Mr Chancellor, Pro-Chancellor, Vice-Chancellor, Distinguished Guests, Colleagues, Ladies and Gentlemen:
When John Masefield, the Poet Laureate, received an honorary degree at Sheffield University he said on behalf of his fellow graduands "There are few earthly honours more to be prized than this which you are now giving us". This certainly is the sentiment of my fellow graduands and I today and we all thank the University of Hong Kong for this singular honour.
I was most hesitant to accept the invitation to address this distinguished Congregation as my fellow graduands can speak with more eloquence and substance. However, this year marks the centenary of Dr Sun Yat-sen's (1866-1925) graduation from the Hong Kong College of Medicine so the Vice-Chancellor considered it appropriate for the speaker to be "medically-related".
The Hong Kong College of Medicine for Chinese was the forerunner of the present University's Faculty of Medicine. At the Sun Yat-sen Museum in Dr Sun's native Zhongshan, there is a record of the grades of the medical students in his class and not surprisingly his was the highest. He practised briefly in Macau and Guangzhou before planning the revolution which led to the founding of the Republic of China. He died of primary cancer of the liver, a common cancer among Chinese. An important cause of this cancer is Hepatitis B virus infection. Hepatitis B can now be prevented by vaccination which means that in years to come primary cancer of the liver should no longer be common. Baruch Blumberg's discovery of this virus was recognised by the Nobel award in Medicine in 1976. This is but one example of the remarkable progress that has been made in medicine since my graduation forty years ago.
Medical matters have been much in the news and these have varied from the reorganisation of hospital services to highly technical procedures such as transplantation of the bone marrow or liver. If Dr Sun Yat-sen were alive today, I wonder what his reaction to all this would be? He would no doubt be astounded by the amount of knowledge a medical student is supposed to acquire; amazed by the advances in medical science and technology, the size and complexity of the modern hospital; gratified by the involvement of medical doctors in community work and politics; concerned about the technical orientation of medicine sometimes to the neglect of human and social factors, and disturbed by the high cost of medical care. These are complicated issues. I thought I would briefly comment on some of them. As medicine is but one of many professions, what I say may have relevance to other disciplines.
Medical education can be arbitrarily divided into 3 phases: the undergraduate course, postgraduate medical education and training (PME), and continuing medical education (CME). From entry into medical school to the time a medical doctor is considered ready for independent practice takes about twelve years. Little wonder many high-school leavers are shying away from medicine!
The undergraduate curriculum has undergone significant changes in recent years and this University’s Medical Faculty is conducting its third review since 1945. Worldwide trends include: 1) Increased teaching in behavioural science; general practice/family medicine; cancer; care of the elderly and ambulatory medicine. 2) Replacing formal examinations by continuous assessment. This requires more staff time but continuous preparation for examinations can suppress individual development and creativity. While degree examinations afford opportunities for external examiners to visit an institution, external assessment and accreditation can take other forms. 3) Instruction on the proper approach to the use of advanced technology in diagnosis and treatment. This is important as medical students are exposed to procedures involving high-technology as soon as they attend large regional hospitals where much "mechanical tertiary care" takes place.
With the rapid progress of science and technology, there has been a literal explosion in medical knowledge and its clinical application. One cannot expect the present day medical student to acquire a fraction of this in the five years or so. It is vital that teachers emphasise important principles, problem solving and how to think critically and do not overload teaching sessions with minutiae. This was certainly the approach of the late Professor A J S McFadzean and he was an outstanding and inspiring teacher. Charles Aring, an eminent US medical educator, says: "It is our duty to lift from the student of medicine the crushing weight of factual material, the method by which some of us feel we are initiating him into the subtleties of medicine". The overcrowded curriculum is one of the main problems facing medical faculties today. Much of the vocational aspects of a subject can be taught after qualification, and this would be facilitated if funding of clinical departments were not so dependent on undergraduate "full time equivalents"!
Much has been said about the declining standard of English among students. This is unfortunate as English is the universal scientific language. However, this issue is being addressed by educationists in Hong Kong. Of interest, is Charles Aring's remark that "in most US medical schools English is given short shrift and in general students graduate with diminished ability to express themselves in clear language, perhaps because they have acquired a jargon". So remedial English courses in tertiary institutions are not the solution.
Before leaving the subject of the undergraduate course, I would like to refer to a letter from an American father to a seventeen year old son who was deciding on a career: "Medicine, for instance, is a pretty good profession, especially for one of your temperament which combines a better-than-average knack of getting along with people and a medical and scientific bent. But too many of our American physicians, though expensively trained and full of medical information, are dull fellows and unenlightened citizens because their knowledge of people is limited to their specialty. This fact should not discourage you from being a doctor: it should simply discourage you from being the kind of doctor who thinks human beings are just digestive machines with pocket books...".
While some medical graduates obtain a higher degree such as the PhD and pursue a career in basic science and research, the majority will practise medicine. Five years or so in medical school are not adequate for independent practice and further education and training is necessary, be it in clinical or laboratory medicine. This applies particularly to those who wish to specialise. The internship year is followed by several years of PME which should be properly structured and supervised and usually involves an examination. In addition to instruction in a particular specialty, communication skills, teamwork, management skills, medical economics, ethical practice and knowledge and skills which cross specialty boundaries should be underscored. It is important to maintain a balance between the acquisition of knowledge and practical skills. In addition, UK General Medical Council's Education Committee states "all programmes of training in clinical specialties should give trainees knowledge and understanding of research methods". This will certainly help in the development of critical thinking and the ability to analyse scientific data and evaluate information.
In Hong Kong, PME has followed the British pattern, with trainees seeking Membership or Fellowship of one of the medical Royal Colleges. However, our relationship with the Royal Colleges will be changing. Furthermore, local postgraduate programmes have been ad hoc, under-funded and lacked overall organisation. In view of this, the Hong Kong Government set up a Working Party on Postgraduate Medical Education and Training chaired by Dr K E Halnan. The main recommendation, published in 1988, was to establish an Academy of Medicine to undertake and supervise postgraduate and continuing medical education and training. This led to the formation of the Hong Kong Academy of Medicine Preparatory Committee in early 1990, with members from the profession and Government under the aegis of the Secretary for Health and Welfare, Mrs Elizabeth Wong. The Committee has completed its main deliberations and the Bill for the incorporation of the Academy is awaiting Legislative Council approval. For the first time Hong Kong will have its own statutory postgraduate medical institution, which will ensure high professional standards to the benefit of the public. The Academy will comprise specialty Colleges in the major branches of medicine, including dentistry, and so far eleven have been formed. The Colleges will organise and supervise training programmes and conduct examinations. The Academy will coordinate their activities and ensure comparability of training and qualifying standards. The proposed training will be for six years after internship; and part of this should be carried out overseas. External examiners and visiting teachers will ensure international recognition. Upon satisfactory completion of training, the candidate will be recommended for Fellowship of the Hong Kong Academy of Medicine, the only locally awarded specialist qualification. It is anticipated that Fellows of the Academy will be placed on the future Specialist Register of the Hong Kong Medical Council. This will no doubt be helpful to the public who, understandably, are confused by the many letters behind the names of medical doctors which do not necessarily mean they are fully trained specialists. This also has implications for fees and medical legal proceedings. Let me add that not all Fellows will be highly specialised doctors as there will be, for example, Fellows in general practice/family medicine.
The Academy and its Colleges will be in a position to advise on manpower requirements and offer career guidance to trainees. While manpower surveys are notoriously inaccurate for reasons of populations shifts, changes in disease patterns and advances in medical treatment and technology, it is important for governments to set targets for the number of medical graduates, the proportions of "generalists" as opposed to "specialists", and in the mix of specialists.
What are the resource implications? The Academy will need headquarters for a secretariat to serve all the Academy Colleges. Teaching facilities in most public hospitals and selected clinics will need to be improved, and the number of staff increased to allow time for both trainers and trainees to participate in educational activities, including research. There is justification for Governmental support in that its citizens require well-trained doctors. Furthermore, the standards of professional care are particularly high in hospitals and clinics where there is teaching and research. Also, since the clinical departments in medical schools are the training ground, so to speak, for future medical academics it appears logical that the universities should bear some of the direct cost of postgraduate professional training.
The increasing importance and advantages of ambulatory care are being recognised. Whenever possible, diagnostic procedures and treatment should be carried out in outpatients' clinics or day wards. This reduces costs and is less disruptive to a patient's life. It is estimated that in the USA, over 90% of the practice of ophthalmology (study of the eye) and neurology (study of the nervous system) and about 35% of surgical operations are performed outside the hospital. There is now a trend to shift hospital care to ambulatory care so much more teaching and training should take place in an ambulatory setting. Modern technological procedures such as endoscopy (the use of fibreoptic instruments to examine say the stomach) and body imaging are being practised without patients being admitted to hospital. It is noteworthy that training in general practice or family medicine has, for many years, been successfully achieved in an ambulatory setting.
There is no need to emphasise the importance of research to this audience. It is a vital function of university teaching staff and the tertiary institutions have been gratified that Government, through the University and Polytechnic Grants Committee, has increased research funding by nine-fold since 1988. This university has a notable record of research and this was highlighted by the Vice-Chancellor in his address to the Congregation on November 21, 1991. However, Hong Kong still spends less on research and development than our neighbours such as Singapore, Taiwan and South Korea. Fortunately we are moving in the right direction. Research is essential for good teaching, and the opportunity to conduct research is what influences many doctors to pursue an academic career.
What about continuing medical education which should be a life long process? This is difficult to enforce but in certain countries specialists have to be re-assessed every five years or so in order to retain their specialist status. The Academy Colleges would be in a position to organise CME programmes and periodically re-certify its Fellows. It is said that there are few who can keep abreast in any field of contemporary medicine without at least eight hours of study a week! It is a duty, owed to patients and students/trainees, to find this time. This would be facilitated if there were more doctors to share in the work and less involvement in administrative responsibilities, nowadays repeatedly asked of hospital staff!
The Hospital Authority (HA) was established in 1990 under the chairmanship of Sir S Y Chung to oversee the management of the public hospitals and to integrate the government and subvented hospitals. It operates outside the civil service and therefore has more flexibility in management, staffing and finances. What will be its impact on undergraduate and postgraduate teaching of doctors and the training of nurses and allied health professionals? With improved management, overcrowding, should be much less. Most medical staff of the HA will be expected to participate in teaching and training and this will be helped by improved staffing ratios. New information systems will be introduced resulting in better patients' records. There will also be more opportunities for research and staff development. But all this costs money. The appropriate funds should be provided if medical standards are to be improved and maintained at a high level. After all, Hong Kong spends less on health and medical care (total expenditure 3.4% GDP) when compared with Japan (6.8%), the UK (6.1%) and Canada (8.6%).
One concern with the establishment of the HA is the separation of hospital and primary health care. These should form a continuum, and one Department of Medical and Health would be in a better position to integrate this type of service, enabling doctors and nurses to practice more holistic and continuing care. In the meantime, it is hoped that primary care or family physicians, nurses, and allied staff in the community, will interact closely with hospital staff to avoid this fragmentation of patient services.
Medical education and training have undergone many changes in recent years. Advances in technology have made enormous contributions to community health and patient care. Dr Lewis Thomas once lamented that we live in an era of "half technology", where high technology is used primarily for palliation rather than prevention or cure. Fortunately this is changing as many serious infections can be prevented or treated, cancers cured and crippling inherited disorders diagnosed before birth. However, the new technology has also generated issues which are often complex and involve much more than just medicine. These include the quality of life, human values, human rights, the dignity of dying, the economics of health care and priorities both within the profession and in the community. While medical doctors are trained to use new technology, they are poorly prepared to deal with these issues. This aspect of medical education and training needs to be urgently addressed by medical schools and postgraduate institutions, such as the Academy of Medicine and its Colleges.
To quote Professor Prawase wasi, Mahidol University, Bangkok "There is a clear need for a new type of physician". This new physician must be a wise man, not a medical mechanic. He or she must have the wisdom to see and to understand things as they are, with the ability to acquire accurate and relevant information for analysis and synthesis, to solve problems and to make appropriate interventions. This physician must understand the word "appropriate" in its holistic sense, and must develop the wisdom to know when to use medical technology and which technologies to use.
Lastly, "Moses lived three score years and ten and after several thousand years of medicine we are living three score years and nineteen!". This perhaps facetious remark brings me to my final comment. Medical doctors should realise that the achievement and maintenance of health is multifactorial. While medical measures such as vaccination, early detection of disease, better therapeutic regimes and modern medical facilities all contribute to a healthier society, equally important, if not more so, are social factors. These include housing, schooling, employment rates, working conditions, the environment; better hygiene brought about by a clean water supply, efficient sewage disposal, food inspection and control of pollution; and last but not least, health education. It is sometimes difficult to determine whether a higher standard of living and better education have contributed more to good health in the community than improved medical care. No doubt each plays an important role as these factors are interrelated. Enlightened governments have rightly sought improvements in these social factors in addition to upgrading public health and medical facilities. One price to pay appears to be an increase in heart disease, cancer, and mental disorders, all associated with a more "developed" and urban society. Be that as it may, our medical graduates must always maintain a broader view of medicine and consider matters beyond the hospital or clinic. They certainly should not be discouraged, but rather encouraged, to pursue careers in social medicine, administration and management or even politics. Surely this is in keeping with Dr Sun Yat-sen's philosophy.
