Dr. C H Leong *
Professional autonomy would consist of two parts - to allow a profession to determine its own criteria to practise that profession in Hong Kong basing on standards; and to empower the peers of a profession to determine whether a member is guilty of professional misconduct and to levy the necessary discipline. Such professional autonomy with no interference from the Government or the state must be the base of any democratic institution, a must for any profession if it aims to advance.
It is along this principle that the Medical Council, the Dental Council, the Bar Council, the Architects Council or any other professional disciplinary bodies must direct their work albeit unpopular to some of their own members, if they were to command respect from the community. Any action otherwise will throw suspicion onto the effectiveness of professional autonomy of that profession involved.
To be fair, the decision of the Medical Council's disciplinary hearing on the latter case must be respected, not because "it is a brave decision to make" as stressed by its Chairman, but because that panel has deliberated conscientiously for some 14 hours before coming to such conclusion to acquit the alleged "culprit". No stone must have been left unturned. Yet, the least the public expects is for the Council to state in no uncertain terms that "it does not condone the use of mobile phone during surgical procedures". Regrettably, this assurance was not forthcoming. Worse, the statements issued by the Council together with the acquittal of the defendant send a wrong signal to the public that the Council considers it "not wrong" for doctors to use mobile phone even during surgery whilst others (patients and visitors) are banned from using them in the name of "danger of interference with sensitive life supporting machines".
In 1984, a group of members of the then Basic Law Consultation Committee representing the nine major professions of Hong Kong took upon their task to be assured of one thing in the Basic Law - that professional autonomy must be so enshrined.
Professional bodies must act for Public Good
Yet, any professional body, where the peers are so strategically placed, must act by one principle and one principle alone - to act for public good by monitoring and scrutinizing that profession in its practice; to be always ready to struck at the deadwood with no remorse; yet never to be standing, or even seen to be standing, on the side of that profession against public interest. The motto of the General Medical Council "Protecting Patients; Guiding Doctors" says all!
Public discontent having brewed for long
The recent uproar of discontent of the public towards the Medical Council is thus of no surprise. It is not a knee-jerk reaction, but an accumulation of frustration from the many apparent lenient penalties imposed by the Council, case after case, inspite of frank guilt of misconduct. The handling of the "mobile phone saga" has become just the last straw. Overnight, the confidence of the public to the Medical Council as their watchdog is shattered. Overnight, the respect the public has on the medical profession is denigrated.
In such light, it is not difficult to understand that the mainstream knee-jerk suggestion of reform is to call for an increase in percentage of non-doctors (lay members) in the Council. Yet there is much more than meeting the eyes. Deep seated problems do exist and should be corrected even if it is just to improve the complaint and disciplinary functions of the Council. Furthermore, there are many needed reforms that can enhance the other functions of the Medical Council to positively win back the doctors' place in the public's heart!
The "mobile phone saga" clearly demonstrates that the public is given to believe that the Medical Council is very loose on its stand of using mobile phone during surgeries. It is regrettable too that whilst the Medical Council is amongst the few professional disciplinary bodies that hold hearings in public and always in the presence of a lay member, it has not sought to use such to its advantage. Those lay members should be present at any media briefing as they are the living proof that "doctors protecting their own boys" does not exist. Despite being possibly outnumbered, these lay members do have their own integrity to exhibit and will no doubt speak out when there is any evidence of being coerced.
Such naivety makes a mockery of this "highest body of the medical profession"; undermines the integrity of those with a "loud mouth", and exhibits the utter lack of a determined and strong leadership. It comes as no surprise and to the dismay of the profession that the media and public are sneering at this body, instead of dutifully respecting it. How sad!
The Medical Council, through its different committees, acts as an investigator and prosecutor against the doctor alleged of misconduct, as well as the judge and the jury in the resultant hearing.
The Preliminary Investigation Committee (PIC) reviews all complaints received. After some very preliminary investigation, mainly asking for the doctor concerned for information, it decides whether or not there is a case to answer on professional misconduct. If yes, the case is referred to the full Council for disciplinary hearing. No details are submitted by the PIC to the full Council, which conducts its meeting with members theoretically completely oblivious of what case and who will appear before the hearing. The Government's Department of Justice provides the prosecutor to prosecute on behalf of the Council. The complainant (patient or relative aggrieved) acts as a witness. The members of the Council act as judge and jury.
Whilst the individuals taking up the investigator, prosecutor, judge and jury roles may well be different, to the public they are all parts of the Medical Council. All these brew confusion.
There is thus a dire need to have separate bodies for investigation and final discipline. The proposal to have a "Complaint Office" taken on the investigatory role is worth deliberating. Such a body should however have wide public participation and be able to call on any professional expertise to assure of more clarity and efficiency. The final functions of the "judge and jury" must still be retain in the hands of the Medical Council, not only to protect the last bastion of professional autonomy, but to ensure that the peer assessment principle is put in the best function.
Let us not forget, the disciplinary council act both as a court of law and a peer assessment convention. It needs experienced prosecutors to wrangle with legal heavy weights representing the defendants. It also needs lawyers who fully understand the spirit of peer assessment which often times cannot purely be legally quantified. Regrettably, such experts are not often forthcoming at Council hearing.
This deficiency must be quickly rectified either through the Medical Council having and training its own in-house prosecutor -- meaning the profession has to contribute more in registration fees to support this person; or the Department of Justice must be behest with training a few designated legal officers specialized in prosecuting suspected medical misconduct to work for the Council.
If every member of the public, whenever they get sick, could be assured of each doctor they visit is of a highest standard, in keeping with medical advances and of good moral standing, confidence of the profession will be a foregone conclusion.
The Medical Council must, therefore, move towards quality assurance for each registered medical practitioner. As a first step, compulsory and stringent Continuing Medical Education (CME) as a pre-requisite of renewing registration to practice is perhaps an easy issue to take on board to show the public that each and every doctor has been subject to a minimal predetermined dose of quality education. Other criteria must, of course, follow.
The honour of the medical profession is at stake. Each member of the profession must play his/her part. We must all take part in and contribute to the deliberation of the reform of the Medical Council. Yet, any reform must be able to assure the public that it will work, and ascertain the profession that there is no denigration of professional autonomy!
Proper Public Relations Exercise required
As a start, the Medical Council does need a proper public relations exercise. Any controversial decision by the Council on policies or disciplinary matters must be properly communicated with the media and the public in the language they understand.
Members must adhere to Collective Decision principle
Every council or institution of significance must work by a principle of collective decision. The members of the Medical Council, be it at the policy decision or at a disciplinary decision, must abide by such decisions made, be it agreeable to them or otherwise, even though they are absent. Unfortunately, this is not the case with some members of this supposedly honourable body. Often times, as soon as a meeting is over, different members would express their own views to the media, sometimes conflicting to the decision of the Council as a whole. Confidentiality is seldom respected -- who said what are often revealed to the public like an open book. The media thus have a field day continuously playing "Pete against Paul".
Perception of Confused Roles
In the complaint handling and disciplinary machinery, many inborn fallacies do exist. Most of these have been there since time in memory; much are legacies of the General Medical Council. Yet these must be changed to keep pace with time.
Shortcomings in Prosecution
There are flaws in the prosecution aspect that call for much improvement. Often times, the charge does not reflect the severity of the case. A doctor who blatantly peddled drugs under disguise of dispensing was often charged with "keeping improper drug records".
Positive move towards Quality Assurance
Yet reforming the complaint handling and disciplinary machinery can only be considered as one aspect of improving the Medical Council. The Council is a body empowered by law to register doctors to practise medicine. This is based on standards - standards to be at par with the world and standards that the Hong Kong public deserve.
Academy able to contribute towards CME
The Academy of Medicine, with its well earned experience in running and accrediting CME, has a ready made system that can extend to support doctors who are not yet specialists. This the Academy has pledged to do.
* Dr. Leong is President of the Hong Kong Academy of Medicine. He was a former Legislative Councillor of the Hong Kong Goverment, representing the Medical Functional Constituency. The views he expressed in this article are nevertheless his personal views and not the view of the Academy.