What is the problem with linking CME (continue medical education) with registration (renewal of annual practicing certificate) of general practitioners in HK?

There has recently been a hot debate on the proposal by the MCHK (Medical Council of Hong Kong) of making GPs responsible for submitting evidence of compliance to certain CME activities before they can renew their annual practicing certificates.

The background is that doctors in HK need to have their names on the general register of doctors of the MCHK before they can practice in HK. They need to renew their registration by applying to the MCHK every year in the form of renewing their annual practicing certificates.

Continue medical education (CME) is a recent hot topic which involves the process of doctors keeping themselves refresh with medical knowledge and update with new advance in medicine. In fact GPs in HK have been actively engaging in such activities.

But what is the problem with this proposal? Does this vigorous response of opposition from docotrs and doctors’ associations really mean that GPs in Hong Kong are lazy and unwilling to update their knowledge? As a GP and a council member of the Hong Kong Medical Association (HKMA), I feel the urge to explain to the public what the problem is.

The problem is that it has gone the wrong way!

1. The “why not” attitude of the MCHK proposal

2. The reversal of the burden of proof just for convenience of adminstration

The MCHK is given power to make rules to control doctors. Each rule would carry far-reaching effects and cause disturbance to doctors. It is very important that the MCHK should not misuse this power. For a rule to be made, especially that with punitive action, all of the following questions need to be answered in the affirmative:

1. Is there a problem?

2. Does this problem need to be controlled?

3. Does this problem need to be controlled by regulations?

4. Is regulation an effective control?

5. Are the existing regulations not effective in controlling the said problem?

6. Is the regulation made precise and not controlling other areas that need not be controlled?

The onus is on the MCHK to convince doctors and the public that these tests are satisfied and any lighthearted decision would be deemed misuse of power. It is not enough just to say that something is good to doctors and citizens. Linking it with punitive action is totally another thing.

For this CME issue, the problem has never been defined. Three years ago, the MCHK suddenly threw out a trial run programme for CME and this has been adminstered with support from doctors’ associations. This programme just ended in October this year. There has been no formal evaluation of this programme in any stage on any aspect of utility, feasibility, propriety or accuracy. There was no interim report. There was no audit. Feedbacks and responses from doctors are not collected. No effort has been shown to improve the programme.

So where is the evidence from the MCHK to convince us to have this issue dealt with in this way? Or does it matter?

For the proposal of linking CME with the renewal of annual practicing certificate of doctor, it is more problematic. It is against the spirit of legislation by shifting the burden of proof to doctors just for convenience of adminstration. Doctors are assumed incapable and not updated until proved otherwise by providing evidence to convince the MCHK.

There has always been mechanism, which has been proven to work well, in controlling the standard of registered doctors in HK. By virtue of s21 of the Medical Registration Ordinance, the MCHK has the power to remove a doctor’s name from the General Register if he is found misconduct in a professional respect, which is defined as “conduct falling below the standard expected among doctors”.

So everything is there. There is absolutely no indication for the proposed legislation.

Even if a doctor is found not fufilling the set criteria of CME, he should have the right to a fair trial by the MCHK under the current mechanism. Directly linking CME with registration means bypassing this established mechanism of fair trial and the burden of proof falls to the doctor. Please think of the situation of an innocent doctor who has for some unknown reasons not able to convince the MCHK of his CME status (This is forseeable. The reasons can be by mistake of the doctor or the adminstrator, by omission, by ill health of the doctor etc. In these three years, I have to submit appeal to the adminstrator every year with evidence that my CME points are grossly underestimated. ) Then he would not be able to practise, might be unaided by his professional insurnace (because it is not a litigation, but registration issue), and he needs to find out what has gone wrong with his CME status and to prove it to the extent that the MCHK finds it satisfactory. He would also likely to first find out in his lifetime that the MCHK would only meet once every month and might not be able to handle his matter in 6 months time.

It is always much more difficult to prove something than to disprove it. So it is the spirit of common law to put the burden of proof to the side which is more powerful and be in the position of being able to carry out investigations more easily; and the side who raises the issue.

There are legislations that violate these rules, but are exceptions concerning very serious matters that have been proven to have detrimental effects to the general public if not acted upon.

The argument that “the MCHK proposal serves good to citizens and why not do it through this simple way” should be frowned upon, if not condemned. If the proposal does not serve citizens any good, it needs not be mentioned. The rules and spirit of legislation should not be violated light-heartedly just because the said issue MIGHT benefit the public; but so far no harm, or even hint of any harm, has ever been evidenced.

The CME issue is not well defined, and certainly not a burning issue that would be detrimental to the health of the general public; not now, and not in the forseeable future.

So why do it this way?

Why make punitive rules light-heartedly?

Why deprive doctors of a fair trial by exceptionally reversing the burden of proof?