16 January 1999

"The Hong Kong Surgeons in the New Millennium"
(16th Digby Memorial Lecture)

(Keywords:- Digby, surgeons, specialisation, training, research, democratisation, surgical audit, advancement)

          To deliver the Digby Memorial Lecture has to be a singular honour to the lecturer. To me, it holds even more significance. I have been the son of the Department where this Memorial Lecture was instigated, having worked in the Department of Surgery of the University of Hong Kong from 1962 to 1978. I was the humble ¡§Ma Chai¡¨ (follower) of Emeritus Prof G B Ong, who had the wide vision of establishing this lectureship around the time when I returned as a proud surgeon having obtained the surgical Fellowship of the College of London and Edinburgh. More, I will be the last Digby Memorial lecturer of this millennium.

          I did not have the good fortune to have been studying under Prof Kenelm Hutchison Digby. If I had been born some three years earlier, I might have been able to absorb his wisdom and gentlemanly manner in person. Fortunately for me, my father, though no surgeon, has been a student to Prof Digby in the early 1930s and it is through him that I transpired the fine qualities of this man that this lecture today dedicated -- a man of dedication to his students, a fine anatomist and a precise surgeon, a great gentleman and a complete man who help in no small way to shape the University of Hong Kong and the medical and health services in those times.

          Today mark the 350th day to the next millennium. What would the global health status be in the 21st century? What sort of health care system will Hong Kong evolve to by then? What role would doctors play in the whole spectrum of health care services? What part can the surgeons play? What can and should the surgeons do to continue and participate more to contribute to this society?

          There is no crystal ball for us to gaze into. Nor could we depend on the fortune tellers to give us the directions. It is perhaps useful therefore to trace the steps of the development of surgeons and the surgical services of Hong Kong from the days of Kenelm Digby till now, take stock of the trend of developments, postulate the possible changes ahead and be prepared for the assault.

          Much of Hong Kong¡¦s development in the last half a century, and the factors affecting it, follow the global trend. Surgery as a microcosm in the larger macrocosm of the society, the factors influence its development in Hong Kong similarly follow global features.

          Firstly, the rapid and varied advancement of medical sciences and technology plays a significant role. Secondly, there has been a change of patterns of medical practice in general, some of which are characteristic to surgery. Thirdly, there are factors that affect medical development that is peculiar to Hong Kong, viz the change in the recognition of social status of health care providers of which surgeons form an integral part.

          Let me ponder with you for the next few minutes over these changes.

          For some time, from the days of Kenelm Digby, who himself must be a general surgeon par excellent, general surgeons are genuinely general surgeons. Like a few who are now in the audience that I had the fortune of working with, I fell on the tail end of the era of true general surgery. Those were the times when we as general surgeons would have to use a handdrill and a gilly saw to do a craniotomy; at another time, to perform limb amputations to the dismay of limb fitters for our stumps never suit their artificial limb designs. With apologies to George Choa, we have also perform not in a small way a number of ENT operations, usually with alarming if not devastating results. Antral washouts invariably ended up in gross facial swelling due to through and through puncture of the maxillary sinuses.

From General Surgery to Over-specialisation

          The days of general surgery has rightly so swung to that of surgical specialisation. Regrettably, in some parts of the world, in particular in the North American continent, over-specialisation or obsessed specialisation has resulted in a specialist becomes technical expert of only a small part of the human body neglecting the fact that it is the men¡¦s total well being that we as surgeons are our concern.

          Under the mastership of the grand general surgeons of those time, the motto had been ¡§for cancer surgery, nothing should be spared¡¨ and ¡§if it is in the way of your surgical field, cut it out¡¨. Today, with medical advances and effective adjuvant therapy for cancer, the pendulum has swung to limited surgery, shortening hospital stays and reducing disfigurement of the patients. But how long will this trend last?

          With the development of fibre-optics and good visual lighting, open surgery has given way to endoscopic surgery. In-patient hospital services are slowly taken up by day care services if at all possible. The downside of such advanced development of course is that our surgical trainees will soon lose the art of open surgery undermining their effectiveness as complete surgeons, and making them slaves to modern technological tools. They would have difficulty in functioning should they ever have to perform surgical services in less developed countries.

          From surgery on the human body, we are now moving into surgery on the foetus and even surgery on the cell -- biological engineering.

          Success of such biological engineering brings on the moral issue of changing the geneticity of a cell and ultimately the human form when developed. It brings on the moral issue of cloning.

Facing Moral and Societal Challenges

          Surgeons today cannot be satisfied with just being operating physicians but they will have to be forced to make surgical decisions basing on moral principles for which they may be at variance with that of their patients. The rapid advances of medicine make it technically possible for a patient to request total sexual change physically against his/her geneticity. Similarly, the surgeon will have to learn how to face a vegetarian renal failure patient insisting that the homograft he/she will receive must be from a vegetarian donor for he/she cannot tolerate a meat eating ¡§kidney¡¨ in his ¡§vegetarian¡¨ body.

          Societal changes and the better education of the public brought about by better communication, initially from publications like ¡§Readers¡¦ Digest¡¨ and ¡§Times¡¨ and lately the computer websites, have brought on the era of more demanding patients -- demanding for better knowledge of the diseases, demanding for ¡§perfect¡¨ results of surgical treatment, demanding for alternative therapy. The days when doctors are demi-gods are thus gone forever. In return is the question of trust on doctors¡¦ decision and surgeons¡¦ competence.

          Yes, such changes are downright disturbing to the basically egoistic minded surgeons. Yet looking at it in a positive way, it must be considered as a milestone in the opening up of the society and an attempt to ensure accountability of the surgeons to their patients, if not the society at large! In Hong Kong, the evolution of the society has been more pronounced and in a quicker pace. Its effect on the development of medicine and surgery will understandably be more overt. I will be return to this at the latter part of the lecture.

Evolution towards Evidence Based Medicine

          Any surgeons would be thrilled if they were to be taken by a time capsule back to the 30s. In those times, Kenelm Digby, as a surgeon, must have been in full control -- dictating treatment, performing surgery in the manner which he and he alone considered the best for the patient according to his opinion. Few could argue that an element of self promotion, self glorification did not exist and there is really nothing wrong with it!

          As we approach the end of this millennium, our health care system is still very much an ¡§opinion based¡¨ decision making system. Such, however, is rapidly changing. Brought about by pressure of resources limitation, clinical decisions must be made explicit. Decision makers and health care providers must produce and describe the evidence on which decisions have been made. In short, opinion based surgery is moving towards evidence based surgery.

          What triggers the evolutionary process towards evidence based surgery and the length of time for the metamorphosis to complete varies with different countries. But it has begun and there is no turning back!

          The universal starting point is often the realisation that health care cost is mounting and that health care budget is limited. Spurred by the need for increased productivity and thus enhanced efficiency, the motto is to ¡§do things cheaper¡¨. In response to increasing patients demand, efficiency, productivity is not enough. Quality improvements are needed -- the result: ¡§do things better¡¨. The combination of efficiency, productivity and quality improvement will lead to ¡§do things right¡¨. If at this point in time, a set of management initiatives is brought to bear, then you will only be allowed ¡§to do only the right things¡¨. In short, to increase effectiveness, the outcome would be ¡§to do the right things right¡¨.

          In short, it is not good enough to do things right according to your own opinion. It is necessary to do the right things right with proper evidence to support.

          In Hong Kong, this evolution began with the setting up of the Hospital Authority. Is it a positive move? Obviously the managers in the audience will spare no time to promote it and history will be the best witness. For the clinicians and surgeons, it has achieved at least two things -- a quasi scientific way to prove to the public and our policy makers that money spent in public medical care is evidence based. Meanwhile, clinicians who have been labelled as poor managers are being forced to learn the new skill of management, to speak with management jargons, and to control the tension of the purse string. Let us hope this new learnt trade coupled with our medical professional knowhow will not only improve the management of health care institutions, but also bring benefit to the sick we serve.

Surgeons face ¡§competition¡¨ from other specialists

          Let us now move on to discuss our role -- the role, or the lack of it, that surgeons participate in the whole health care team.

          Gone are the days of Kenelm Digby when surgeons, then called ¡§Mr¡¨ rather than ¡§Dr¡¨, are the only specialists equipped with the skill, the knowledge and the sentiment to use the scalpel or to perform anything interventional on patients. Yes, we were called barber surgeons at one time, but the fact remains we are operating physicians.

          With advancement of modern sciences, the role between the surgeons, the physicians and the radiologists and radiotherapists become blurred.

          Endarterectomies and vascular bypasses which were at one time the coveted realm of vascular surgeons are now replaced by intravascular dilatation or internal vascular stenting done by cardiologists.

          Radiologists are known to be introducing percutaneous biliary stents to relief obstructive jaundice. I personally have witnessed a total of some nine stents so introduced into one patient.

          Prostate biopsy, once the bread and butter of urologists, are now done by radiologists. God forbid they are even doing transperitoneal pancreatic biopsies.

          With the development of the gamma knife, radiotherapists are ablating small brain malignancies and vascular abnormalities -- areas where even neurosurgeons fear to tread.

          Physicians are now venturing into the realm of removing renal and even gall stones with the advent of the Lithotriptor.

          It really scarred me as a urologist and I though my career is over when physicians are contemplating prostatectomies using the overrated, highly theoretically magnificent microwave ¡§prostate cooker¡¨.

          But my dear fellow surgeons, do not despair. For all is not loss. Surgeons superiority lies not just on our technical expertise but on our ability to adopt a scientific approach to surgery.

          To wit, not all renal stones are completely fragmentable by the lithotriptor of any make and model. Large stones often require percutaneous nephrolithotomy for debulking. Obstructing ureteric and renal stones frequently need pre ESWL proximal decompression and not uncommonly partly broken stone fragments can block up ureters requiring endoscopic clearance.

          As for the prostate microwave cookers, success if at all depend very much on positioning of the active microwave probe in the prostate urethra. Such exact placement needs a total understanding and accustomization of the length and curve of the urethra when the prostate is enlarged. Wrongly placed probes call for disaster. I have personally witness in three patients where the external sphincter was completely destroyed or cooked presumably because the doctor left the active probe at the sphincter site. The prostate in all these cases were left intact. These patients presented with massive per urethra bleeding from sloughing of the external sphincter, at the same time their urinary retention ere not relieved because the prostatic enlarged adenoma were all left intact. It is challenging, yet such challenges make a complete surgeon, and such challenges make the surgical life tick.

          No, there should never be any animosity between the different disciplines of the medical profession, nor should there be any back stabbing or infighting over work delineating territorial boundaries. Instead the best service for our patients has to be team work of the service providers. Today when medical science has developed so much, few could or even should claim to be Jack of all Trades. Instead, we should each develop into Masters of some!

          Having done this far, we should however never be slave to over-specialisation, for whilst medicine may well be a science in its own right, medical practice is an art. No doctor is complete if he does not know the human body and its interactions during diseases. No urologist is complete if he knows not the anatomy of the bowels or stomach. Often he needs these non urological organs to replace removed ureters or bladders. A gynaecologist is a dangerous one indeed if he/she is not aware of the course and relationship of the ureters. I can go on and on with examples. In fact in the States, having gone so far to glorify super-specialisation, there are those who are swinging the pendulum back to take up ¡§holistic¡¨ or ¡§total body¡¨ care!

Merger Government support in training and research

          The development of a surgeon or medical practitioner is often times influenced by the social climate and the attitudes of policy makers.

          Kenelm Digby must have lived in glorious times with an air of superiority, for a doctor or a surgeon by those time were fairly rare species. With special professional skills and often holding the health if not the lives of the population from the Governor to the man-on-the-street in his hands, he must have been very much wanted in high social circles and loved by the public.

          Let us have no more illusion. The days when we are more equal than others are never to return, and so it should be. Let us have no illusion too that the Government has always been kind to the profession. Nor has there been solid example by Government to help quality improvement of doctors.

          To wit, the budget allocated to tertiary institution for research and development is ridiculously inadequate. Compare with other advanced countries, even amongst South East Asia, we are only running at 0.27% of our GDP whilst others are ranging from 1 to over 3%. Yes, the Policy Address this year showed that the research budget for the seven tertiary institutions this year is around $3.2 billion, a fairly substantial sum it may seem. Yet do not be misled for this sum includes one-third of the salaries of all senior academic staff as each is supposed to spend one-third of their time doing basic researches. Nor has Government given adequate emphasis on post-graduate training amongst the medical profession. In the largest public health care institution -- the Hospital Authority which must be the cradle to nurture medical specialists -- no special funding has ever been allocated for training purpose ever. Instead staff employed to the Hospital Authority and the Department of Health are specified that their employment is for health care services only.

          One may argue that Government has been extremely generous in establishing the Academy of Medicine by statue, provided a piece of land at no cost and contributed though in a very small way to the cost of the construction of the Academy of Medicine Building. Regrettably, allowing the Academy to set training standards and vet competency, yet giving it no say in employing trainees and trainers leaves very little room for this statutory body to work towards achieving the best specialised medical standards in Hong Kong.

          Let me take this opportunity to remind the Government that whilst Hong Kong holds some of the best indices of international health care standards and our medical doctors fare with respect round the world, the effort of training has been, and still is, the effort of the profession using their own time, both trainers and trainees alike, for which Government has never contributed its financial support!

Impact of Sovereignty Change

          Ladies and Gentlemen, it has been said that development of medicine and its specialties should never be influenced by politics. Few would disagree, for medicine sees no borders. In Hong Kong, however, if one traces the development of medicine from the days of Kenelm Digby, the effect of politics is starkly obvious.

          In the beginning, Hong Kong has been extremely fortunate to have our former colonial masters bringing in experts from the UK not only to treat the sick but also to introduce the time honour British medical education system and programmes. Yes, the missionaries played a very important role. Yet again they were also British based! It was on the British medical education system that our medical schools were based. It was on the British practising benchmarks that we set our registration standards and it should be no surprise that the criteria of specialist training used by the Royal Colleges of the different specialties were also used then as our own yardsticks. All these have worked well through the decades and Hong Kong has derived succinct benefit. The fact however remains that Hong Kong then was a borrowed time in a borrowed place.

          The political reality, the problems of why Hong Kong has to stick to the British system and to use the British yardstick, and whether we in Hong Kong should carry on with the British system after the return of sovereignty became clear as 1997 drew near. The medical profession reacted. We pushed for a universal licensing exam to register doctors to practise based on Hong Kong standard. Graduates from British universities will also have to take the exam, which previously they needed not. Regrettably this was overturned, at least on a temporary basis, by the legislature upon passing a private member¡¦s bill raised by a legislator with scant knowledge of the function of the profession but with support from some within our own rank. The political bickering was thus reincited. Graduates from the Mainland, now our sovereign, are renewing their call for equal treatment -- that is, they should be exempted from taking the exam.

          The profession also pushed for setting up post-graduate colleges to set local training standards and vet local qualifications under the Academy of Medicine, so as to have no direct visible linkage with the Royal Colleges. Instead, we formed partnership with them to ensure that our highest surgical standards are internationally accepted. But for Hong Kong to be further assured of our international status, we must extend our connection network -- with North America, with other European organisations, with advance institutions in the Mainland. After all, it is on the international forum that Hong Kong has excelled and on it that Hong Kong is, and will be, different from the rest of China!

Influences of Democratisation

          The indisputable fact that there will be a change of sovereignty has brought on yet another issue that affect the medical profession in no small way. In preparation for ¡§Hong Kong people ruling Hong Kong¡¨, the then colonial sovereign woke up all too late to the need for the development of a representative government. Overnight, an appointed colonial legislature was transformed into an elected legislature. Overnight, formerly suppressed public were given the power to raise their voices through their elected representatives. Overnight government had to be made open, issuing pledges, establishing citizens¡¦ rights and in the case of health care ¡§patients¡¦ rights¡¨.

          The whole transformation, though a natural process in the evolution of democracy, was complicated in Hong Kong by confusion of the future, suspicion of communist rule and the lack of confidence in the change of sovereignty. The society became divided into ¡§the haves and the have nots¡¨; ¡§the Government and the public¡¨; ¡§the grassroots and the establishment¡¨.

          For whatever reason, doctors are somehow classified as part of the ¡§establishment¡¨. We are also labelled as the ¡§haves¡¨ -- surgeons in particular. Overnight, the doctors lose their trust. Overnight, our superiority is denigrated, our usually unchallengable positions are shaken. Overnight, the overdogs become the underdogs. We have been unreasonably criticised for our effort in spite of our continuous strive for public good. This is too much for the medical profession to accept. Our self esteem is crushed! Unfortunately, perhaps it is our constitutional make up, perhaps we the medical profession belongs to a more conservative group, often we swallow our pride, bury our grievances and carry on with our daily duties to treat the sick with no vengeance. Hong Kong has sailed through a political transition. The medical profession is to face yet another transition of no less magnitude.

          Ladies and Gentlemen, as we move into the next millennium, what can we do? How can we react to lift the gloom? How can we regain loss ground?

Keeping Abreast of Medical Advancement

          Let us do not forget: whether it is the next millennium or the one after, people will still be sick; new diseases will still be discovered. The health care professionals will always be needed to care for those that are ill. The medical profession will always have to take the lead of the health care team to master new technologies to provide yet further chances of cure for those in suffering. The surgeons will always be required to complete the team. This is where we must begin.

          We must keep abreast with medical sciences to give whatever little better we can offer to our patients. Keeping up with rapidly increasing modern technological advancement is by no means easy. Whilst I am here to learn from you what new techniques are we to expect, yet we can easily forecast that advances will go along the lines of genomics, gene therapy and biological engineering. Even Michael Fox, the leading actor of so many cinema blockbusters, is venturing the use of brain tissue transplant for Parkinsonism with notable success. With cyberspace and information superhighways, telemedicine for diagnosis, consultation and even patient care is just round the corner. Perhaps surgeons can easily operate in their comfortable plush offices directing a remote control robot. Yet, will we as surgeons be satisfied without the odour of the diathermised burning flesh or the tension associated with spurting arterial blood?

Workable Surgical Audit a must

          At the same time, we must also show our patients that we really and truly care for them through posing to them our results.

          The establishment of a workable surgical audit is a must.

          Surprising enough, the importance of surgical audit was coined by Florence Nightingale, the mother of the nursing profession, when she said: ¡§I have drafted model statistical forms which will enable us to ascertain the relative mortality of different hospitals, different diseases and injuries at the same and different ages.¡¨

          Workable audit utilises proper and up-to-date good quality clinical data to produce regular report of activities, morbidity and mortality of each one of us in active clinical practice for open scrutiny by our peers. This must be the yardstick for our College of Surgeons to maintain Hong Kong¡¦s surgical standards.

          Earlier on in my speech, I stressed that we are moving towards evidence based medicine. Yes, while diagnostic skills and technical expertise will always be a critical requirement for surgeons and physicians, the quintessential features of the outstanding practitioners will be, by the next millennium, the capacity to engage well informed patients in doctors¡¦ decision making.

Enhance International Connections

          I have stressed the importance of continuing with our international relationship to ensure that our medical standards are universally acceptable. But there is more. We have to try our best to enhance our international connections, through active participation in regional and international conferences, take a positive role and be involved in medical regional and international bodies. For as the rest of China improves its medical standards, and it will, the only edge Hong Kong has over them is our international medical relationship. Let the flag of Hong Kong be seen in all international medical organisations.

          The Basic Law has given us the autonomy to participate in the world¡¦s medical bodies in our own right. Let us capture on this and retain it to our best interest. It will be hard work for our medical leaders to be always on the go, carry the Special Administrative Region flag and fly it, but it must be done for future good!

Team Work with all health care disciplines

          As scientific technology develops, the division of labour between the different disciplines of medicine become progressively blurred. Even amongst other members of the health care team, there could be a merge. It is happening. As it is, radiographers are doing simple ESWL under the direction of doctors. There are centres in the US where surgical technicians are being trained to remove saphenous veins for the cardiac surgeons to use as coronary bypass graft.

          In Hong Kong, we are seeing the registration of the Chinese Medicinal Practitioners soon. They will be part of our health care team. You will notice that I have dropped the word ¡§Traditional¡¨ for this is what they are. They are not ¡§Traditional Chinese Medicinal Practitioners¡¨ any more. In China, the majority of medical students are trained both in Chinese Medicine and Western Medicine. The Chinese Medicine cum Western Medicine practice will be the trend of tomorrow. Yes, Chinese Medicine may not replace the scalpel in removing a tumour, but they might prepare a patient etter for surgery and promote post-operation rehabilitation.

Leading and Participating in Societal Affairs

          Finally the surgeons and doctors in Hong Kong must participate more in the society. Medical problems, societal problems and ethical problems are no more clear cut. The decision on reproductive technology and transplantation surgery for example cross many disciplines and cannot be solved with hard medical knowhow alone. The surgeons of the next millennium must learn more of the society at large to influence the society.

          Talking about influence, the medical practitioners have a distinct advantage. Our patients come from all sectors of the society -- from Kings to paupers. They basically trust us as they have pledged their lives in our hands.

          We have to speak out for the profession and for the society. We must take part in the different tiers of Government engaged in elections not only to provide our unbiased input, professional expertise but also as patients and society¡¦s advocates. For if we believe that the disharmony of the society is the root of all diseases, then we as healers of individuals cannot refrain from extending our role to heal the society. Helping the society will invariably result in helping ourselves.

          There will be those of you who will ask ¡§why me, why us?¡¨ Let us not ask why; but ask why not.

          Yes, all these mean changes in our basic instinct and culture as a doctor and a surgeon, perhaps even a change at how the society will perceive us as medical practitioners. But let us create a change if a change is for the better and let us not await to react to change.

          When Emeritus Prof Tan Sri G B Ong gave his inaugural speech on assuming the Chair of Surgery of the University of Hong Kong, he concluded by saying: ¡§A stout heart and a sharp knife will go a long way¡¨.

          Ladies and Gentlemen, time has changed. This is not enough for a complete surgeon of the next millennium when he/she will need a Stout Heart, a Sharp Knife and Societal Leadership to make Hong Kong tick.

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