A Measure of Gold: Hong Kong Anesthesia at 50

In Hong Kong, the character of the educational system, along with the pattern of government involvement in medical and health services, played an important role in the genesis of professionalism in anesthesia. Government medical officers carried joint clinical appointments at medical schools. The first deans of both medical schools were Directors of Medical and Health Services, who were chief government medical officers.3 Kok-Cheung Yeo, C.M.G., M.D., D.P.H. (1903–2004), was Director from 1952 to 1958. A graduate of the University of Hong Kong, Dr. Yeo received further training in England at Cambridge University and at the University of London. A specialist in tropical medicine, he was appointed Assistant Medical Officer in 1928 upon his return to Hong Kong with a joint appointment as lecturer and examiner in Public Health at the university. He ultimately became Director of Medical and Health Services, was appointed to the Legislative Council, and became Vice-Chair of the Urban Council. As Director, Dr. Yeo was part-time Professor of Social Medicine at the University of Hong Kong. His contacts with surgeons convinced him that the state of anesthetic practice was inferior; he was determined to remedy this deficiency to bring a new level of professionalism in anesthesia. Toward this end, K. C. Yeo decided to introduce a position of “specialist anesthetist” to head a subdepartment in the Hong Kong Government Medical and Health Services. He traveled to England in 1953 and interviewed Dr. Zoltan Lett of Nottingham, outlining the challenges and opportunities for this new position. Dr. Lett accepted the offer, as his decision was reinforced by an opportune consultation with the chief of surgery of the University of Hong Kong who had been vacationing in England at the time. Lett arrived in Hong Kong in April 1954.4 With Dr. H. P. L. Ozorio, he organized Hong Kong anesthesiology. They shared a similar military service as anesthesiologists during World War II. Lett was a naturalized British citizen of Czech descent; Ozorio, born in Hong Kong, was of Portuguese lineage. To their colleagues and friends, they are fondly known and remembered as Lefty (for Dr. Lett), and Ozo (for Dr. Ozorio).

Born in 1918, Zoltan Lett (fig. 1) was a fifth-year medical student in Czechoslovakia in 1939. As Nazi Germany closed off Czechoslovakia, young Lett made his way to England and there joined the Czech Free Force. Two years later, the Czech government in exile arranged for students in the Czech Free Force to train and sit for medical qualifying examinations in England, intending to develop Czech physicians in exile to serve their homeland after the War. Lett finished his training at the University College Hospital, London, and successfully passed the qualifying examinations. He was one of 23 Czech graduates to receive their medical degrees from Oxford in 1942 (fig. 2). Short of physicians during the war, England gladly incorporated young Dr. Lett into the Royal Army Medical Corps. He was assigned to the field ambulance corps for deployment to Burma, where he assumed the task of anesthesiologist to an obstetrician–gynecologist who was in charge of medical and surgical care for all wounded or sick. Postwar brought Lett to the British National Health Service as a registrar in anesthesia posted to Nottingham, where he met Dr. K. C. Yeo and interviewed for the first Specialist Anesthetist position in Hong Kong.5 

A modest and dedicated physician, Dr. Lett noted the low standard of anesthesia practice in Hong Kong. He soon envisioned elevating anesthesia from a colonial medical service to a professional medical specialty. His gregarious nature engendered goodwill, enabling him to build an international network of friends in anesthesiology who would help to advance his mission. His dedication to professionalism won him the admiration and appreciation of his peers. A visionary but also a pragmatist, Lett would implement his plan, and harness any available resources to advance anesthesia in the colony. His long and productive career in anesthesia encompassed decades of service in the colony in different capacities in government service, academia, and consulting to nongovernmental hospitals. He is revered as the Father of Hong Kong Anesthesia.

Three years Lett's senior, Horatio Percy Loui Ozorio (1915–1973) was born in Hong Kong (fig. 3). A graduate of the University of Hong Kong, Dr. Ozorio practiced obstetrics–gynecology and anesthesia. He was also part-time lecturer in anesthetics at the Hong Kong College of Medicine starting in 1939. During the war years, Dr. Ozorio anesthetized more than 1,200 patients for Kenelm Hutchinson Digby, M.D. (1884–1954), first Professor of Anatomy and Professor of Surgery at the University of Hong Kong, until Dr. Digby was interned by the Japanese in World War II. During Japanese occupation, Ozorio escaped to Macao, a Portuguese colony west of Hong Kong, then made his way to wartime China, and eventually reached Burma. Like Lett, he joined the Royal Army Medical Corps, serving as specialist anesthesiologist. During his military service, his friendship with two fellow physicians paved the way for postwar professional anesthesia training at Oxford. Upon demobilization, one of these colleagues was to join Sir Robert Macintosh at the Department of Anesthetics at Oxford. The other, a surgeon friend of Sir Robert's, wrote a personal letter in 1948 recommending Ozorio for professional training. Upon completion of his training, Ozorio followed Sir Robert's advice to return to Hong Kong in 1951 to help develop anesthesia there. In 1959, he invited Sir Robert to the colony, and then accompanied his former teacher to the Philippines. Dr. Ozorio had met and married an operating room nurse in England while he was training with Sir Robert. For personal reasons, in part for the education of their son, he and his family returned to England in 1960. For the next 13 yr, he practiced anesthesia in England as a consultant under T. Cecil Gray, M.B., Ch.B., F.F.A.R.C.S. (Emeritus Professor, University of Liverpool); he also practiced obstetrics and gynecology. Dr. Ozorio died in 1973.6 

Previously, providers with limited experience and qualifications administered anesthetics. To elevate the status of anesthesia, Lett and Ozorio pursued two strategies. First, they sought and trained promising physicians for specialist certification to fill senior government positions. Then, through organized anesthesia, they encouraged participation of anesthesiologists in medical and healthcare policy matters in the larger medical community. Three decades later, anesthesia was prominently represented in the founding of the Hong Kong Academy of Medicine.7 

Anesthesiologists in Hong Kong government medical and health services could not assume senior positions unless they were accredited through examinations sponsored by recognized testing bodies such as the Faculty of Anesthetists of the Royal College of Surgeons in England (FARCS) and the Faculty of Anesthetists of the Royal Australian College of Surgeons (FARACS). In the early days, the Government Medical and Health Services arranged for only one trainee annually to travel to England or Australia for further training and examination. It also sent candidates to the World Health Organization for anesthesia diploma courses in Copenhagen and Manila. Inadequate anesthesia manpower in Hong Kong government hospitals limited the duration of time such trainees could remain out of the country, however.8 In the late 1960s, the Australian Faculty of Anesthetists sent examiners to conduct training and examination of candidates in Hong Kong. Later, Hong Kong anesthesiologists were appointed to fill this role. The first primary examination of the FFARACS in Hong Kong was held in 1969. Fifty percent of candidates passed on their first attempt. In 1977, Hong Kong officers who served for the Australian accreditation examinations were elected Fellows of the Faculty of Anesthetists of the Royal Australian College of Surgeons.9 

Y. K. Poon, M.D., a medical graduate from China, was the first chosen to travel to England for specialist anesthesiologist training and examination. Poon had administered anesthetics in government hospitals even before Lett's arrival in 1954. He was elected the first Treasurer on the SAHK Council. He left Hong Kong in late 1954 after the founding of SAHK.10 Within 12 months, Dr. Poon took all three conjoint qualifying examinations in Scotland, passing each on his first attempt. He returned to Hong Kong and became the second specialist anesthesiologist, preceded only by Lett.11 Later, Sylvia Hui, M.D. (now Sylvia Hui Marshall, M.D., of Rochester, New York), traveled to England to sit for the FFARCS examination held in December 1958. She became the first and only Hong Kong recipient of the Nuffield Prize.12 Dr. Hui returned to the colony and actively assisted Dr. Lett in organizing and coordinating clinical education programs, establishing close liaisons with international leaders in anesthesiology. She later emigrated to the United States, where she practiced anesthesia in upstate New York. Min-Hon Yeung, M.D., paid his own way to England for anesthesia training with Professor T. Cecil Gray in Liverpool, and returned to Hong Kong to become the first full-time academic anesthesiologist at the University of Hong Kong. The number of trainees traveling to England for Fellowship examinations decreased when the Australian Faculty of Anesthetists began to conduct examinations in Hong Kong.13 

Refresher courses played an important role in raising the level of anesthesia practice in Hong Kong. Dr. Lett and his colleagues in government service lectured on clinical anesthesia and invited basic scientists from the medical school to teach pharmacology and physiology. The clinical and basic science faculty would later serve as examiners at the primary examinations. Lett further enhanced preparation for specialist examinations by forging an educational alliance with the medical industry. In 1976, he petitioned the Hong Kong Oxygen and Acetylene Company to establish an educational foundation to fund a visiting Faculty Tutor from the Australian College of Anaesthetists to present 2-week crash courses in clinical anesthesia designed to prepare trainees for FFARACS examinations. This program lasted nearly two decades, until 1995. Later, more formal education courses conducted by local senior anesthesiologists were developed, and were ultimately assumed by the Hong Kong College of Anaesthesiologists (HKCA) in 1990.14 

In the 1970s, under austere circumstances when funding was limited, early leaders enhanced clinical education by inviting international speakers to visit Hong Kong before or after attending meetings elsewhere in Asia. World leaders in anesthesiology were visiting lecturers without financial compensation. This trend continued to the 1980s, benefiting local anesthesiologists and attracting Chinese anesthesiologists from the mainland. Such educational programs enhanced reciprocity and stimulated clinical and scientific investigations.15 Gradually, modest continuing education programs were replaced by weeklong conferences sponsored by SAHK. To fund educational events, SAHK leaders turned to the pharmaceutical industry for assistance. Growing sophistication of such conferences improved the financial stability of the Society, allowing it to engage professional management in operation.16 

Traditionally, the government specialist anesthesiologist held a concurrent appointment at the department of surgery as honorary clinical lecturer at the Hong Kong College of Medicine to teach undergraduate medical students. Dr. Z. Lett assumed this dual role as clinician and teacher between government service and academic responsibility from 1954 to 1977. Upon retirement from government service, he was named full-time Lecturer, and later upgraded to Reader, of Anesthetics at the Department of Surgery. His tenure continued until 1983. Although Dr. Lett moved anesthesia to the forefront of medicine and surgery, it remained a division of surgery.17 

In light of Dr. Lett's imminent retirement from the medical school in 1983, the British Council Committee for International Cooperation in Higher Education invited British anesthesiologist M. D. Vicker, M.B., B.S., F.R.C.A., to visit Hong Kong and review the teaching of anesthesiology at the medical school. Dr. Vicker consulted at the college for a week and issued his Vicker Report in 1982. It recommended the formation of an independent department of anesthesia. As a result, the Department of Anesthesia at the University of Hong Kong was founded in 1987, with Australian anesthesiologist Ross B. Holland, M.B., B.S., F.F.A.R.A.C.S., as founding chair and professor. Dr. Holland revamped the teaching curriculum and retained most of the government anesthesiologists as honorary clinical lecturers. In addition to Queen Mary Hospital, clinical teaching was extended to include Queen Elizabeth Hospital in Kowloon. Dr. Holland completed his 3-yr tenure and returned to Australia. He was succeeded by Douglas Jones, M.B., B.S., F.F.A.R.A.C.S., of Tasmania, who had served at the department as Senior Lecturer under Dr. Holland. Jones assumed the chair and the professorship from 1990 to 1993. He stepped down to take a similar position at the University of Queensland. The void of leadership at this academic department after 6 yr was filled by a government service specialist. The Chief of Anesthesia at Queen Mary, J. Ronald Lo, M.B., B.S., F.F.A.R.A.C.S., was appointed interim chair. He held the position until December 1993, when Columbia University–trained Joseph Yang, M.D., was appointed professor and chair. During the interim, Dr. Lo extended anesthesia service to include pain management and intensive care, a service he had initiated at Queen Mary. Government service in anesthesia continued to play a major and vital role in academic anesthesia.18 

The founding of the second university in the colony, The Chinese University of Hong Kong, included a Faculty of Medicine. This provided an opportunity for the establishment of an independent department of anesthesia and intensive care in 1983, 4 yr ahead of the University of Hong Kong in the founding of an independent department for anesthesia. Andrew J. Thornton, M.B., B.S., F.R.C.A., was appointed professor and chair. He brought along his team of anesthesia specialists to serve with him. Jean Horton, M.B., B.S., F.R.C.A., and Cindy Aun, M.B., B.S., F.R.C.A., were recruited as professors of anesthesiology. The United Christian Hospital was designated as the provisional teaching hospital for the faculty of medicine, until the new Prince of Wales Hospital was constructed in 1984. Professor Thornton was succeeded by Teik Ewe Oh, M.D., in 1988. The pride of this new independent department included the responsibilities for scheduling operating room activities and managing the intensive care units.19 

The SAHK was founded in June 1954. Three years later, in 1957, it was admitted to the World Federation for Societies of Anesthesiologists as a full member. Z. Lett, M.B., B.S., F.R.C.A., and Jean Allison, M.B., B.S., F.R.C.A., served as delegates.20 Half a century later, with the return of Hong Kong to China in 1997, World Federation leadership pondered upon the membership status of SAHK within the world organization, in consideration of Hong Kong being a part of China. SAHK leadership, after lengthy discussion and deliberation with the world organization, convinced the world federation to retain its full membership and independence, pointing out the vast difference in the healthcare systems between mainland China and Hong Kong.21 The development of a professional organization in anesthesiology from a very humble beginning to its eventual role as a viable member in the world fraternity of organized anesthesia indeed is a true sign of professional maturity.

This professional movement began in 1954 at the University of Hong Kong Alumni Association, where Z. Lett and H. P. L. Ozorio gathered the handful of anesthesiologists with several surgeons for an inaugural meeting of the Society. Lett and Ozorio represented government medical health services and academia. Other anesthesiologists came from private practice and the military. Initially, SAHK membership was open to all physicians, including nonanesthesiologists. The founding fathers, however, reserved the Council membership to anesthesiologists only. Because the Society was so small, the Council decided the title of its leader to be the Chairman of SAHK. This designation for a fledgling medical society would remain for 5 yr. Dr. H. P. L. Ozorio was elected Chairman, and Dr. Z. Lett was elected Vice-Chairman. At the time of incorporation, government records showed that SAHK was the first scientific medical society founded in Hong Kong. The objectives of SAHK, crafted by the preparatory committee, may be summarized as to raise the awareness of anesthesia as a vital component in medicine, to provide optimal training environment for anesthesiologists, to create opportunities for continuing clinical education, and to improve public perception of anesthesiology as a medical discipline.22 

The first three decades of SAHK was a diligent struggle for a fledgling profession for recognition and representation within the house of medicine. The small membership of the Society was indicative of the lack of popularity for anesthesia in the medical community to be attractive to medical graduates. The struggle was evidenced by the seeming perpetual rotation of the same group of officers of the Society in its first 30 yr. The overall mission of the Society reflected such reality when it aimed to promote interest in anesthesia as a medical science and a practical medical art. Even in the public eye, anesthesia was not properly perceived, so the Society made it a priority to educate the public and promote understanding of its mission. To achieve these goals, SAHK focused on the clinical education of anesthesiologists through networking and on bringing the specialty to mainstream medicine to secure rightful representation.23 In three decades, SAHK succeeded in representing anesthesia in Hong Kong, protecting membership benefits and welfare, and serving as a liaison with other medical groups locally and abroad. It also formulated educational programs for nonphysicians and operating room nurses.24 With the advent of the millennium and the end of British sovereignty, Hong Kong was gradually moving closer to the mainland. SAHK became an important liaison connecting Hong Kong anesthesia with its mainland counterparts to advance anesthesia. Consequently, the two parties began to organize joint clinical and scientific conferences in China.25 

In the 1980s, SAHK began to position itself for a prominent voice in the house of medicine. The opportunity arrived for the founding of the HKCA, an equivalent of the American Board of Anesthesiology. The objectives between the two professional agencies were similar, but the struggles for their establishments varied under different societal and cultural circumstances. The American Board of Anesthesiology became an authority of American anesthesia through political skill of a maturing profession in 1938, three decades after the founding of the American Society of Anesthesiologists.26 In a parallel time frame, under different circumstances, and half a century later, SAHK created HKCA in 1989 for the same objectives of assuming professional authority for accreditation and setting standards in anticipation of the establishment of a super medical agency through government legislation known as the Hong Kong Academy of Medicine in 1993.27 

Medical leaders in Hong Kong in the early 1980s had been considering the formation of the Hong Kong Academy of Medicine by government legislation, an agency to represent all branches of medicine in the colony. A maturing society for anesthesiologists seized the opportunity to make its presence felt in the larger medical community. In 1984, SAHK leaders created a Board of Studies in Anesthesiology and Critical Care to address the requirements in the training and education of anesthesiologists in anticipation of the formation of the Academy. Dr. Andrew J. Thornton of the Chinese University of Hong Kong chaired the Board. He retired in 1987 and was succeeded by Michael Moles, M.D., of the University of Hong Kong, and Vice President of SAHK. The Board met 24 times before formally incorporating it as the HKCA on September 26, 1989, 35 yr after the founding of the SAHK. It became the second medical specialty college in the colony, preceded only by the Hong Kong College of Obstetricians and Gynecologists. Dr. Moles was elected founding president; Brig. Gen. Ivan T. Houghton, R.A.M.C., whose extensive legal expertise helped craft the bylaws of the College, was elected Honorary Secretary. All incumbent members of the Board of Studies became founding Fellows of the College. HKCA would collaborate with the future Hong Kong Academy of Medicine in the development of professional standards for medical care in the colony. It further aimed at developing Fellowship examination curricula, setting regulations and requirements for Fellowship examination, providing guidelines for the safe practice of anesthesia, and establishing accreditation standards. The President of HKCA would represent the specialty on the Hong Kong Academy of Medicine Council. Only HKCA Fellows were eligible for consideration for Hong Kong Academy of Medicine Fellowship.28 

The SAHK leadership created the College to set professional standards and to represent anesthesia in medicine. SAHK and HKCA maintained a symbiotic relationship, sharing identical mission and operating many programs, some of which were duplicate. Through experience and mutual evaluation, they began to delineate their respective functions in service to anesthesia. SAHK assumed definitive roles that the College would not or could not fill, such as promoting solidarity and fraternity within the anesthesia community, setting professional standards and guides for nonspecialist anesthesia providers, and offering them educational opportunities. It also maintained a cordial relationship with industry to gain support for educational programs. The College, meanwhile, addressed issues of education, certification, and accreditation and set professional standards for anesthesia. Its most important role in Hong Kong medicine remained the establishment and oversight of programs relevant to conditions and needs of a unique social environment in Hong Kong, particularly after China assumed sovereignty of the former colony.29 

The emblem symbolizing organized anesthesia in Hong Kong did not exist in the first three decades since its founding, as the fledgling group had been struggling for status and recognition. In the late 1980s, in the process of professional maturation, the leadership began to consider an accreditation mechanism for anesthesiology. The need for symbolic organized anesthesia in Hong Kong as a group identity became evident. Michael Moles, M.D., of the Prince Philip Dental Hospital, commissioned the design of the artwork, and instructed the graphic department at his hospital to develop a color version of an official seal for the Society (fig. 4). It has an imposing dragon, holding two balls in its right claw and three balls in its left. In its left lower claw, the dragon clasps the Caduceus staff, representative of medicine. The legendary dragon is symbolic of the Chinese people. The five balls in its claws are chemical symbols for nitrous oxide and oxygen, an anesthetic made popular in the last quarter of the 19th century by Edmund Andrews. The black and white version of this emblem gives the notion that there are rings in the claws of the dragon. In the color version, however, the rings turn to color balls, representing chemical molecules. The two white balls in the right claw of the dragon represent the oxygen molecules. The left claw holds one white ball and two blue balls, representing the cluster of one oxygen molecule and two nitrogen molecules comprising of the chemical formula of nitrous oxide. This symbolism of the SAHK emblem was introduced by Dr. Moles and passed by the Society Council in late 1980s before the incorporation of HKCA in 1989.^† The emblem of the College is of straightforward symbolism, a golden dragon clinging to a poppy plant, symbolic of the Chinese associated with the plant of pain relief and anesthesia. Enveloping this dragon–poppy symbol is the name Hong Kong College of Anaesthesiologists, enclosed by the College motto in Chinese, which stands for “Vigilance Ensures Safety” (fig. 5).

The development of anesthesia in Hong Kong in half a century witnessed the genesis and growth of a medical specialty from an obvious void since its introduction in mid-19th century to a vital component of modern medicine. Key to such achievement of status and substance were education, recognition, representation, and accreditation. Professional organization was the thread that pulled all elements to a satisfying reality of Hong Kong anesthesia today. The founding of SAHK in 1954, and the ultimate development of HKCA in 1989, representative of a strong segment of medicine, indicate mature professionalism in the course of half a century.

Organized anesthesia in Hong Kong in 50 yr has evolved toward professionalism with pragmatism influenced by its dual cultural characteristics. It began as an aspiration for professionalism in a quest for representation in the house of medicine. At 50 yr, it stands as a bona fide representation of a full-fledged member of medicine in Hong Kong, as the specialty extends its involvement to pain management, intensive care, postoperative care and management, resuscitation, and trauma care.30 Leroy Vandam, M.D., defined professionalism as a calling in which a professed expert would serve his or her own profession and instruct, guide, and advise other like-minded individuals to profess the same expertise to manifest the profession. Medical professionalism manifested by such principles would engender progress of the special expertise to advance a branch of medicine for the benefit of all other components of the profession.31 In Hong Kong, professionalism in anesthesia emanated from a visionary pioneer desiring to organize like-minded practitioners to represent an interest, promote a vision, and implement measures to achieve such vision. The long, productive, and dedicated career of Zoltan Lett to Hong Kong anesthesia epitomizes such professionalism. Dr. Lett and Hong Kong anesthesiologists were adaptable to circumstances unique to indigenous elements in bicultural Hong Kong. They turned seeming obstacles to assets and filled voids with pragmatism to benefit the development of an important branch of medicine. Dr. Lett encountered inferior clinical anesthesia and had to cope with the paucity of qualified providers when he assumed responsibility as specialist anesthesiologist upon arrival in Hong Kong. He instructed physician anesthesiologists and dispatched them abroad for further education and acquisition of recognized qualifications. Painstakingly, he organized his professional brethren with support of sympathetic practitioners outside his specialty for professional alliance. He became an effective catalyst for his chosen medical profession, as he established liaison with the international anesthesia community and gained admission for his nurtured group to the world anesthesia fraternity. In three decades, Dr. Lett joined the collective leadership of organized anesthesia in Hong Kong to provide an effective voice to Hong Kong medicine by creating a mechanism to set standards, guide acceptable practice, and certify specialists for optimal patient care. Even his final retirement from anesthesia aided a maturing medical discipline in becoming truly independent in academia. The legacy of Dr. Lett's long career influenced generations of anesthesia leaders and paved the way to advance anesthesia in the new millennium with confidence as Hong Kong returned to China.

The author thanks Donald Caton, M.D. (Professor Emeritus of Anesthesiology, University of Florida-College of Medicine Gainesville, Florida), for reviewing the manuscript and offering valuable critiques.