It is patently clear that whereas there have been turbulent times for medicine in the Western world, we are now having our share in Hong Kong. Recent years have brought changes not only in increased competition among doctors but also in societal control of the practice of medicine,^1-3 resulting in a professional landscape quite different from the one even ten years ago.

Local doctors are facing increased hardship. Nudged along by economic pressure, medical practitioners have been forced to concede, not always willingly, in the reshaping of the health care industry. To the disquiet of the medical circle, the administrators of the prepaid schemes or health maintenance organisations are increasingly able to influence some areas of health care delivery.

One of the major reasons for this unrest is changes in expectations from patients. On one hand, they expect doctors to be faultless in managing them. Obviously, there is little possibility of assured infallibility in the human world. However, while we never reach perfection, we are still capable of continuous improvement. There is nothing in our make-up which prevents us from improving, but equally nothing which guarantees it.

On the other hand, as confidence in medical profession declines, patients are now demanding extra say in and control over their medical care. Patient pressure groups are formed and have grown more and more vocal and influential in the local scene. In this context, with doctors under fire from some quarters, it is hard to turn our back on the compelling feeling that the medical profession is now 'on trial'.⁴

From our point of view, the image of professionalism as a cloak is deemed not only vital but also assumed. Needless to say, a cloak is at the least a form of protection against the hostile elements. However, it can be a large and rather unwieldy garment.

Like it or not, we have to acknowledge the fact that times change and change is the only constant. Much has already changed since the information technology age came into being and few things stay the same. In fact, many of the changes buffeting health-care today result from the development, organisation and flow of information. The advent of the Internet merely expedites the inauguration of a new epoch.

I believe it is time to stop hankering for something that is becoming an anachronism. After all, there is a lot of padding under the impossibly broad shoulders from which the cloak of professionalism hangs.

In the current climate, there is a palpable cry that the medical profession needs a new garb. We are in need of a new professionalism to fit the changed circumstances in which we find ourselves as the third millennium sets in. To this end, we ought to take a long view on the whole machinery, instead of putting up sporadic responses to rising social sway.

Margaret Stacey, a professor in medical sociology, drawing her experience as a lay member of the General Medical Council, produced a swinging critique of that body with a call for a 'new professionalism' in the shape of a rethinking of the agenda of regulations.⁵

There is no doubt that the recent reform proposals from the Working Group of the Medical Council are timely and certainly a step in the right direction, even though some critics might say it has not gone far enough while others defy them wrathfully. It still leaves several questions unanswered: Are these new clothes meant to shield us from the chill or just to be an eye-wash? Can these be counted as changes in the direction of new professionalism? Are we as yet fully prepared for the 'Brave New World'? How far are we ready to rise to the challenges? Where do we go from here?

One of the issues worth consideration is concerned with 'autonomy'^6-8 or, in a similar vein, 'empowerment',⁹ which merely reflect nuances in perspective. Rappaport¹⁰ defines empowerment as a process: 'the mechanism by which people, organisations and communities gain mastery over their lives' and Gibson¹¹ embodies this in her definition: 'empowerment is a social process of recognizing, promoting and enhancing people's abilities to meet their own needs, solve their own problems and mobilise the necessary resources in order to feel in control of their own lives.

I propose an outside-in approach in the process of empowerment, which means a gradual and systematic bringing in of the novice but truly interested citizens and turning them into the knowledgeable in the end. The initial aim is to involve users of services in order to obtain feedback as a preliminary to achieving service improvement. An appropriate prototype is to include in the governing committees of the public hospitals more lay persons who are the regular users of the service and more private doctors in the community who are the gatekeepers and the all-time partners to secondary care. It is important that in the first place the methods of seeking involvement from people should not be designed to contribute to their personal empowerment as individuals. People may be selected to provide feedback as representatives of users of different needs (as from populations of the elderly, the minorities, or the chronically ill). Secondly, empowerment should aim to increase the service users' abilities to take control of their lives as a whole and to take heed of their plight which may be of their own making, not merely to increase their influence over services. This, I hope, is in step with the swelling undercurrent of consumerism and in keeping with our frequently underlined patient-centred approach^12-14 which has always been at the very heart of family medicine.

The first and foremost objective of the development is to foster a new professionalism that can be received by society in metamorphosis and to get as far as possible to a system based on shared values. Although there is merit in the argument that everyone should have the opportunity to be involved in the debate, the assumption that anyone can participate in the reforming of health care is mistaken, as the average users of the services lack the same knowledge and information base as the profession herself. The inclusion of more representation from the mindful lay persons into the governance of the institutions at the front line of delivering care should go a long way in finding common grounds for mutual understanding on concerned issues and appropriate revamping of the entire service and paving the way for taking people truly in the know into the Medical Council.

For some this might take a leap of faith in the cosiness of the new outfit which, none the less, will certainly cast a long shadow on the future of the profession in Hong Kong but the beauty of these clothes should be that they can, and should, be tailored to the community needs should this be called for. One thing to be sure, regardless of the inevitable growing and transmuting pain, old and new professionalism are likely to continue to coexist for many years to come. Notwithstanding, the future is of our own making; we can transform ourselves and our societies. It is up to us.