At The Other End Of The Slit-lamp Table..

As eye doctors, we examine the eyes of our patients with the aid of a slit lamp machine. Through the eyepieces of the microscope, we shine an almost unbearably strong light across different parts of the eye to detect pathologies otherwise unidentifiable by naked eyes or a simple torch. That’s a pretty standard description of how ophthalmologists work everyday. We seldom wonder how it feels to be sitting at the other end of the table, as with many other things that we have taken for granted in life.

Until last Saturday morning, I was woken by an indescribable discomfort striking across my right forehead.

As I looked into the mirror, I found my right eye had turned bloody red and the lids slightly swollen. The surface of the eye felt as rough as a piece of sandpaper, and with each blink the pain worsened and the eye couldn’t stop tearing. The thought that ‘Something isn’t right’ kept repeating in my head along with a list of differential diagnoses. I recalled seeing a patient with acute conjunctivitis the evening before, and the next thought that came to mind ‘Oh no I must have caught the virus!’

For the whole day I experienced almost every one of those unimaginable symptoms described by my patients. Tingling, stinging, aching, pulling sensation, photophobia, heaviness, soreness, grittiness, and the tiredness of the fellow eye were only a limited list of my assorted feelings, and of course not to mention my worries about permanent detrimental effects on my vision.

Those who don’t work in this field might not appreciate it, but having caught a red eye is as common but also as feared as a taboo for most if not all ophthalmology people. Not only because the condition is embarrassing, but it also signals to everyone that you are not fit to continue with your clinical duties – for the sake of infection control, you are temporarily banned from practice.

Like most doctors experiencing illness, I found excuses in procrastinating my visit to a proper examination until late that night, upon which, surprisingly, found not only an inflamed eye but also several epithelial defects on the cornea. Half startled, I knew I needed to be more vigilant about my illness and be more compliant to my treatment, otherwise there was an apparent risk of it going worse and becoming a bad infection. I had never thought how hard it would be to stick to a schedule and keep applying eye drops every hour or so.

Sitting at the other end of the slit lamp table, I came to realize how it feels to be a patient in our clinic. To have your chin up the chin rest and your forehead pressed against the strap really puts you in your patients shoes. It was much harder than you think trying to withstand the dazzling light placed only inches away from your teary, painful eye. Any lightest touch or finest manoeuvres triggered your heightened sensation. Those are the things that could never be learnt from pure imagination, but only through personal experience you gain sight into the work of your patients.

During the day I had much difficulty walking with my eyes open under the bright sunlight, it was only then I recognized even the tiniest defect could not only bring discomfort, but indeed it also impairs daily living and work.

And believe it or not, a tight eyepatch and a not-so-tight one makes a huge difference in terms of symptomatic relief. From this I learned that even such a small detail counts and every step, if done perfectly, makes a significant impact in the management of our patients. As doctors who deal with such small organs yet with such great bearings in terms of quality of life, there is as little as nil room for errors or below-par treatment.

Last but not least, during these days as I reflect upon my illness and role as a junior eye doctor, I wish to thank all my
seniors and colleagues for their undying support and kind endurance, and I wish to apologize for my absence and many duty rearrangements during this period of time.

Thanks to all those who dropped by or called or left a ‘take care’ message on Facebook, I am really grateful for your wishes and I’m sure under so many good hands of my fellow colleagues, I shall recover soon and return to duty ASAP!

The Other End Of The Slit Lamp

再說一次理想

Credits: Washington Post

公營醫院的眼科診所，永遠是眾多專科門診之中堆滿最多病人的地方。未曾來「拜訪」過的朋友可能不知道，我們半晝的舊症籌數閒閒地都超過三百人。一朝得六到七位醫生應診，每位醫生平均看上四五十人，還未計當日新症，除以四個小時的診症時間，每位病人真正見到醫生的時間有數得計。

由於每位病人病情都不一，診斷時間亦理所當然地人人不同。病情轉壞的當然要花多一黠時間照顧、解釋、診治，但你問：四小時五十籌，一人不只得那三四分鐘？額外的時間哪裡掙來呀。沒錯，唯一的辦法就是儘量節省和病情穩定的病人溝通的分鐘。但坐在診症室裡的醫生不是先知，沒有辦法估計到門外有幾個病人轉差轉好，於是唯有每症皆衝，直至努力衝完爲止，屆時又往往過了下午一時了。

隨著人口老化，公營病人越來越多，加上近幾年HA出現離職潮，醫生護士的數量就只有越來越少，變相每位病人得到的時間越少，新症輪候時間則越長，以我們中心為例，早已破一百周大關了。意即是說，若然你今日交封轉介信到我們診所，分分鐘要等到2014才有空看你。但事實是醫生護士並無偷懶，從早到晚都做得沒停過手，無奈苦候的病人太多，久久抱恙就是為了等待那還不夠三分鐘的應診（有時什至連問候的空都沒有），自然心裡不好受。但想想，若然不是如此狂風掃落葉地爭（搾）取醫生的一分一秒，哪又怎能在短短時間裡照顧所有有病的人。畢竟公家不能像私家般，人人說它二三十分鐘，但將心比心，當你家人有身體上的毛病的時候，你還不是希望多了解一點，多聽醫生說多一點嗎？況且正正因為時間實在不足，真正解釋病情的時間根本少之又少，稍一不慎，醫生病人之間又就擦出很多不必要的火花，接著又是見報上訴醫療失誤，於是大眾對醫療服務的信心再度下挫，如此一個惡性循環，相信任誰都看得懂．．．

如此的制度乍聽上來的確荒謬，但細想一下卻是滿懷無奈和苦衷 ﹣光是看著過去五年急速增長的求診人數，不難想像未來的日子，三百籌、四百籌，步步加上去，新症的日子越推越遠，三年、五年？假如今時今日HA再不想想辦法改善現今殘缺百出的公營醫療制度，誰知哪裡會是盡頭？

也許盡頭就是當醫生護士人皆殆盡，暴斃離場。也許盡頭真是不遠矣，君不見網頁上都是醫護人員呼救吶喊的聲音，政府你可聽到沒有？你可把垂死一群人的話聽進心裡去嗎？

正如我一直相信的是，幹醫護一行不是有甚麼特別比人「巴敝」神聖的地方，我們都是一群充滿本土文化的打工仔，早在入行的一天就預計不求回報的付出了。我們當中有許多同袍都願意為病人奉上自己僅有的休息／私人時間來照顧病人，甚至連自己性命都犧牲上的故事亦不只一次感動我們香港市民，但付出過後的我們又能看到什麼一片前景呢？

可能你會認為，現在病人多，對年輕的醫生來說不就是好事嗎？一天看七八十個病人，經驗該長得比許多其他國家的初級醫生要快啊！是真的，對，我們真的很需要這些讓我們成長的經驗，我亦認同「如何能好好分配四小時來看六十個病人」都是訓練的一部份，所謂快而準，都是靠苦練出來。那，在我這種初級醫生而言，是沒有甚麼問題的。但部份病人不會明白（他們是知道的，卻不會去明白）年輕醫生的弱點，正正是經驗不足，年輕醫生若然一不留神，少說一句半句，隨時都有可能踏進圈套，觸發病人的偏見，再加上他們經已呆坐了三四小時冷板凳，所謂「佛都有火」，一場口角勢必如箭在弦。又聽過「揠苗助長」這句說話嗎？我總在想，倘若一切不變下去，十年八年後，我們屆時的新同事會是每人看七八十籌嗎？那種制度，真的是我們期待見到的理想嗎？

數到中高層的前輩，面對的困境肯定比年輕的一代更加嚴峻。眼見自己的舊同學跑私家的，一天就賺回了你一整個月的糧，你還要兼負一拖三四五位受訓醫生，勞心勞力教之餘，還有數之不盡的Admin duties，怎教人不身心疲累？光是想起這就覺得HA真是待這班人比紙還要薄，還要制定這樣那樣的行政要求（例如“縮短”新症輪候時間 ﹣are you kidding me?），為的就是「做靚條數」，為的就是一班坐在冷氣房間總部不食人間煙火的大老闆。你可想而知，為何HA走的人只有越來越多，留下來的則越做越辛苦。你又會明白為何有私家醫生寧可Part-time 開咖啡店，都不願回巢（HA）𢭃你那份少得不合比例的糧。他們並不是都向錢看，叫他們心淡離場的，只是找不到要留下來受打的理由。

總括現在的公營制度底下，不管你是資深醫生抑或學徒仔，護士還是病人，人人都是這個制度下的受害者。醫生有口不能言（沒空），病人有口不敢問（沒空），最終只會弄成兩敗俱傷的局面。如何拆彈？我認為政府先要拿出誠意，好好反省現今制度上的缺失，把問題都真真正正identify了，才有下一步構思solutions、編織願景的空間。另外不妨多學習其它國家的醫療制度的利弊，例如推行全面醫療保的話，絕對可以參考美國行這一套的得與失。永不探求，坐以待斃，則HA淪為沉船勉指日可待。

正如老闆所言，Admin 的事永無對錯，制度總會有利有弊。我們不介意來一場轟轟烈烈的醫療革命，但起碼我們必需要看到我們理想中的風景。沒有理想，所有制度都只會腐化，正如這個城市，只會繼續 Dying 下去。

Credits to RTHK: Not An Uncommon Scene

600mg Slow K = ?? bananas

A patient suffering from glaucoma walked into a doctor’s office for her usual follow up. Examination noted markedly elevated intraocular pressure of her eyes which indicates pressuring-lowering treatment in order to bring the pressure down to a more favourable level.

One of the medications used for lowering ‘eye pressure’ – acetazolamide, bears a side effect known as hypokalaemia, an abnormally low level of potassium in blood, which could in turn affect cardiac function, thus it is a usual practice to prescribe oral potassium supplement at the same time.

When the doctor asked her about her compliance to medications, she confessed her fear for taking too many pills at a time and hence discontinued the potassium supplement by herself. Instead, she told us that she has been taking one banana everyday as a natural substitute. Then she asked,

‘Doctor, how much potassium is there in a banana? ‘

‘Am I getting enough potassium if I take one banana per day instead of the slow K?’

For sure these are some pretty interesting questions, and honestly I really don’t know anything to answer her questions if I were her doctor. So I ran a quick search on Google for a more reliable reference from the nutritionalists. And there it goes,

FACT: One medium size banana contains ~450mg of potassium.

So that is the answer to her first question. But if you take her second question one step further, now that you know even though a slow K pill contains roughly around 150mg more potassium than a medium size banana, how much significance would that little difference contribute to our clinical practice and patient management?

And who set the line at 600mg instead of 559? Is it possible to measure exactly how much potassium is being lost in excess of our normal daily excretion after taking 500mg of acetazolamide? Is 600mg the exact amount we need to combat the effect of Diamox?

Bear in mind in medicine, there are quite a lot of arbitrary lines and boundaries that are drawn from previous experiences and data, for example those testing dosages extracted from large scale trials and cohort studies. So we know 600mg is not a definite magical figure, but the reason that we use this dosage is probably because it works most of the time.

So next thing she asked, can two bananas replace one slow K pill?

Well honestly I still don’t know. If you only look at the absolute amount of potassium, then the two bananas probably contain more. But if you are taking into account of the differences in terms of digestion, absorption, metabolism, elimination and the fact that bananas actually contain other nutrients apart from potassium (and it’s tasy!), it’s very hard to make a good quality verdict.

So is there any other fruit that contains even more potassium? Yes, it’s avocado.

According to the website i found on the Internet, an avocado contains 900+ mg of potassium, so it’s almost equivalent to two bananas or 1.5 x Diamox pill, and hence a good alternative if you don’t like eating bananas.

The woman then said, ‘Well you know, I’ve been keeping an eye on my weight. I don’t like bananas, but avocado certainly has way too much calories for me! ‘ Yes she’s right, Avocado contains 300+ calories, that is roughly 3x of one banana which contains only around 100kcal. ‘So is there any other ‘natural’ options for me?’

‘Well, in that case,’ the doctor then turned to her slowly and looked in her eyes, and he said,

‘why don’t you just take the pills and gtfo?’

LOL!

白袍

雪白的長袍一直是醫生的身份象徵，代表着專業的操守和高尚的醫德。在醫院裡只要披上白袍，病人、家屬、甚至一切陌生的面孔都會認定你是醫生。

根據 wikipedia，原來醫生穿白袍己有超過一百年的歷史。在美國，某些醫學院更會每年舉行「白袍禮」來慶祝學生修畢 Basic Sciences 的課程，正式踏入 Clinical Training成為真正治理病人的醫生。

但隨著年代變遷，白袍亦變得普及，再不是醫生的專利，美國的牙醫脊醫視光師一樣都有白袍禮。在香港，就連非專業人士都可以穿白袍，只要你在隨便一間商場裡逛一圈，你就不難發現穿白袍的人其實多得是。先是連鎖個人護理用品店的藥劑師，再有眼鏡店裡的視光師，還未計大大小小美容院或者化妝品店的售貨／接待員小姐或嬸嬸，Dr. Xong店裡頭替你「度足」的哥哥，藥房裡的櫃臺叔叔，統統都很有型地穿著白袍，顧客於是就更覺得他們專業可靠了。

別誤會我的意思，我絕對相信藥劑師和視光師都受過專業訓練才能出來執業的。但的而且確，真的試過有公公婆婆一直以為自己定期在見眼科醫生覆診檢查，誰知原來他們只不過是到樓下眼鏡店的視光師作簡單驗眼而已。千萬不要少看這些公公婆婆，他們可真會把聽到的話照單全收，視光師說可能他們有白內障，他們就深信自己患上了白內障，至於會否是其他眼睛的毛病呢？那就不得而知了。又有聽過一位婆婆，常跟我說她買了一箱又一箱的補品，我問她在哪裡買，她答道是商場裡的醫生著她買她才買的，她還讚那店子裡還有許多東西賣，例如洗頭水、護髮素，就連替人染髮的東西都有，實在方便。聽罷頓覺心知不妙，再問阿婆那位醫生叫什麼名字？她想也不想就答：「屈臣氏！」

一件白袍不單只是一套工作服，在許多人眼中穿白袍的人就是醫生，尤其是在香港生活了好多年，一些上了年紀的老人家，他們根本不懂得分。假如商人看準這個漏洞，繼而運用白袍的潛力去推銷某些健康產品的話，消費者就相對容易中招了。

合理不合你？

二十來歲青年男子遭人狂毆後頭部受傷送到我工作的醫院，因傷口主要涉及眼睛，當值的同事應召到急症室檢查傷勢。一輪檢查功夫過後，同事斷診他右邊眼球爆裂，需要入院馬上動手術。

由於傷勢甚大，加上本身 ruptured globe 一般就算動了手術修補了都沒有很好的 visual prognosis，受傷的眼睛很大機會會失去大部分視力。手術前，同事早已花了不少時間向病人和他女友解釋清楚，他們亦簽下同意書接受手術。

手術很成功，同事和前輩通宵就把爆裂的地方修補好，之後留院不夠兩天就出院了。

臨出院，女友問醫生他眼睛康復情況，醫生如實相告：「他受傷的眼睛很大機會再看不到東西了。」女友聽罷當場再度落淚，整個人崩潰了。這又難怪的，二十歲人就此失去一邊視力，又真教人惋惜。

出院後一星期，男子回來覆診。檢查視力後，發現動了手術的眼睛竟然出乎意外地恢復了20／30視力，只是平以前多了點散光而已，配副眼鏡的話視力不就跟普通人一樣了嗎？

正當醫生護士都因此感到既高興又安慰的時候，冷不防病人劈頭第一句就質問替他動手術的醫生：

「點解我隻眼宜家睇野仲係朦架？」

點解會朦？為何不想想自己當初要不是撩是鬥非惹人毒打，又怎會弄傷眼睛？況且自己又不是傷得輕，整顆眼珠爆開了，比着幾十年前，早就註定瞎了。如今還要奢求看得比以前清？未免要求太過份了吧！

不知你又有沒有發覺，隨著一個地方開始變得富庶起來，人民恃着有錢有福利，開出的要求就變得愈高，有時甚至變得無理取鬧，硬要在雞蛋裡挑骨頭。美國的醫療制度也許就是當中的表表者。當病人的身份價值被保險劃分之後，窮和富的分野則愈趨明顯。有錢人指望用金錢去買起某某醫生的技術，沒有錢的人則把所有責任推到政府頭上，有理無理地認為自己的病是政府該付的責任，政府醫生若是治不好就只管投訴到大字報，輪候時間太長？投訴。醫生護士禮貌欠佳？投訴。投訴醫院不遂？不怕，我們去找立法會議員，請願、遊行，就是知道政府無能，惡人的聲音就越響。

這是一個投訴成風的社會。醫生提供的是被標上價錢的服務，正因付了錢，理應百發百中，百分百成功，不容有一絲的失誤。在這種令人窒息的無形壓力下，莫講仍在受訓的醫生感到被縛手縛腳的滋味，做頂頭的下下都要親自出馬，毫無出錯空間的壓力倒真叫人吃不消，受不了唯有離場。

香港人要是如此咄咄逼人下去，未來我們一班仍在受訓中的醫生的生存空間只會越來越少，香港的將來還會有敢動刀下藥的醫生嗎？

公私不分

舊同事提到他部門裡有顧問醫生正打算離開公營醫院轉投私家市場，為了確保客源，最近幾個月都頻頻在門診裡派名片，順便推銷自己的去向。

其實政府醫生由公轉私並非新鮮事，正所謂「東家唔打打西家」，人之常情矣。

可是最叫同事看不過眼的是，有好幾次他聽到該位顧問醫生在鄰房看症，前後進了兩個病人，可是說話的態度卻是一百八十度的轉變！同事事後向姑娘打探之下，才發現原來先進來的病人是私症，所以足足檢查加講解了差不多二十分鐘，語氣恭敬得叫人難以想像平時他對公立病人的刻薄。

另一位年資較深的前輩聽道，便淡淡拋下一句：「你倆還小，現實就是現實，棄公投私不就是向錢看。」

「醫生都是人，都要養妻活兒，時下香港教育一片混亂，送對仔女到外國留學動輒都過百萬，樓價又節節上升，想搵多個錢傍身都好正常啫。眼見比自己年輕的同儕早就開檔發達，賺的錢分分鐘是自己的幾倍，很難叫人不動心出去闖一闖的。」師兄一口氣說了這堆話，隨之然是三人的一聲嘆息。

師兄的話定有他的道理，縱使然未必反映著事實的全相。許多醫生公家唔打轉私家，各自都有除了錢以外的原因，可以是制度問題，行政工序，人事或者是升職仕途統統都是 Push Factors，至於投身私家自立門戶是否必賺，當然非也，說到底都是搏一舖。但畢竟，金錢的魔力倒是迷倒了許多醫生的心。

「可能那位顧問醫生就是一直希望實行自己心中一套對待病人的態度呢。」我插咀道，「我總相信有許多同袍都曾希望把自己每一個病人當作私症般，用最親切的心和耐性來對待呢。可惜制度上病人太多醫生太少，時間太少才產生『衝症』的情況呢。」

「你錯了，不是人人都像你那般天真及傻。根本「公制私症」的錢從來都不進自己袋，而是屬於部門的，既然都決意離開部門了，還幹嗎要特別呵護這班公院私症？假如一心只想開拓客源的話，那麼也可以嘗試吸引一班公家客，為甚麼只顧殷勤服務私客而敷衍一眾公症？」同事說得漲紅了臉，一臉激動。

「說穿了，這不是奴性是什麼！」同事冷不防噴了兩滴口水，險些毀了我碟意大利粉。

師兄又嘆了一口氣「總之我們做細的，不用接私症倒算走運了，與其要我利用公家醫院的時間去看私家症，怎樣說心裡總是過意不去。況且要在現實中真正做到公私不分，倒是有一定難度吧！」

「小伙子，有些時候，人在江湖身不由己啊！」

Honey On The Moon

Two weeks ago, we were known to the rest of the world as house officers, the bottom-most survivors in the huge medical food-chain, enduring a life that comprises both hardship and a certain degree of monotony.

Two weeks later, we became officially registered as real doctors, and it’s great to know that most of us had found the residency that matches our interests and desires. We no longer have to endure the pains of working in a unit which barely whetted our appetite, and we finally got to lay our hands on stuffs that we genuinely like.

Two weeks. Can’t believe our lives have changed so much in merely two weeks.

Having said that though, starting fresh as a resident did remind me of my very first month of internship – the poignant feeling of incompetence combining with the total lack of knowledge, it certainly made one feel like an SOL (space occupying lesion) on many occasions. This is perhaps even more true in the place where I’m working right now – the Department of O & VS.

Unlike other fields in medicine, ophthalmology is a very specialized study that is rarely touched upon during our undergraduate years. Our specialty involves the use of many different optical instruments that most medical students don’t even get a chance to learn how to use them during their clinical years. So as newcomers, one of our prime tasks as first year residents is to learn how to handle these instruments properly so that we can get to examine our patients’ eyes, and most importantly, we have to learn it fast.

Fortunately in our unit, there is a honeymoon period (of around half a year) for newcomers like myself that allows us to pick up these bread and butter skills before we are given our full duties.  For instance, during the first month of training we are scheduled to sit in our seniors’ clinics and observe how they manage their outpatients as properly and as efficiently. Then starting in the second month, we shall be given one-fifth of our expected workload (around 10 cases) for us to manage by ourselves, and the number of cases goes up month-by-month until we finally hit our target – that is around 50 patient / half-day session at the end of 2011.

Apart from our well-structured clinic duties, we also have a buddy system whilst on call, i.e. both a higher trainee and I are put on call on the same day/night and get to see patients together during the first few months. In other words, there would be no more worries as to missing an important diagnosis or not knowing how to manage a condition, because our seniors are always there as our back-ups. The benefits of having a more experienced call-partner, is that not only do we get immediate feedback on our clinical competence  (by double-checking our examination findings by our senior residents), we also get a chance to grasp some tips and tricks from their sharing of experience too. I reckon this is one great way to learn and sharpen our clinical skills in the shortest possible period of time.

Thinking back in time, and as I reflect almost every single day during the past two weeks, I cannot be more grateful for having come so far and so smoothly along the path that was once my dream and now became the reality. I am truly delighted to have joined this department and share the joyful journey of becoming an ophthalmologist.

This is definitely my dream coming true. I have found the honey on the moon.