In competitive and fast-paced Hong Kong, the problem of doctors leaving public hospitals to strike out in the private sector is increasingly common. However, it would seem that one sector of public healthcare, intensive and/or critical care, will always be there for the public, mainly because private sectors lack a healthy ICU market due to it being time-intensive and expensive. Patients seem to agree that the ICU of public hospitals is providing quality service. Dr Pauline Yeung, a clinical assistant professor of Critical Care in HKU who practises in the Intensive Care Unit of Queen Mary Hospital, certainly agrees that the doctors themselves are trying their best.
Dr Yeung studied in HKU in her undergraduate years, graduating with an MBBS in 2008. Having spent her whole life in Hong Kong, it has always been one of her dreams to gain overseas experience. After obtaining her Critical Care fellowship, she applied for numerous overseas programs and was accepted into a research program at Harvard. Although she initially applied for a clinical placement position, in the end, she says, the research position she obtained opened up new opportunities for her. Although HKU previously had no clinical professoriates in ICU or Critical Care, upon her return from the US, she discussed with the University and established a new position over the course of a year.
A typical day in the ICU goes like this: the clinical handover from the night shift to the day shift happens at about 8:30 am (doctors have to work shifts because the ICU has to be staffed with specialists on site 24/7). During the handover, the night team gives a patient progress update to the day team, and they work out a plan for the patients. From then on, it’s business as usual: Dr Yeung makes her rounds with a resident, splitting the responsibility amongst the team to check up on each patient’s needs. Lunch occurs at around 1:30 pm, although on busier days it might be delayed for a while, or for quite some time. After lunch, they check in on the patients again. In the ICU, the patients’ conditions can change rapidly, and hence the need to be frequently reviewed. Dr Yeung checks in every hour or so, until the handover to the next shift.
As for her non-clinical work, Dr Yeung spends 2 to 3 hours of the day on teaching, and the rest of her time on research. She also spends most of her free time after hours on research. She believes this is a core requirement for researchers: to be continuously thinking about and working on research ideas and knowledge acquisition. In contrast to many other specialties, the ICU sees a wide variety of patients each day, ranging from heart attacks to major trauma to postoperative care. Therefore, a main area for research is what Dr Yeung dubs ‘big data’, i.e. clustering the physiological parameters of patients (such as blood pressure and lab test results) and identifying risk factors which correlate with 30-day and 90-day outcomes of the patients. Then, with that data, they refine their skills and execute targeted intensive management. In the future, machine-assisted analysis of patient data may help provide outcome predictions and thus guide clinical care. There is also promise for artificial organ support for the brain and the liver, technologies which are not available at present.
The reason Dr Yeung entered critical care is simple: she enjoys the dynamics of the experience. On one hand, in the ICU, encountering the unexpected is the one thing you can expect. Dr Yeung enjoys its excitement and challenge, as well as its adrenaline rush. On the other hand, she enjoys working in a team-based environment. While other specialties have certain areas of the body they watch over, the ICU is a system of ‘organ support’ specialists, administering medications to maintain organ function for as long as possible, in order to buy time for the patient to recover from their underlying disease. With such a wide range of patients, it’s impossible to possess all the knowledge needed. Thus, care delivery in the ICU is jointly given by ICU doctors, non-ICU specialists, nurses, and allied health specialists. In complicated cases, the ICU serves as the central coordinator amongst the different departments. For instance, if the patient needed a balloon angioplasty but the contrast agent for radiology might damage their kidneys, she would discuss with all the specialists to find a middle ground that would benefit the patient. She is glad that her work enables her to encounter and collaborate with a wide range of people, both as colleagues and as patients.
The idea of teamwork is essential since the training of Critical Care doctors. It’s a lot of learning on the job, and Dr Yeung herself oversees residents as they work through the day, which means that even junior doctors are never left alone. It’s easy to ask for help and get instant feedback, which makes it easy to learn quickly and adapt. She also regularly reviews with her residents and helps them identify areas for improvement.
Having done government-funded training abroad in the US, Dr Yeung recognises both the shortcomings and strengths of the HK healthcare system. The US healthcare system is mostly privately funded, which makes it easier to access better care if you have the financial resources, but it’s a clumsy and redundant system full of referrals. Meanwhile, although HK offers more efficient care, the system is understaffed. Dr Yeung praises the efficiency and dedication of frontline doctors who work long hours, but she thinks that the public needs to understand the resources needed to fund proper care, especially in this time of aging population and rising medical prices. As specific treatments develop, prices will rise, and the current system will break down sooner or later. Furthermore, the understaffing means that doctors get to spend less time with each patient, which impedes communication in areas such as understanding why the patient isn't complying with a treatment program or addressing concerns a patient holds about a specific treatment.
Moreover, Dr Yeung believes that HK needs to develop a better system for primary care. During her rotation as an ER doctor, she realized that up to 70% of the patients seen were not in emergency conditions. They just showed up because they had nowhere else to turn to and the ER provided easy accessibility to affordable care. She believes that patients should form longitudinal relationships with their primary care physicians, so that the physicians could formulate a better overall healthcare plan.
Regarding the pandemic, Dr Yeung outlines the system for staffing isolation units in the hospital: staff work in isolation units for 2 weeks before being substituted by another team. This pandemic is much more widespread than historical pandemics, mostly due to globalization. As people are prone to travel for leisure or business, the infection is spread easily to different areas. During the pandemic, the doctors have learnt to be more judicious with their resources, especially with their personal protective equipment (PPE). To those who say that it is selfish for doctors to prioritise their own health and protection first, Dr Yeung has a reply: it is not selfish because if the doctor is not well-protected and healthy, they could infect other patients under their care and spread the disease further.
There’s also a problem of equipment shortage during pandemics and in less developed places. Since sudden surges in demand for high cost and sophisticated equipment in the ICU cannot be met, a transparent system with well-defined criteria for patient prioritization and equal allocation of resources is imperative. This not only leads to a smoother running of the hospital, but also lowers the psychological burden on the doctors who have to make the choices. This ensures that patients get the best and fairest care possible.
Lastly, Dr Yeung offers some advice to aspiring medical students:
1. Always be prepared.
2. You must have stamina in both research and life, and not be set back by failures, rejections, and tedium.
3. Be open to new opportunities!
Furthermore, she stresses the importance of holistic development, as academics are only one part of the whole system. Doctors must be sensitive and be a team player, communicator, and listener. By being observant and open, we can learn from those both older and younger than us; by frequently reminding ourselves that there is much we don’t know and much we’re wrong about, we stay humble and continue to learn. She leaves us with some parting advice: Always stay inquisitive, work hard, and maintain a healthy mindset towards work and life!
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