Summary

Professional autonomy is a privilege. It is not a right. To keep this privilege, the medical profession has to continuously assure society of the professional standard and discipline of doctors. Failing that there would be openings for outside managers to step in, manage and monitor doctors, and assure society on their behalf.

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Dr Donald Li, Members of the Council of the Hong Kong College of Family Physicians, colleagues and friends, at the 1998 Annual General Meeting of your esteemed College, I gave a talk titled, “Primary Health Care Financing”, subtitled “Taking the Medical Profession into the New Millennium”. Now that Y2K is almost over, and the new millennium is at our doorstep, it is my duty as your representative in the legislature to talk, if not take, the medical profession into the new millennium. This is the reason why I am here tonight.

It is a pleasure talking to you. Some of my wishes came true after talking to you last time. I hope the same will happen this time. I cannot tell you what my wishes are, but if you were to invite me for a third time, you may know.

Professional autonomy is a privilege. It is not a right.

A privilege is given to us, when we contract to fulfil certain requirements. We can only keep a privilege, by continuing to fulfil the requirements. The requirements change with time.

In contrast, a right, once acquired by a person, cannot be taken away, unless under some extreme and exceptional circumstances. When a person has a right, another party has a duty to upkeep that right. For example, the birth right of a person to reside in a certain country and claim citizenship cannot be taken away lightly. The country has a duty to allow and facilitate the person to exercise this right.

Professional autonomy is not a right. Society does not owe us anything. Society is not obliged to allow us and to facilitate us to exercise any rights as doctors. Society has given us the privilege to practise medicine, to charge fees as medical practitioners and to be known publicly as medical practitioners.

We owe society for these privileges and have to continuously fulfil the requirements of society to keep these privileges.

What are the requirements of society?

We have to self-regulate to maintain (1) our standards, and (2) our discipline.

We as a profession assure society that persons registered as medical practitioners fulfil the basic standard to practise medicine. This standard is assured through the Medical Council recognising the training of the two local medical schools as sufficient, and through the licentiate examination for non-local graduates. The internship and the certificate of experience are other quality assurance measures.

The Academy of Medicine and specialist registration by the Medical Council ensure that doctors registered as such fulfil the basic requirements of becoming specialists. Compulsory Continuing Medical Education (CME) ensures that specialists continue to study after their registration.

Society has been demanding more assurances, for example, more regulation of the private practitioners’ clinics.

The medical profession is exploring more relevant means to continuously assure the quality of doctors, for example, by Continuous Professional Development (CPD) programmes.

The medical profession assures society of the discipline of doctors, through disciplinary investigation and hearings of the Medical Council. The Medical Council has decided recently to take up complaints regarding excessive fees, although according to Dr Lee Kin Hung, Chairman of the Medical Council, the excess has to be astronomical before it is regarded by Council as such. The Medical Council is exploring the means to set up a Professional Performance Committee to investigate complaints arising from poor professional performance of doctors. The Council has not yet arrived at a final decision on the power and operation of the Committee.

Despite all these initiatives, there are always voices demanding more, for example, there have been incessant demands for an independent and expedient mechanism for making complaints against doctors and health care providers.

The medical profession has been given the privilege to assure society of the standards and discipline of doctors by self-regulation, because it is in the interest of society to do so. Self-regulation is not the only available mechanism for making such assurance, but is believed to be the most cost effective means to do so. No one knows doctors and the professional activities of doctors better than doctors themselves. Therefore, if doctors can undertake to self-regulate in a fair and open manner, it will be the most cost effective means to do so.

There are, of course, other means to regulate doctors. For example, the Government may regulate doctors directly, by requiring them to go through a licensing examination conducted by the Government, and further regulating them by a team of Government employed censors.

The present system of self-regulation of doctors is provided for by the Medical Registration Ordinance. The system does not give doctors complete autonomy, but is a compromise accepted by the medical profession. 14 of the 28 members were elected from doctors. 10 of the remaining 14 are also doctors, appointed by the government from the two medical schools, the Academy of Medicine, the Department of Health and the Hospital Authority. The remaining 4 are Government appointed lay members. Doctors accept this arrangement largely because of financial consideration. We are using Government premises and staff. We are also using Government resources when the Medical Council defends its rulings in the higher courts.

It is a Government policy to charge fees related to professional regulation according to the user-pay principle. It remains to be seen, whether our professional autonomy will increase with the increase in fees charged, and whether doctors welcome such increase in professional autonomy.

I met Professor William Hsiao, the author of the Harvard report, last week. He re-iterated his advice to the American Medical Association 12 years ago and the Hong Kong Medical Association 1 year ago: “If doctors do not regulate themselves, somebody else will step in and do it for them”.

Medical services in the United States have been dominated by Managed Care Organisations (often abbreviated by Hong Kong Doctors as Health Maintenance Organisations, or HMOs), in the 12 years since the Professor has given his advice. Managed care in the United States owes its success and survival to customer satisfaction. It assures customers with measures that doctors themselves are either unwilling or unable to adopt. For the managed care organisations, there are two groups of customers to satisfy. The first group are the employers who buy health care packages for their employees as part of the employment benefits. The second group are the end users.

Managed care organisations assure employers by the promise to maintain their employees’ health at an affordable cost. They put a lot of emphasis on immunisation and disease prevention. They have a stronger incentive to keep their clients healthy.

The successful managed care organisations assure endusers of a reasonable quality of service, by removing the incentives for doctors to under-treat or over-treat, by training, by treatment guidelines, and by supervision.

Have doctors practising on their own been able to provide clients with such assurances? If not, why not?

It was, therefore, a pleasant surprise to me, when some leaders of our profession, who have long been known for their confrontational style, and have a history of opposing Continuing Medical Education (CME), advocated publicly that if their ‘doctors owned’ HMO can be formed, there will be CME requirements for participating doctors and peer review within the group.

I wish them every success. I appeal to them to work for the survival of the medical profession, rather than just for votes in elections. Votes after all are merely a means to an end. The end, within the context of doctors, is the well being of our profession.

It is no longer helpful to try to mystify the practice of medicine as an art, even though it can still be an art. The science of management of the behaviour of doctors has advanced to such an extent that what is happening inside the consultation room and the operation theatre can largely be measured. These measurements are used to justify the existence of managers, but managers can only exist if there is a need for their services. There is a need for their services because our customers need assurance.

Doctors, despite the resentment of being monitored, must take steps to understand the science of Managed Care, get on top of it, so that they can be masters of this science, rather than becoming its helpless and angry slaves. We can explain to the public the ‘evils’ of Managed Care. We can also demand legislation to regulate Managed Care. But what we need more is the support of the public. We can only have the support of the public if we can provide them with an adequate assurance on the quality of our services.

Doctors do have something to learn from the successful Managed Care Organisations. Rather than merely criticising them for their exploitation and for taking away our professional autonomy, the medical profession will be well served, if we can re-visit the meaning of professional autonomy, which, I believe, is based on an adequate assurance of customers, failing that there will be openings for outside managers to step in to give the assurance on our behalf.

I will end with the Physician’s Prayer.

Lord, Thou Great Physician, I kneel before Thee, since every good and perfect gift must come from Thee.

I pray.

Give skill to my hands, clear vision to my mind, kindness and sympathy to my heart. Give me singleness of purpose, strength to lift at least a part of the burden of my suffering fellowmen, and a true realisation of the rare privilege that is mine. Take from my heart all guile and worldliness, that with the simple faith of a child I may rely on thee.

Amen.

Key messages

1. Professional autonomy is a privilege.
2. The medical profession has to continuously reassure society on the standard and discipline of doctors, in order to keep the privilege of professional autonomy.
3. Managed care organisations owe their survival to customer satisfaction. They satisfy corporate clients by keeping the health care cost of the employees affordable, and reassure the end users by ‘managing’ the doctors.
4. The medical profession has to keep its house in order, so as not to leave openings for outside managers to step in to reassure patients on its behalf.

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