The tragic decline of public doctors

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Our public hospitals are haemorrhaging medical talent to the private sector, leaving patients to linger on enormous waiting lists. Special report by Shirley Zhao. Photography by Brett Elmer

Eighty-eight-year-old Lung King-fai has been waiting four years for cataract surgery on his right eye at the public Hong Kong Eye Hospital. He received similar surgery to his left eye in 2010, after a wait of six years. His geriatrician at Kwong Wah Hospital – another public hospital – struck him from the unit’s waiting list late last year ‘for more urgent patients’. And to add insult to injury, he has worsening lower back pains, for which he is on another waiting list.

“In the last appointment [with the geriatrician] they took four tubes of blood from me for testing,” Lung tells Time Out. “Then they cancelled my next appointment. I argued they should follow it up, but they told me they lacked the staff. They said my cardiologist [also at the same hospital] should follow this.”

The next appointment with his cardiologist will not occur until April this year, four months after his last appointment. Had he not been struck off the list, Lung could have received his blood test report in September last year. “These days my back pains are getting worse, and my legs ache too,” he says. “Sometimes it becomes so painful that I can barely stand up and walk, but I still have to wait until April to have them checked out.”

Lung shows Time Out a large collection of capsules and tablets. “They gave me all this medicine, enough for several months or years, and then asked me to wait. Fortunately I’ve taken them for long enough not to mix them up.”

At present, a waiting time of more than a year is not uncommon among Hong Kong’s public hospitals, which handle about 90 percent of the city’s inpatients and 15 percent of outpatients. Given Hong Kong’s aging population and the increasing demands on experienced doctors in the lucrative private healthcare sector, the public hospital system is now running on maximum overload. According to statistics from the Hospital Authority (HA), which manages the city’s public hospitals and their resources, since 2009 the number of both inpatients and outpatients has been steadily rising, while the supply of local medical graduates has fallen from 310 a year in 2009 to 280 in 2010 and further still, to just 250, last year. The situation gets even worse. Some 267 doctors left the authority for the private sector in 2011 (a turnover rate of 5.3 percent). According to Dr Leung Pak-yin, the chief executive of HA, up until last September the authority had 200 doctor shortages for various units and a further shortage of 300 doctors for its new service programmes.

Among all departments, the shortage is at its most critical in accident and emergency (A&E), anaesthesia and the medicine departments because of ‘exceptionally long working hours and fewer opportunities for promotion’, according to Dr Choi Kin, president of the Hong Kong Medical Association. This month alone, the average waiting time among non-urgent patients in A&E wards has passed the three-hour mark.

“If we don’t have urgent needs, why go to the A&E ward in the first place?” asks Lee Kui-chan, who recently waited two-and-a-half hours at Tseung Kwan O Hospital for a severe diarrhea complaint. “I went to the bathroom there several times, feeling very unwell,” he says. “Even if your needs are less urgent than others, your symptoms can still get worse while you wait.”

According to Choi, in July each year, fresh medical graduates are assigned to different public hospital departments for training, but fewer graduates are choosing A&E wards because of the frequent requirement to work overnight, as well as the slim chances of promotion and the less likelihood of them joining the private sector in the near future.

Keith Yeung used to practice in the medicine department at Tuen Mun Hospital. In October 2010 he left the hospital and became a private doctor. “I felt I couldn’t have a good career development in HA,” he tells Time Out. “Myself and several other doctors had been requesting training for a long time, but it was never approved. In the frontline we had a very heavy workload because there were not enough people, so I decided to quit.” Yeung says he worked around 60 hours a week at Tuen Mun Hospital. “The working hours [in the private sector] are similar,” he admits, “but now I have a more flexible schedule.”

Yeung thinks the HA has not effectively used its budget, which reached a total of HK$36.8 billion in the 2011-2012 fiscal year, amounting to around two percent of the city’s GDP in 2010. “HA puts a large share of its budget on increasing non-urgent services like plastic surgery and renovating hospital buildings,” says Yeung. “Meanwhile, the busiest departments can’t get enough money to promote more doctors. I’m not saying those services are unnecessary but our society should really have a real discussion about the focus of the public hospital system.”

In an emailed reply to Time Out, a spokesperson for HA admits to a ‘critical situation of its doctor manpower shortage’ but stresses various methods employed to keep doctors from leaving, such as enhancing professional training and providing better ‘promotion prospects and remuneration packages’. However, Yeung tells Time Out that in 2010 the authority cancelled several positions for promotion at public hospitals in the New Territories West cluster (Hong Kong’s public hospitals are geographically organised into seven clusters), including Tuen Mun. The reasons were due to limited budgets, he claims.

The New Territories West hospital cluster, along with New Territories East and Kowloon East, has a relatively longer waiting list than most other hospitals. According to statistics from HA, the median waiting time of non-urgent outpatients in the Kowloon East cluster is 60 weeks, compared to just seven weeks in the Hong Kong West cluster.

Leung Ka-lau, a legislative councillor, believes the difference in waiting times shows an imbalanced allocation of resources. “HA doesn’t distribute its resources according to the patient-doctor ratio in different clusters,” says Leung. “So far we still remain in the dark about the standards HA take when distributing resources.” HA declined to comment on its resource allocation system.

According to a report discussed at a recent meeting of the Legislative Council health services panel, serious medical errors occurred between October 2010 and September 2011. Although there is no direct link between the shortage of doctors and increasing medical errors, research conducted in 2011 by the Frontline Doctors Union shows that about 80 percent of the 700 interviewed public hospital doctors admitted that their medical judgements had been affected by ‘overworking’, with a further 40 percent saying they had made ‘medical mistakes’ due to long working hours.

This month, to ease the pressure on public hospital doctors, nine non-local doctors were recruited by HA under limited registration and without a qualification examination. Selected from 160 applications by the Task Force of Limited Registration, these nine doctors were assigned to Tseung Kwan O Hospital, United Christian Hospital, Prince of Wales Hospital and Queen Mary Hospital. Six will serve in anesthesia departments, two in medicine, and one in A&E.

Dr Tse Hung-hing, former president of the Hong Kong Medical Association, opposes the recruitment.

“These doctors haven’t been trained in Hong Kong’s public hospitals,” Tse states. “They didn’t even take the examination. The one assigned to Tseung Kwan O Hospital’s A&E has never worked in A&E before. Recruiting them is putting Hong Kong’s citizens at risk.” Tse also calls the hiring of doctors from Commonwealth countries without examination ‘unfair and politically incorrect’, whereas doctors from mainland China and other non-Commonwealth countries have to take an examination to register in Hong Kong.

Terence Yuen Mang-ho, vice-president of the Frontline Doctors Union, says that while he ‘will not reject’ non-Hong Kong doctors without examination, some concerns remain. “In many other countries like Britain the standard working hours for doctors are 44 hours a week,” he states. “These doctors could easily get exhausted under Hong Kong’s long working hours and heavy workload.”

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