Introduction

Hong Kong, the Pearl of the Orient, became a Special Administrative Region of China after being a British Colony for almost 150 years. It has a population of 7 million and is economically well developed with a GDP per capita at US $23 880 in 2004.¹ The public healthcare sector spends 3.1% of GDP while the total spending on healthcare is approximately 5.5% of GDP.² Only 9% of the public health expenditure is spent on primary care.³ This is despite a resurgence of interest in developing more cost-effective health care outside the hospital in many developed countries. The healthcare system in Hong Kong underwent a major review in 1999 by a team of experts from Harvard University.⁴ It was criticized for being too hospital-oriented with an under-developed primary care provision. It recommended that family medicine should be promoted in Hong Kong.


Family medicine vocation training

After many years of lobbying by family physicians, the Hong Kong Government has finally recognized the importance of family medicine in the overall provision of health care to its citizens. This has resulted in the Family Medicine Vocational Training Scheme now being the largest training scheme, with over 400 trainees⁵ among all specialties in the public system. This is a far cry from 1995 when there were 40 trainees and only five in the inaugural program in 1985.

The standards of training are set by the Hong Kong College of Family Physicians.⁶ The training program lasts for 6 years, with 4 years of basic training and 2 years of higher training. Two years of the basic training course are hospital-based and the remaining 2 years are spent in the community setting. This basic training aims to allow the trainees to acquire the knowledge, skills and attitudes for the practice of family medicine during these 4 years. At the end of the training period and after being certified to have completed the training satisfactorily, the trainees may sit the conjoint Fellowship examinations awarded by both the Hong Kong College of Family Physicians and Royal Australian College of General Practitioners.

The trainees will then proceed to 2 years of higher training which is supervised and yet independent. The trainees have regular contact with their supervisors to obtain advice on patient care, practice management and professional development. At the end of the 6 years of training, the trainees will sit for the Fellowship examination of the Hong Kong Academy of Medicine (HKAM) which is a specialist qualification to register with the Hong Kong Medical Council. And yet, by the end of 2005, there were just 162 (out of a total of 4684)⁷ Fellows of HKAM who are in the discipline of family medicine (Table 1).

An emerging system which places the importance of patient care in his/her own community, recognizes the values of patient care by family physicians and the cost-effectiveness of an efficient primary care system is therefore only slowly beginning to develop in Hong Kong.


Family physicians and family medicine practice

However, what kind of knowledge and skills do family physicians need to possess in Hong Kong? To answer this question, one should probably look at what the general public expects of their family doctors and the role of family physicians in the local health care system. Despite Hong Kong being a much Westernized city, many of its citizens adopt a traditional Chinese explanatory model for their common illnesses.⁸ For instance, a patient may think he has a liver problem if he/she develops visual disturbance. This happens because, according to the traditional Chinese medical theory, vision is dependent on liver function. As a matter of fact, most of my nursing staff would much prefer to consult traditional Chinese medicine practitioners for their upper respiratory tract infections because they view Western medicine as being “impotent” for dealing with the commonest complaint in family medicine.

The health care system in Hong Kong is also unique, with the public system running parallel to the private system. Western-trained private medical practitioners provide 75% of primary care while public doctors provide 15% and the rest by other health care providers, such as traditional Chinese medicine practitioners. However, over 90% of specialist and hospital care is provided in the public system. Referral to attend a private specialist by a family physician is not necessary in many instances. This may make the gate-keeping role of family physicians less obvious when compared to other countries. However, it also opens a lot of opportunities for family physicians to develop special clinical interests.

Patient characteristics also demand special skills from family physicians. Life expectancy at birth was 78.6 years for men and 84.6 for women in 2004.⁹ This put Hong Kong women just behind their Japanese counterparts in the forefront of the longevity ladder. On the other hand, the birth rate hit a record low of 7 per 1000 population in 2004.¹⁰ The population is therefore rapidly aging. Furthermore, it has a very high population density and a high elderly suicide rate. Income inequality is also an issue with the richest 10% of families enjoyed 34.9% of the total income of Hong Kong while the poorest 10% only enjoyed 2% of total income.¹¹

Family physicians working 7 days a week is a norm in Hong Kong. They also work most evenings with a break in the afternoon. Most clinics are run by single-handedly by doctors and they also dispense their own medications. Moreover, little obstetrics is practised by most family physicians. However, the Government appears to be keen to see more group practices in Hong Kong.¹²


Future Developments

Hong Kong will probably need to develop family medicine with its own unique characteristics, while maintaining the core values of the discipline, that is, primary, continuing, comprehensive and whole-person related. It will have to prove its worth as a cost-effective alternative to the present hospital-oriented system. Family physicians should be able to develop special interests which will allow them to provide special care to their patients, for example, mental health and chronic illnesses such as diabetes mellitus and hypertension. Research in family medicine will also need to be promoted so that the practice of family medicine is evidence-based.


References

1 Hong Kong SAR Government. Hong Kong Year Book 2004. Available from: http://www.info.gov.hk/yearbook/2004/en/app_06_01.htm [accessed March 2006].
2 Health Welfare and Food Bureau. Domestic Health Accounts Summary Report. Available from: http://www.hwfb.gov.hk/statistics/en/dha/dha_summary_report.htm#D [accessed March 2006]
3 Department of Health Hong Kong SAR Government. Annual Report 2003/2004. Available from: http://www.info.gov.hk/dh/publicat/index.htm [accessed March 2006].
4 The Harvard Team. Improving Hong Kong’s Health Care System: Why and for Whom? Hong Kong: Hong Kong SAR Government Printer, 1999. Available from: http://www.hwfb.gov.hk/en/press_and_publications/consultation/HCS.HTM [accessed March 2006].
5 The Hong Kong College of Family Physicians. Handbook on Vocational Training in Family Medicine 2003 Fifth Edition. Available from: http://www.hkcfp.org.hk/handbook/handbook2003.pdf [accessed March 2006].
6 The Hong Kong College of Family Physicians. Vocational Training. Available from: http://www.hkcfp.org.hk/ [accessed March 2006].
7 Hong Kong Academy of Medicine. Fellowship Statistics. Available from: http://www.hkam.org.hk/fellows_area_fs.html [accessed March 2006].
8 Lam TP. Culture and Medicine. The Hong Kong Practitioner 1999; 21: 201–2.
9 Hong Kong SAR Government. Hong Kong Year Book 2004. Available from: http://www.info.gov.hk/yearbook/2004/en/08_01.htm [accessed March 2006].
10 Hong Kong SAR Government. Hong Kong Year Book 2004. Available from: http://www.info.gov.hk/yearbook/2004/en/20_01.htm [accessed March 2006].
11 The World Bank Group. World Development Indicators 2005 (Table 2.7). Available from: http://devdata.worldbank.org/wdi2005/section2.htm [accessed March 2006].
12 Health and Medical Development Advisory Committee. Building a Healthy Tomorrow – Discussion Paper on the Future Service Delivery Model for our Health Care System 2005 July. Available from: http://www.hwfb.gov.hk/hmdac/english/dis_papers/files/hmdac_paper.pdf [accessed March 2006].



Table 1 Distribution of Fellows of the Hong Kong Academy of Medicine, College number of Fellows

Anesthesiologists	304
Community Medicine	80
Dental Surgeons	195
Emergency Medicine	189
Family Physicians	162
Obstetricians & Gynecologists	362
Ophthalmologists	181
Orthopaedic Surgeons	296
Otorhinolaryngologists	112
Paediatricians	471
Pathologists	194
Physicians	1037
Psychiatrists	172
Radiologists	320
Surgeons	609
Total	4,684

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