The Hong Kong College of Family Physicians celebrated her 25th Anniversary in 2003. It is perhaps time for us to look at the future of Family Medicine in Hong Kong. What or who will shape the future of Family Medicine in Hong Kong? Will it be by default, by decree or by design?

If we leave the present system unchanged, the future of Family Medicine will be shaped by default. I was inspired by a description of the ideal future Family Physician / General Practitioner formulated by small discussion groups during the Royal Australian College of General Practitioners scientific meeting in October 2003:

"As Family Physicians we make a difference in the health and lives of ourselves, our patients and our communities in a privileged way. Central to this is the unique depth and breadth of the doctor patient relationship. Family Physicians achieve this individually and collectively through a richness of diverse and flexible practices, organisational structures and career paths. This satisfies Family Physicians as they change throughout their professional lives. They receive wide recognition, trust, and personal fulfillment, intellectual and financial reward."

To achieve this, the future of Family Medicine must be shaped with the proper design and with proper decree.

By default, the practice of Family Medicine in Hong Kong is influenced by existing socio-cultural issues. After all, Family Medicine is western medicine practiced in the context of a different race with a different culture. Moreover, the Hong Kong patient is recognised to have a particular pattern of health seeking behaviour. This includes the lack of the concept of Family Medicine; not having a family doctor but attending direct consultation with specialists. A lot of patients are symptom orientated and place value in the amount of medication received. They tend to go doctor shopping and have little appreciation of the importance of continuity of care.

Since the release of the Harvard Report, the Hong Kong Healthcare system is under change in organisation and delivery. A healthcare system is emerging that places greater emphasis on community based primary care. Family Medicine practice has proven to provide effective primary care to individuals and families and its effectiveness is linked to improvement of public health outcomes as well as reduced costs. Thus the future of Family Medicine has been determined in part by decree by the Healthcare Reform. The commitment by Government to training more Family Physicians is a good example. Nonetheless the future of Family Medicine shaped by the present decree has its shortcomings. With its effect on Medical Education, there is at present little support for undergraduate Family Medicine teaching. We see shrinking Family Medicine Departments in both Universities despite the evolution of innovative new teaching methods which includes subject based learning and problem based learning. Although it is by decree, that almost all new medical graduates are channeled into Family Medicine training, the concern for budgetary deficits, uncertain career prospects as well as failure to re-allocate resources is posing a lot of strain on those organizing Family Medicine training.

The future of Family Medicine should be by a design that fits the demands and needs of the Hong Kong society. The design needs to find favour with peers, patients, administrators as well as politicians.

For Family Medicine to meet peer expectations there should be a career path that leads to a portable sustainable satisfying lifelong occupation with continuing longitudinal exposure to promote the diversity of Family Medicine. The system must be adequate to enable delivery of quality care. The length of Family Medicine training needs to be appropriate taking account of duration and intensity. Family Medicine in the private sector is different from that practiced in hospitals and trainees need proper exposure. There must also be sufficient Family Medicine Consultant posts in hospitals to maintain the proper presence. The design of Family Medicine for the future needs to address the hopes and fears of practitioners. We all look for a professional life where there is growth, development and advancement of the profession. We look for professional fulfillment, and a healthy personal life with a sense of well-being and satisfaction with allowance for passion, security and autonomy. At present common fears and threats experienced by Family Physicians and for that matter probably all doctors at large include the demands of a high level of patient contact, bureaucracy, the need to be accredited by authorities, medical indemnity as well as cut throat competition generated from workforce crisis.

When we look at designing Family Medicine to meet patient expectations, we must understand that when a patient consults a doctor, he or she is looking for knowledge and predictions; wondering what is the diagnosis and whether with or without treatment the disease will go away. Patients expect holistic care - whole person, comprehensive, continuous care. Patients also expect innovative care which would include addressing problems of an ageing population, provision of chronic and terminal care, treating A.I.D.S. patients and of course SARS. Needless to say the care is expected to be cost-effective.

To meet the expectations of administrators, government and politicians, the design of Family Medicine will centre on the gate keeping role of the Family Physician in the healthcare system, the cost-effectiveness, quality of the care and indicators of public satisfaction including public health outcomes.

In order to achieve the optimal design for Family Medicine for the future we need change: change in the present healthcare system, change in individual practitioners as well as change in patient and public expectations.

Regarding changes of the present healthcare system, there needs to be more organization of primary care. The Medical Council should consider establishing a primary care registry which will allow those who have received structured training as well as showing a commitment to lifelong learning by engaging in Continuous Medical Education to become registered. The setting up of a Primary Care Authority should be seriously considered to allow better forward planning and administration of primary healthcare in Hong Kong. This Authority can focus on population based community orientated care. This is a paradigm that balances doctor's obligations to the individual patient with that of society at large. This is care that integrates principles of community medicine and public health into the delivery of primary health care.

There has been a lot of discussion about building a seamless healthcare system with public / private shared care. What needs to be addressed is how to return patients back to the community after they have received adequate care in hospitals. To achieve this, information sharing will be most important.

The future of Family Medicine in Hong Kong also depends a lot on change in the healthcare economic principles in Hong Kong. The best incentive for quality is reward. Unless Family Physicians can charge what they feel they are worth, low professional fees will become an obstacle to holistic care. The present fee-for-service system that neither values nor reimburses for time and resources required for holistic care must be changed. The escalating medical indemnity insurance posed upon Family Physicians is a concern that needs change. There should be reward for those committed to self improvement by continuous professional development.

Changes in the career structure of Family Physicians will also shape the future of Family Medicine in Hong Kong. A career in Family Medicine can be quite diversified and can be structured according to the different stages of our lives. The career should include teaching, research, and service to the discipline such as work for the College as well as service to the community. We have different priorities during different phases of our professional and personal lives. All of us will probably be busy building our clinical practices in the first ten years after we finish our training; however into the thirtieth or fortieth year we may be more stimulated by research, teaching or even medico-legal work. Diversity will make our professional lives more fulfilling.

Ultimately, the future of Family Medicine will depend on individuals - Family Physicians themselves. The hardest thing however to change is to change one self. Individual change needs to include change in the care of the neglected self - self being the physician himself or herself. Practicing what we preach, issues related to proper nutrition, adequate exercise as well as relaxation need to be addressed. We should look at work as being fun, asking ourselves how many times we have laughed during the working day. We need to question whether we are giving ourselves a chance to pursue non medical interests such as music or sport. Change results in balance. Achieving balance in one's professional and personal live is the key to well being.

I sincerely hope that the future of Family Medicine in Hong Kong is a future designed by the profession for the profession that will become the decree. I do hope it will be a future that is built by mutual support and delivered by a workforce of fortified Family Physicians with the right balance. I hope we are strong enough so that future practice will not be dominated by managed care, medical insurance companies like that in the United States and that the future of Family Medicine will continue to place emphasis on keeping the patient out of hospital beds. I hope we will produce future Family Physicians who are balanced and fulfilled. I hope Family Medicine will be the career choice of the best graduates. I hope Family Medicine will gain the public recognition it deserves, giving Family Physicians status amongst peers. I believe the future Family Physician will provide comprehensive and lifelong holistic health care which is humane, and that care and comfort to the individual is as valued as medicine and technology based interventions.