This is a personal blog. The theme is ‘perceptions and deceptions’ related to professional practice. There is a lifetime of blogging in this theme, but let me move on. Consider that fabulous bit of TV drama where HBO were setting up the series Newsroom: a reluctant, but articulate and evidence based response to a naïve sorority girls question that ended up with the statement, “America is not the greatest country in the world anymore.” If you have not seen it, take a break and look at this link: https://youtu.be/q49NOyJ8fNA
Naivety? Defined as lack of experience, wisdom or judgement. That allows us to deceive ourselves and we go along with perceptions that just do not stand up to question and critical thinking. I am quoting, “Doctors are the most trusted profession (sic)”. This is Sir Bruce Keogh the Medical Director of the NHS in England who is writing in The Guardian newspaper and I'm reading this online on 11 April. The article was flagged up on the Junior Doctors Contract Facebook forum with the headline, ‘Withdrawing emergency cover crosses a line – it will damage trust in doctors’.
He goes on to say, “Doctors are the most trusted profession. This trust is a privileged gift bestowed on us by society, but it brings responsibilities and expectations. One of these expectations is that we are there when people need us most”. He carries on to talk about emergency cover and suggest that medical emergencies are when doctors are really needed. He is so wrong. So wrong.
Where to begin? “Doctors are the most trusted profession”. Sir Bruce, are you deluding yourself? Okay forget the construct of the sentence but tell me on what basis can you say such a thing? Of course people want to trust doctors. Of course doctors say that they can be trusted. I truly believe that there are a significant number of idealistic people who go into medicine to fulfil the perception that doctors have humanity, do care, have compassion and yes, can be trusted. But, I say this as ironic humour: I felt safer walking in the slums of Kolkata than I did in the medical institutions in Hong Kong or in the United Kingdom.
How many times have I been urged to ‘walk away’. Most recently a long-time colleague and friend in Hong Kong said that the corruption in the medical profession (in Hong Kong) ran so deep that it was pointless to try to change it. And he is part of the collective team teaching medical students in Hong Kong how to be good doctors, professional doctors, ethical doctors. Who is deceiving whom?
The junior doctors in the UK are being faced with the reality that politicians cannot be trusted, that the media is not impartial or honest, and that they do have a strong body of support from a broad section of the population. I hope as they progress through their careers some of them will remain wary of ‘authority’ and keep their professional commitment to patients. I know that the General Medical Council (GMC) in the UK is not without criticism but for the newer doctors who were not around in the last century I can say it has changed out of all recognition from those bad old days. It was described as quagmire of corruption, self-serving deception, old school boy networks, a club culture and a neglect of professional responsibility and accountability. Those were the days of the Bristol Children’s Cardiac Care scandal, (required reading for any teacher of professionalism and ethics in medicine). Those were the days of Harold Shipman, the most prolific serial killer in the history of medicine in the UK. As a result of the detailed reports from extensive enquiries the GMC has changed dramatically and is doing much better in fulfilling its principal role of protecting patients. Yes. That has to be the number one priority of a body legally sanctioned to ‘regulate’ the medical profession.
There is no doubt that the GMC in the United Kingdom is very different now from the GMC that existed in the United Kingdom in the middle of the last decade of the last century, when Hong Kong was returned to the Peoples Republic of China. And yet the Medical Council of Hong Kong (MCHK) has not changed. What is the incentive? Anybody who speaks out is silenced. The MCHK protects doctors at the expense of patients. It is self-serving and I really do not know whether, as my friend said, the corruption is too deep to change or whether the deception is too deeply embedded for those who can, and should, face up to the fact that there is a problem.
If you made an enquiry you would learn that there are Government proposals to amend the Ordinance that controls the composition and conduct of the MCHK. These ‘amendments’ amount to the worst of cosmetic surgery. There are fundamental problems that need to be addressed but it is easier to cover them up than to deal with them.
I am no longer a registered medical practioner in Hong Kong as my licence to practice was tied (limited) to my University position. When my tenure expired at the age of 60 the rules dictated that I could no longer treat patients. With regard to rules, I have similar views about them as Saint Augustine has about laws. The famous legal maxim attributed to him is “Lex iniusta non est lex”. Do I need to translate for the brightest and the best who may read this? Okay, put it simply an unjust law is no law. So what do you do? Walk away? How they would love that. Who is the ‘they’? We are going to find out.
This is going to be a PBL blog! With critical thinking, objectivity and a rigorous approach to professionalism, clinical practice and justice I think we can make a change. If we can stop deceiving ourselves and face up to the fact that the medical profession cannot expect or demand trust we will have made progress. Trust needs to be earned, both individually and collectively. We all make jokes about the legal profession, with its sharks and ‘criminal defence’ lawyers. As an aside, I always thought that was a rather unfortunate term; lawyers who defend criminals or lawyers who were criminals?!
Rules of the blog? It is and must be professional, but as a rider all views expressed are solely mine. I will discuss only that which is in the public arena. I will only make evidenced based statements and opinions. With a view to protecting patients I want to put both the medical profession and the legal profession on notice that the cases I will be sharing come within the area of medico-legal practice. This has now become a sophisticated industry where too many victims of medical blunders, medical errors and medical crimes are being denied justice. It is not a simple issue but a failing of a complex system. A worthy goal is to expose the deep seated nature of the problem and look at solutions. I would hope that by the time the junior doctors of today become the leaders of tomorrow that the whole nature of medico-legal practice will have changed. A common expression used in TV legal dramas is “follow the money”. Well the major money that drives a significant amount of the medical-legal practice in the United Kingdom and Hong Kong comes from the Medical Protection Society (MPS).
To give the MPS credit they state in their name they are there to protect doctors. It is a self-serving organisation that puts the doctors (and the MPS) interests over and above those of patients. Is the MPS an ethical organisation? Is it accountable? Let us defer comment and move onto the first case.
The patient's name was Leung Kwan Zoe. She was born on 4 May 1986 and was certified dead on 11 May 2010. Her brain had died some days before. On 30 April 2010 she lay down on the operating table in the clinic of Dr Wong Kar-mau with expectation that she was in safe hands and was going to undergo a straightforward procedure to make her breasts appear larger. He used two potent and potentially lethal drugs in order to be able to perform the surgery. A catastrophic event occurred. The patient’s brain was starved of oxygen for a prolonged period and she was transferred to a public hospital with fixed dilated pupils noted on admission.
What happened and why it happened is what I want to explore in the following series of blogs. We shall look at the evidence, look at the statements made by ‘experts’ and discuss their worth. We will look at the legal representation and strategy and decide whether it is honest and ethical.
In order to prepare for an informed discussion I would like you to consider the two most dangerous and potentially lethal complications to the administration of lignocaine hydrochloride as a local anaesthetic agent: anaphylaxis and toxicity. What is the pathophysiology? What are the signs? What are the symptoms and what is the lifesaving treatment? This is particularly relevant to readers of PMFA News as lignocaine hydrochloride is most probably the commonest drug you will use in your professional lifetime. So please be involved. This is our professional responsibility.