What would Dr Sun have done?

Gabriel M Leung 梁卓偉

HK Pract 2016;38:78-82

Secretary Ko, Under Secretary Chan, Dr Miller, President Chan, honoured members of Council, Presidents and Officers of the other Academy Colleges, fellows, distinguished guests, ladies and gentlemen,

The year 2016 marks an important anniversary for the Chinese nation, across the Straits and throughout the diaspora. We are celebrating the 150th anniversary of Dr Sun Yat-sen’s birth. Dr Sun was also one of the first two graduates of the Hong Kong College of Medicine for Chinese, to which The University of Hong Kong (HKU)’s medical faculty traces its roots. To be given the opportunity to present the eponymous Oration for the Hong Kong College of Family Physicians is therefore a doubly special privilege. I am however under no illusion that this honour belongs squarely to the HKU Faculty of Medicine, and I merely a vassal, as Dean, to represent the collective. Nevertheless the burden is heavy and I beg for your indulgence over the next half-hour.

To doctor is to teach. I am a huge fan of teaching. In fact I still carry the same teaching load as my junior colleagues. I enjoy teaching so much because I have found that time and again, I learn nearly as much from my interactions with students than they from me. So in helping me think through the many difficult decisions I have had to make during my deanship so far, I have often invoked the titular question of my Oration, “What would Dr Sun have done?” Let me relate three such questions that I, as the latest dean, have posed to our school’s first student as thought experiments.

First, Hong Kong is now said to be seriously torn between the young and those not-so-young, between the haves and the have-nots, between those who identify with our nationhood and those whose singular focus is on the local here and now. Regardless of one’s political persuasion, most would agree that these tensions first became apparent and was perhaps driven in part through “Occupy Central” or the “Umbrella Movement” in late 2014. As a university leader, I found myself in the eye of the storm during that critical time. A major decision I had to make, even before tear gas was deployed, concerned whether I would allow students to be absent from class and perhaps even request my colleagues to reschedule and/or post their lectures and tutorials online to facilitate students to self-study.

In 1913, two decades after Dr Sun graduated, he declared that “medical affairs and hygiene are truly the roots of the affairs of men”. This was very much in the same vein of the famous dictum by the great German physician, Rudolf Virchow, who was about one generation Sun’s senior, which reads:

“Medicine is a social science and politics is nothing else but medicine on a large scale.”

What does not get quoted nearly as often though, and which made me reflect a lot before making that key decision, goes on to say:

“Medicine as a social science, as the science of human beings, has the obligation to point out problems and to attempt their theoretical solution; the politician, the practical anthropologist, must find the means for their actual solution.”

In other words, it would be fine, in fact morally obligatory, for us as doctors to diagnose society’s problems but it would be foolhardy for us to imagine that we should be responsible for actually executing solutions. At least this is what Virchow proposed.

But students of history will immediately point to the fact that treating political ills was precisely what Sun did, and in large part succeeded in doing, albeit never completed.

So, having taken in these historical facts and words of the wise, I had an important decision to make. Here was how I reasoned it. I respected students’ resolve to hold fast to their political beliefs and to act on them. My only advice to them at the time was that they should think through all the interconnected, complex issues, weigh their pros and cons, then arrive at a conclusion that they could justify to their own conscience and would not live to regret. At the same time, given the statutory power of certifying satisfactory completion of licensure requirements granted the University, and I as its authorised person to administer, I could not excuse class attendance no matter how noble or worthy the cause in the eyes of students, especially when our curriculum is so reliant on in-class participation and continuous assessment. I became the only dean, or vice chancellor for that matter, to have spoken out unequivocally on this issue of maintaining course requirements, including class attendance. It was nonnegotiable.

That said, I took my pastoral role seriously enough to have been among the first to visit students at the occupied sites within 24 hours of tear gas canisters exploding on Harcourt Road, and not once but three times over the course of the next 79 days. I did not allow the usually conservative, pro-Establishment lens expected of a senior administrator blinker how I saw and acted towards those students who chose to support the civil disobedience campaign. After all, if one were to really believe in Dr Sun’s legacy, were he not once a student leader who plotted against the then millenniaold dynastic regime? Did he not assemble with other like-minded student agitators while reading medicine at the College? In fact, during his homecoming in 1923 to the University, in his address Dr Sun proclaimed:

“Where and how did I get my revolutionary and modern ideas? The answer was, ‘I got my idea in this very place; in the Colony of Hong Kong.’”

Mind you, he satisfied all the course requirements and in fact received some very good grades, thus was able to become one of two first graduates when in fact ten others enrolled at the same time but graduated in later years. He did not shirk his academic responsibilities as a student, nor sought special dispensation. Whatever political action he undertook, he made the corresponding personal sacrifices that made his civil disobedience all the more respectable.

On the other hand, is the job of a dean not one to look after students, not because of but in spite of their actions, which are often deemed “wrong” or at least inappropriate in the eyes of the Establishment? Were it not for the personal intervention by the College’s second dean and surgeon, James Cantlie, the captive Dr Sun would not have quite so easily escaped his kidnap by the Chinese legation in London in 1896, barely four years after graduating from the College.

Moving on to my second thought experiment with the legacy of Dr Sun as guide: our profession has been engaged in a tug-of-war with government and patient groups, and indeed with itself, over the addition of four lay members to the Medical Council. The crux of the matter is really about whether this represents the start of a slippery slope towards more external oversight and intervention, and indeed at its heart about the admission of non-locally qualified graduates. Dr Sun’s short but by all accounts brilliant medical career holds sobering lessons for this case.

Sun Yat-sen enrolled at the Hong Kong College of Medicine for Chinese based out of a couple of rooms in the brand new Alice Memorial Hospital in 1887 and graduated in 1892, together with Kong Yingwah (江英華). Both were presented with the Licentiate in Medicine and Surgery of Hong Kong (LMSH) certificate by then Governor William Robinson. However, the paradox of paradoxes was that this pair of newly minted licentiates were not actually licensed to practise in Hong Kong. Note well that the licentiates of yesteryear are very different to the fully qualified licentiates (LMCHK) today. In fact, none of the College’s graduating licentiates throughout its entire 25-year history were recognised as licensed medical practitioners. Belatedly in 1923, 11 years after the College closed down, as if to add salt to injury although it was probably intended as an act of reconciliation, the Medical Registration Ordinance, the very same one in question today, was revised to contain the following provision:

“Notwithstanding anything in this Ordinance contained every present and every future licentiate of the Hong Kong College of Medicine shall be entitled to practise medicine and surgery and to demand and recover reasonable charges in respect of such practice: Provided that no such licentiate shall be entitled to sign any certificate required for the purposes of the Births and Deaths Registration Ordinance, 1896, unless he has been authorised thereto by the Governor.”

Fortunately HKU graduates have since the time of the University’s founding enjoyed direct registration without further external examination to this day.

Going back to our protagonist Dr Sun – he was refused permission to practise in the very place he graduated. One cannot help but feel the irony of his circumstances especially when viewed through today’s localism lens. Governor Robinson, as Patron of the College, was so keen to put the first two graduates into gainful employ that he wrote to Nicholas Robert O’Conor, British Minister Plenipotentiary in Beijing who in turn petitioned Imperial Minister of Beiyang (北洋大臣) Li Hongzhang (李鴻章) to intervene. Li gave a swift positive response and asked them to report to Beijing as quickly as possible for their appointments. Before they were to proceed however, Cantlie had to take the two graduates to Canton to see Li Hanzhang (李瀚章), elder brother of Li Hongzhang and Viceroy of Guangdong and Guangxi (兩廣總督), to process their Badge of the Fifth Grade of Imperial Commission (欽命五品軍牌) , where upon they were asked to complete a genealogy of their respective families going back three generations. Sun took this as a personal affront typical of the decaying Qing officialdom, therefore refused to comply and left.

For every door that was closed to him, Dr Sun opened another. Given the proximity to Xiangshan (香山) , his ancestral home, and the apparent permissiveness of the authorities, at least initially, he proceeded to Macau and opened the Chinese-Western Apothecary (中西藥局), combining western allopathic practice with traditional Chinese herbal therapy. He also performed surgical procedures at Kiang Wu Hospital (鏡湖醫院), often with the assistance of James Cantlie.

“When major operations had to be done I went on several occasions to Macao to assist him, and there, in the presence of the governors of the hospitals, he performed important operations, requiring skill, coolness of judgement, and dexterity. It was a goodly journey to Macao by sea, and took me away a considerable time from my daily routine of work. Why did I go this journey to Macao to help this man? For the reason that others have fought for and died for him, because I loved and respected him.”

So the good teacher spoke. But this barely lasted the year 1892, as Cantlie went on to describe:

“Sun, however, had to quit Macao, because, under Portuguese regulations, no one not possessing a Portuguese diploma could legitimately practice there, and so he removed to Canton to work.”

Harold Schiffrin wrote in his book Sun Yat-sen and the origins of the Chinese Revolution:

“…the Portuguese physicians, who monopolised European medicine in their colony, saw in him a professional threat and prevailed upon the Macao authorities to bar him from practicing on the grounds that he lacked a Portuguese degree. The real reason was probably the lack of reciprocal recognition between the medical authorities of the two colonies. Since Portuguese as well as other degree holders were barred from practising in Hong Kong, the Macao government was under no obligation to recognise a Hong Kong medical diploma, especially one that did not even meet British standards...Thus shortly after he began his dual practice in Macao, the local authorities disqualified him from treating Portuguese patients; later they went a step further and forbade all pharmacies to fill prescriptions sent by foreign doctors.”

Again it was a matter of licensure.

He set up practice in partnership with Wan Man-kai (尹文楷), a Qingdao medical graduate. Soon afterwards, as his revolutionary activities gathered momentum, Dr Sun gave up practice entirely and donated his surgical instruments to a former Hong Kong College of Medicine for Chinese schoolmate Kwan King-leung (關景良), also known as Kwan Sum-yin (關心焉), who graduated a year later than Sun. Kwan was the first College graduate to eventually set up a practice in Hong Kong and served on the board of the then fledgling Yeung Wo Nursing Home (香江養和園) – predecessor to the present-day Hong Kong Sanatorium and Hospital.

And so Dr Sun’s medical career lasted only two years until 1894. I have often wondered, what would have been the course of our nation’s history had he adhered to Li Hanzhang’s (李瀚章) requirement of a family history check? What would have happened to the republican movement had the colonial authorities granted our College licenciates a proper and full licence; or for that matter had there been mutual recognition of licensure with Macau, or in other words between the Portuguese and British governments (which today there is through the European Union of course, at least until Brexit)?

Viewed from this historical perspective and the lived experience of Dr Sun, today’s rancour over the addition of four lay members to the Medical Council is but a storm in a teacup, and a mere footnote to the long arc of history. As Martin Luther King Jr. once said, “the arc of the moral universe may be long, but it bends towards justice”.

The third and final question I posed to my imaginary interlocutor Dr Sun was about how I should have responded to the apparent attempt to lure away top-scoring high school graduates by allowing some to skip the first year of general and broadening education at our sister institution on the other side of the Lion Rock, despite their University’s own pioneering role in the provision of such.

Dr Sun was 26 when he graduated from the College. His fellow licenciate of the same year, Kong Ying-wah was 21. The other 10 of the original 12 who enrolled in 1887 with Sun and Kong, did not graduate until 1893 through 1895, making their studies 6 to 8 years long. Today our graduates are usually 23 years-old by the time they walk across the stage in a ceremony much like the present gathering.

Before Sun Yat-sen was admitted, he first attended Boji Medical School (博濟醫學堂) in Guangzhou in 1886, then transferred to the Hong Kong College of Medicine for Chinese when it opened its doors in 1887. This was after an extended transcontinental preparatory education from age 10 in Xiangshan (香山), followed by an overseas stint with his brother Sun Mei (孫眉) in Honolulu from 13 to 16 years of age, then Hong Kong from 17 years-old onwards until graduation as a licentiate. If this n-of-1 trial is any indication, great leaders are a synthesis of their diversity of experience, a culmination of their life journey, which could only be fully realised if given the time and patience in its nurture.

Importantly, there was absolutely no evidence to suggest that Dr Sun at any point during his extended educational journey looked for, let alone sought, to skip over the prescribed curricula at any of the schools he attended. In particular, he had already finished the first year of Boji’s medical programme, yet still went through presumably much of the same foundational pre-clinical content during his first year at the Hong Kong College. If anything, this apparent overlap might well have allowed him more latitude to germinate the intellectual seeds of republicanism. How much the poorer we would all be were he to have focused exclusively on the mundane technicalities of anatomy, physiology and pathology! If judged by current efficiency-obsessed standards, he reaped very little value for his 6 years of medical education only to have practised for 2 – a stunningly poor return when compared to an average practising career of 40 years!

Some of you are probably thinking that those were the days of an age past when the pace of life cannot be compared to the über intense competitive pressures of the present digital age. Let me then raise the examples of Bill Gates, Steve Jobs, Mark Zuckerberg, and so on, who all actually escaped the straightjacket of college education and dropped out altogether. Another archetype of those apparently “lost in life” during their twenties comprise such creative luminaries as Ang Lee, Harrison Ford, JK Rowling and Andrea Botticelli who shared a meandering life course until they finally found their calling in their early thirties. As Tolkien remarked: “Not all those who wander are lost.”

In the life and death world of health care , I dare say we fit into neither category of digital entrepreneurs or creative artists. The spectacular rise and fall of Elizabeth Holmes of Theranos is more instructive. She too dropped out of Stanford to establish a mass diagnostics startup that was once valued at United States Dollar 9 billion. It turned out that the technology was not all that it was made out to be, and the United States Food and Drug Administration and the Securities and Exchange Commission are both launching criminal probes against the company. Last week a civil class action suit became the latest setback for this once darling “unicorn”. The reason for its inevitable downfall was simple. John Ioannidis of Stanford Medical School summed it up best in a just published JAMA commentary:

“For any technology, and even more so for one aiming to affect health care at large, scientific peer-reviewed articles are a requirement.”

In other words, there are no shortcuts to medical science. Patient tilling and rigorous study are the sine qua non of success in our profession.

What then should we aspire to? If I may be so bold as to suggest that instead of making shortcuts for the sake of creaming off a handful of high scorers, who may or may not turn out to be good doctors after all, university dons should instead spend the time enriching the curriculum, and to the extent possible free up extended periods for self-exploration, either in research, at the bedside, going on exchanges and humanitarian tours, or otherwise giving space for the little grey cells to wander. Who knows what may result? How far do we really wish to push back the starting line? As Hippocrates quoted, “vita brevis, ars longa” – life is short and the art is long – enjoy the journey and make the most of life.

I feel completely at home on this point here at the College of Family Physicians. We have both struggled with the magic number “6” in terms of training duration. We have both held on to our common belief that there is no shortcut to quality education and training. We have both gone against the popular tide for an expedited route towards qualification. We have both believed that contrary to the famous cosmetics commercial trumpeting that “less is more”, less is really less and more is always more. Any logic-defying slogan is but just that, empty rhetoric to unsuspecting consumers. Neither of our institutions have thought those under our charge to be induced into their vocational calling should be treated as clients or consumers.

I shall not rattle on any longer. If you will permit me to do a bit of advertorial here. My full set of arguments on this issue that has plagued high school leavers and both local medical schools alike for two years running can be found in my weekly am730 column – 博極醫源 – which takes its name from the first chapter of the ancient medical treatise《備急千金 要方》by Tang dynasty medic 藥王 孫思邈.

Finally, allow me to leave you with the following images and hashtags. They are food for thought indeed, as we prepare to munch on a proper supper.