CHRISTY LEUNG
There are different types of doctors: some work in hospitals while others in private sectors, some prescribe drugs while others spend time in operating theaters with scalpels, some care for elderlies while others treat children. The latter is known as pediatricians who mainly take care of individuals aged eighteen and under, although it is not uncommon to find adults in long-term follow-up clinics. Pediatrics comprises various subspecialties, ranging from neonatology (neonates are those aged less than four weeks), hematology and oncology (including blood cancers like leukemia), allergy and immunology, and more.
In Hong Kong, there are two types of doctors in university hospitals; one group is employed by the Hong Kong Hospital Authority (HKHA), while the other group is university-affiliated. The Journal of Young Investigators had the pleasure to interview Professor Ting Fan Leung and understand his career as a university-affiliated pediatrician. Leung was the Department Chairperson of Pediatrics at the Chinese University of Hong Kong (CUHK) for six years and is currently the Alice Ho Miu Ling Nethersole Charity Foundation Professor of Pediatrics at Prince of Wales Hospital, one of the two university-affiliated teaching hospitals in Hong Kong.
Graduated from CUHK in 1992, Professor Leung completed his internship year in four specialties: pediatrics, internal medicine, obstetrics and gynecology, and surgery. Having been immersed in various specialties, Dr. Leung ultimately chose pediatrics. During his time as a pediatrician in the Prince of Wales Hospital, his senior, the eminent pediatric hematologist/oncologist, Professor Patrick Yuen, recognized his talent and perseverance, subsequently molding him into an academic pediatrician. Yuen supported him to receive subspecialty training on immunology and allergy at the world-renowned Hospital for Sick Children in Toronto, Canada from the year 1997 to 1998. Since then, Leung has followed the common pathway of obtaining membership and fellowship from the Royal College of Pediatrics and Child Health (MRCPCH and FRCPCH), the former a prerequisite for declaring specialization.
Leung’s qualification as a pediatric specialist opened doors for different subspecialties, but he ultimately had to choose one. Reflecting on his internship year, Leung remembered the essence of medicine, which is to treat patients as human beings and care for their psychosocial health. His devotion to the field of allergy sparked upon learning about the heavy allergy burden, both globally and locally. Although not commonly fatal, allergy can be debilitating. An example is dust mite allergy — an omnipresent dust mite that causes “sneezing fits”, which can cause embarrassment and disruption if they occur during solemn ceremonies or exams. Moreover, food allergies to peanuts, nuts, and seafood can cause anaphylaxis, in which uncontrolled bronchoconstriction triggers respiratory compromise. Acknowledging such physical and psychological limitations, Leung was determined to embark on a career to develop accurate diagnostic and therapeutic approaches to allergy.
The above mentioned transition to an academic pediatrician meant significant changes to Leung’s role. Leung describes its key objectives as a triad of offering clinical services to his pediatric patients, teaching medical and postgraduate students as well as conducting translational and clinical research. Translational research may imply translating pre-clinical (commonly in vitro or animal) studies to human clinical trials or translating research findings to determine “best practices” in communities. Clinical research includes clinical trials to understand pathophysiological mechanisms, determine the effectiveness and safety profile of therapeutic interventions, or investigate human behavior, health services, and more.
Depending on personal preference, HKHA employees may also teach medical students and perform some small-scale studies; although offering direct patient care is nonetheless still their major responsibility. On the contrary, Leung pointed out that university academics may spend over half of their working time on teaching and research; their performance in such areas is critically assessed for contract extension and substantiation. That said, academic pediatricians are still required to perform clinical duties in various settings — inpatient wards, outpatient wards, specialty outpatient clinics (SOPC), and even the accident and emergency department when required. Patients at ambulatory wards are usually admitted for medical investigations, infusions, or day surgery and do not have to stay overnight. The frequency of outpatient clinic sessions is subspecialty-dependent; Leung attends three to four sessions weekly to meet the high local demand from allergic patients. Combined with one to two teaching sessions or research meetings daily, his day can be rather hectic. Leung arrives early at the office every day, providing himself with ample time to warm up and prepare for a day of activities.
Despite his heavy clinical responsibility, Leung finds direct patient care rewarding. When asked about a memorable moment in his career, Leung recalled an infant with severe chest infection about ten years ago. “His condition is so critical,” a senior remarked. “Maybe we have no choice but to intubate him and start ventilator support now”. The team also initiated a set of investigations for the infant. However, they could not detect any infectious cause even after bronchoscopy, so the team had to proceed to lung biopsy, despite its invasiveness and accompanying risks. Lung biopsy results were conclusive for the potentially lethal opportunistic pathogen, Pneumocystis carinii, and it was crucial to guide curative treatment. Upon his recovery, this boy underwent additional immune work-ups that revealed a rare form of primary immunodeficiency called hyper-immunoglobulin M (IgM) syndrome which is caused by CD40L gene mutations. Even though bone marrow transplantation was unfortunately not possible for his case, appropriate immunological therapies alone were sufficient to stabilize his condition; the patient is still alive, healthy, and happy to date. This case highlights the importance of risk-benefit weighing, and that clinical vigilance and meticulous investigations can pave the way for lifelong disease control.
Clinic encounters can be troublesome at times, especially in patients with atopic dermatitis, otherwise known as eczema. The first-line pharmacological treatment option for eczema is topical corticosteroids, a drug that suppresses the immune system. Steroid phobia is prevalent in Chinese families, and they tend to resort to alternative therapies such as acupuncture and traditional Chinese medicine. In such cases, effective communication is key. This involves listening to their concerns and fears, and subsequently addressing any misconceptions. Patients come from different educational backgrounds, so it is normal that some fail to understand the mechanism, benefits, and side effects of steroids. Leung then shared that one of his “tricks” for tackling such situations is to clarify the route of steroid administration. The route of steroid administration is imperative as oral steroids may cause worrying side effects, such as metabolic disturbances or moon face appearances. However, topical steroids for eczema are meant to be applied on affected body areas, with the dosage just one-tenth or lower than that given orally. This empathetic “trick” demonstrates that while professional risk-benefit weighing is necessary, it is also a skill for doctors to explain their decisions to lay people.
Research also plays a significant part in Leung’s career. The CUHK allergy team has been working on shellfish allergy for nearly one decade, and the main reason for his team to focus on this food relates to the high local prevalence of shellfish allergy. Realizing the high false positive rates in existing diagnostic methods like skin prick tests and blood IgE assays, the team devised novel cell-based methods to assess the responsiveness of patients’ white blood cells upon in vitro exposure to different shrimp proteins. Eventually, Leung and his team found a special test called basophil activation test (BAT) to be much more accurate in identifying shrimp allergy when compared with the conventional allergy tests. The in vitro nature of BAT also provides a safer and more cost-effective alternative to the double-blind placebo-controlled food challenge, which is the gold standard for food allergy diagnosis currently. Leung hopes that BAT will revolutionize the diagnostic approach for shrimp allergy. Following discoveries, doctors attend conferences to present their findings. Leung has participated in local, regional, and global conferences; he advises aspiring conference attendees to know their topics well by searching for relevant literature beforehand, rehearsing presentations well in advance, and preparing for questions that the audience may ask.
Allergy may not be an eye-catching field with emergency life-and-death decisions, yet it remains a meaningful subspecialty considering the ability to restore patients’ quality of life and uphold their health and morale. Leung highlights that allergy is an evolving field with ongoing inventions in immunotherapeutic approaches for active outgrowing of food allergy, in addition to novel diagnostic platforms like the previously mentioned BAT. Leung holds a positive outlook on the future of food allergy. “We expect a paradigm shift for food allergy, in which food avoidance is no longer necessary.”
Thirty years have passed, and Leung still finds his job as an academic pediatrician rewarding and satisfying. If provided with the opportunity to step back in time, Leung would encourage his young self to actively take up challenges in his career, no matter how insurmountable they may seem to be. Passion, perseverance, and commitment are inevitable for a career in medicine, which is a profession that suits committed people with different styles and personalities. The essence is to respect life and treat patients as human beings, assessing their physical and psychosocial health from time to time. Despite the hustle, “work hard and play hard” remains Leung’s favorite motto — one that his seniors mentioned during his medical school orientation camp days.
References
University of North Carolina School of Medicine, North Carolina Translational and Clinical Sciences Institute. Available at: https://tracs.unc.edu/index.php/clinical-translational-research. Last accessed: 30th September 2022.
Gloucestershire Hospitals, NHS Foundation Trust. Available at: https://www.gloshospitals.nhs.uk/your-visit/our-wards/paediatric-day-unit/. Last accessed: 30th September 2022.
CUHK Medicine. Available at: https://www.med.cuhk.edu.hk/press-releases/cu-medicine-proves-basophil-activation-test-has-much-higher-diagnostic-accuracy-for-shrimp-allergy-than-conventional-allergy-tests. Last accessed: 30th September 2022.