire the refine craftsmanship of cutting open the dura not to damage the brain nor its conglomeration of blood vessels. How you use the operating microscope, how with dexterity you would clip off Berry¡¦s aneurysms, how with gentility you would raise the brain to work on the base of skill. I salute you. To those neurosurgeons who operate in theatres next to me at the HK Sanatorium & Hospital, I have another area of admiration --- the fees they charge. Mind you, the patients are very happy to pay, and our neurosurgical colleagues with no embarrassment deserve all of it and more.
Where do we go from here? Let me be bold enough to share with you my thoughts on the areas of threat that neurosurgeons might have to face and opportunities that might be there for you to grasp.
No, the general surgeons will not dare to take up neurosurgery anymore, Instead interventional radiologists will be eating away a sizeable portion of your share of work. To wit with the advent of the gamma knife, very small brain lesions could be identified and treated with no need for actual knife, vascular embolisation will obliterate A-V fistulae and malformations without resolving to surgery. It may be disturbing yet as science progress, it is paradoxic that as subspecialties emerges, the boundaries between specialties are getting hazy and blur. Furthermore for the best for the patients, team work amongst health care personal must be the order of the days and there should not be any territorial domination.
Opportunities also abound, at least in 3 directions:
| I. |
More accurate diagnosis |
| |
With the development of more and more sophisticated functioning MRI, clearer images in particular vascular lesions could/ will be identified to make way for more succinct treatment.
Computer AID Diagnosis is now the ¡§in thing¡¨. Using computer matching with stored image and data can bring about even rare pathologic diagnosis of a brain lesion paving the way for proper preparation of treatment. |
II. |
Gene therapy |
| |
For year, it has been known that implantation of foetal brain tissue could improve Parkinsonism and that stem cell are even be more effective. The ¡§hot off the oven¡¨ discovery that human embryos could be cloned or ovum be cloned through a process of parthogenese forming embryos that could divide up to a six cells stage manufacturing thus stem cells for therapeutic use raised much enthusiasms and hope. Yet thus must be balance with the moral fear that the path is now open for the cloning of a whole human being. The issue is thus not a technical one, nor a medical one, it is a ethical or a moral consideration. To a medical or scientific technocrat condemning such a process in an interference of research and tantamount to snubbing scientific progress which could be for the benefit to improve mankind. To the moralist, allowing such research has the potential of ultimately cloning of a human being. To those ethical inclined, the prolife group for example, even the production of six cell embryo for therapy would mean the creation of life and destroying it to save another and thus unacceptable.
The debate predictably will be a long drawn out one, a global one. It is doubtful that all nations of the world will finally come to an agreement of the best approach. This debate will soon be an issue to HK , I would urge that the medical profession should take an active lead. |
| III. |
China and the WTO |
| |
For years the medical profession in particular those in private practice are lamenting that there is not enough work to do. Rightly so, the accusing finger is pointed at the Hospital Authority for continually increasing its market share; or perhaps at the Government policy for clear definition on ¡§what the heavily subsidizes public health care service is for and for whom¡¨. Yet even with pragmatic Government policy, with uncurb production of new graduates and the relative slow growing population, the result is obvious. The ratio between the number of population to one doctor will drop. In short the medical profession in HK should extent its vision to consider not just serving a rather stagnant 6 million plus population in HK but to extend its market of the over 1 billion people in China.
The time is now, if not already too late. Let us examine the facts. 10-15 years ago when the people in China was poor, any health care that could sustain life is good enough. Today when the per capita income in the mainland raises many eyebrows and are ever rising, it is just natural that the people will be looking for ¡§quality health care¡¨ which many in the mainland believe are not yet available inside China to the levels of expectation. This perception, though possibly erroneous has occurred for sometime. When China is still in the days of the ¡§bamboo curtain¡¨, leaders who came down with illness often seek treatment in the then Soviet Union. Today many still dream of seeking treatment overseas, yet barricaded by financial cost, by difficulties in obtaining the necessary traveling papers and more important language and cultural differences, the majority are disappointed. HK doctors being ¥b¬v°¤l should thus an edge over.
China¡¦s joining the WTO means it has to open its market to other members of the WTO as determined by the Uruguay convention, Professional, like doctors could soon be allowed to practice in the Mainland albeit with restriction like having to pass a language test and licencing examination. The motto therefore should be ¡§Go North, Young man¡¨.
Where does HK stand? As I understand it other nations are already making preparations. A Taiwan group is building a 5000 beds hospital in Beijing with subsidiaries in Shanghai. The American and the Singaporean are making similar move. Regrettably, the local profession is still very much engrossed in internal political bickering and power struggle. Without unity and long term vision and looking ahead, the niche in the Mainland which could be so much in HK¡¦s favour could be unconditionally surrendered to high powered medical corporates of foreign nations. How disappointing, how sad! |
Mr Chairman, Colleagues, for the last half an hour I have tried to bring you though the history of neurosurgery in HK from a passerby¡¦s eye. I have also tried to glimpse with you the possible development in the future. There are opportunities and at the same time threat. I must admit that what I have said could just be ¡§bringing coal to Newcastle¡¨. Needless to say, I, as the President of Hong Kong Academy of Medicine, welcome your feedback.
But as for now, neurosurgeons are still being considered as one of the ¡§Creme de la Creme¡¨ of the medical profession. You will still be like stars shining in the galaxy. Thus the title ¡§Neurosurgeons Galore¡¨.
|
