May 2004, Vol 26, No. 5 |
Letter to the Editor
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Medical education and health care in Hong KongP C Y Lee 李仲賢 Dear Sir, In my Keynote Address delivered to the 13th WONCA Asia-Pacific Regional Conference last November in Beijing (full text published in the February, 2004 issue of the "Hong Kong Practitioner"), the pivotal focus and basic fundamentals of the Discipline of General Practice/Family Medicine were succinctly defined in the following paragraph:- "Academic General Practice/Family Medicine is the essential source of nutrients on which the health and well-being of the Discipline of General Practice/Family Medicine depends, and Research on General Practice/Family Medicine is the soil on which Academic General Practice/Family Medicine thrives and being nurtured. For these reasons, there is no better way to enhance "Quality General Practice in the New Century" than to bolster Academic General Practice/Family Medicine and Research. It is therefore imperative that every medical school or university must have strong departments of General Practice/Family Medicine with well-funded and well-organized research projects". In pursuance of this ideal, I made repeated representations to the Council of the University of Hong Kong, "to upgrade the existing Unit of General Practice/Family Medicine to a major Specialist Department in the Faculty of Medicine". Unfortunately, the previous University Councils were so dominated by academics that my efforts were tantamount to knocking one's head against a stonewall. I am glad to inform you that under the enlightened and dynamic leadership of our new Chairman of Council, the Governance of the University went through radical and tremendous changes in many aspects by attaining constitutional amendments to the Hong Kong University Ordinance and Statutes and by securing their formal approval by the Hong Kong Legislative Council in November, 2003. The most striking reform which merits our attention involved the membership and responsibility of the University Council. Not only is the membership in the Council scaled down from its previous 60+ to the present 21, but the number of academics in Council is also limited to not more than one-third. Furthermore, all members are obliged to take their places in the Council as "trustees" to serve the University and the Community of Hong Kong as a whole, and NOT vested- or self-interest. Because of these cogent changes in the University Governance, I feel that time is ripe for me to re-submit my appeal once again. The paramount importance of the issue to the health and welfare of the People of Hong Kong, and its relevance to the local medical profession in particular, prompted me to share with you the contents of this submission by reproducing its full text (without the appendices mentioned therein) as follows:-
The opening statement of "A Guide to the Medical Curriculum" in the "Student Handbook 1997-2002" distributed by our Faculty of Medicine to all new medical students in 1997 to explain the launching of the "New MBBS Curriculum", and in answer to its own question: "What Sort of Doctor Will We Produce?", had this to say:
Arising out of this, I assume that the standards and priorities of medical education in our Faculty of Medicine should be designed and formulated to ensure that our medical graduates are able to serve the health and medical needs of our population with competence, compassion and humanity. I have devoted much time, efforts and financial resources during the past 30+ years to try to transform Hong Kong's ineffectual and bankrupt hospital-based Health Delivery System into an efficient and cost-effective community-based one ever since I introduced the then new medical discipline of General Practice/Family Medicine into Hong Kong in 1973. In addition to repeatedly petitioning the local government to modernize the antiquated medical and health system, I did attempt to bring the matter up for discussion in the HKU Council several times in the past by:
I understand that the Governance of the University had undergone radical changes recently and that the present Council has been re-constituted according to the newly amended University Constitution and Statues. I therefore take this opportunity to re-submit my views once again to the new Council in the hope that a full debate on this subject may be conducted in the name of the University as well as for the sake of the People of Hong Kong. I begin by stating that nearly 95% of all demands for medical services in the Community are for primary and ambulatory care. It is therefore evident that the quality of primary/ambulatory care has the greatest impact on the health and welfare of the population because it is the type of medical services which are most likely to be patronized by individual citizens, and there can be no denying that Family Medicine/General Practice IS the medical discipline which specializes in the provision of "effective, humane, economic and ethical medical care", as proclaimed by the Medical Faculty in its "Student Handbook 1997-2002". It is gratifying to note that the Hospital Authority had in recent years become increasingly aware of the fact that a totally hospital-based health delivery system could not be sustainable, and had come to realize that only primary care could alleviate the situation. To better serve Community needs, the Hospital Authority had since 1998 gradually introduced into its hospital system trainee posts for family medicine, which posts were never heard of before. In close collaboration with the Hong Kong College of Family Physicians, the Hospital Authority has at this moment strategically allocated over 50%, or more than 450, of its trainee posts reserved for the training of its young doctors in the specialty of family medicine - more than all other specialties combined. Given the Medical Faculty's public pronouncement that it "should take more account of feedback from its major employer, the Hospital Authority", how does our Medical Faculty respond to the Hospital Authority's obvious policy change in favour of primary care in recent years? For the past quarter-century, I spared no effort to exhort, prod and persuade the Medical Faculty to place more emphasis on the teaching of General Practice/Family Medicine to medical students because of its crucial importance to the standard of medical practice in the context of the Hong Kong environment. I was instrumental to have $100,000 donated to the University in 1982 to establish "Hong Kong College of Family Physicians Visiting Professor in Family Medicine" to enable distinguished medical doctors from other territories to be invited to visit the Faculty of Medicine and to participate in the Faculty's teaching and research activities in family medicine. In September 1991, I made a further donation of $100,000 to the General Practice Research Fund of the Family Medicine Unit to encourage and stimulate research in General Practice. In 1992, I proposed to top-up the senior lectureship post to full professorial status by personally donating $1.5 million to the University (spread over three years) to finance the cost difference, and to name the new Chair of General Practice in honour of the Father of Modern China and Founder of the Republic of China. This offer was accepted by the Council, and the "Dr Sun Yat-sen Chair in General Practice" was thus conceived. Prof Tony Dixon became the University's first "Dr Sun Yat-sen Professor of General Practice", and the Inaugural Ceremony of the Chair was held in the Rayson Huang Theatre in June 1995, to coincide with the World Congress of the World Organization of Family Doctors (WONCA) held in the Hong Kong Convention Centre. I was at that time the World President of WONCA, and was privileged to be the Principal Speaker at the Inauguration (Full Text of speech in Appendix IV). I am pleased to have this chance to place on record that Hong Kong in general, and HKU Medical Faculty in particular, benefited tremendously from Prof Dixon's expertise during his eight-year (1994 to 2002) tenure of office in the Faculty. Without his stupendous input, it would be difficult to imagine how the Faculty could have achieved its modernization by revamping the entire medical curriculum and radically changing the whole teaching methodology in time for it to be introduced in the summer of 1997. Because of their respective relevance and significance to the issues at hand, and to give Council Members a clear insight into the raison d' I deeply regret to inform the Council that not only was Prof Dixon's prodigious contribution not duly recognized by the Faculty but his departure from the University was also allowed to pass unnoticed and without fanfare. But what is even more depressing, and what to me is completely incomprehensible and without warning, was the Faculty's decision to abolish the "Dr Sun Yat-sen Chair of General Practice" following Prof Dixon's departure in 2002, in direct contradiction to the Hospital Authority's current policy of emphasis on family medicine. Is this what the Medical Faculty meant by taking "more account of feedback from the major employer, the Hospital Authority"? To make matters worse, the senior lecturer's post left vacant by Prof Dixon's departure was not filled, resulting in manpower resources in the Family Medicine Unit being even worse off than before 1995 when I personally injected $1.5 millions to the University to top-up the post. At present, the number of academic staff in the Family Medicine Unit has been reduced from four to three (two senior lecturers and one lecturer). Since the loss of the Chair Professor, the professional leadership role of the Family Medicine Unit is greatly diminished, and its teaching capability, already thinly stretched to cope with the workload of the current medical curriculum, is additionally weakened as a consequence. I understand that the amount of teaching in Family Medicine may even be further reduced if no additional manpower is added in the near future. I do not need to emphasize that this downgrading of General Practice/Family Medicine teaching in our Faculty of Medicine is most detrimental to the health of the population and the health care system of Hong Kong, not to mention that it also adversely effects the quality of our medical graduates. It appears to me therefore that the Medical Faculty is trundling in reverse back to the 19th Century, concentrating only on teaching the students subjects relating to hospital and specialist care in its ambition to achieve academic elitism, at the expense of the welfare of the community and the medical needs of the people of Hong Kong, by willfully neglecting the education of undergraduates in the field of primary and ambulatory care. There is nothing wrong with "academic elitism", but we must not forget that the basic and fundamental requirement of our Medical Faculty is to supply good, well-balanced and all-round medical graduates to serve the average citizens in the streets in the community in general, and NOT just in hospitals. This, I am sure, must be our prime concern and No. 1 priority. Continuing our discussions on the revamping of the MBBS curriculum, I wish to inform the Council that, even though the syllabus and teaching in Primary Care has on paper been much enhanced, the actual exposure of students to family medicine, the core discipline of primary care, is pitifully insufficient and disappointing when compared with other medical specialties because of the smallness of the Family Medicine Unit (only three academics). The learning opportunities in the problem-based tutorials in the first two years, and the Primary Care Programmes in the 4th and 5th years, cannot be exploited to the full for the benefit of students because the Family Medicine Unit does not have sufficient manpower and resources to provide any significant input.「有等於無」. As a result, the teaching of the current medical curriculum of the University of Hong Kong is still mainly hospital-based, which tends to give medical students a distorted view of our health care system, bearing in mind that less than 5% of those seeking medical attention are actually admitted to hospitals, whilst the overwhelming 95% of disease patterns of those members of the community who are not admitted to hospitals, that is, 95% of illnesses prevalent in the community - such disease patterns - are not seen in hospitals and are therefore totally denied to the students, and our graduates are expected to practise in the community with their minds filled with grandiose visions of exotic diseases, but without the practical knowledge of how to deal with the mundane "trivial" ailments of the man-in-the-street. I take the liberty of enclosing herewith a copy of the official Primary Care Programmes of the MBBS curriculum of the University of Hong Kong, 2003-2004, (Appendix VII), and invite members of the Council to decide for themselves whether such an extensive curriculum could be adequately handled by the current Family Medicine Unit with only two senior lecturers and one lecturer. We must not forget that the subject matters to be taught in the current HKU Primary Care Programmes are only the bare minimum that is required and can be considered as "restrictive" or even "inadequate" when compared with similar programmes in medical schools of developed countries. General Practice/Family Medicine teachers are usually required to assume a much broader mandate to deal with issues such as primary care, diagnostic process, medical ethics, communicative skills, social/family/sexual problems, psychological illnesses, patient compliance, medical consultation and history-taking techniques, doctor-patient relationship, terminal illnesses, bereavement, practice management, special aptitudes required to deal with hosts of social and interpersonal relationships in community settings of solo- or group- medical practices outside the hospital environment, etc. It can therefore be seen that the Primary Care Programmes of our Faculty require much support and expansion in scale, scope and content before we can keep pace with the rest of the world. These are all issues of paramount importance at all levels of care and are just as useful to all graduates irrespective of whichever specialty he or she may wish to pursue after graduation, but which subjects and courses are not taught coherently or systematically at any other point in the medical undergraduate system except in the general practice/family medicine department. It is therefore no exaggeration to postulate that Family Medicine/General Practice is the "Foundation Stone" of medical education on which all other specialties are built. The bigger and stronger the Department of Family Medicine is in a medical school, the better and more solid will be the graduates it produces. This brings to mind the official statement from the Medical Council of Hong Kong in its 2003 Review of the Medical Faculty of our University. The Medical Council Review expressed concern that "the limited size of the Family Medicine Unit gives insufficient exposures of students to family medicine and does not inspire or attract graduates to a career in general practice or family medicine", and "invites the Faculty of Medicine to consider possible expansion". This, of course, is "officialdom double-talk". In real life, however, whether the graduate likes it or not, market forces will eventually determine that over 50% of graduates will gravitate towards general practice, and therein lies the absolute necessity and utmost exigency to bolster and strengthen the discipline of Family Medicine in the Faculty of Medicine for the sake of the people of Hong Kong, and for the health and welfare of our Community. For all these reasons, and in the light of recent clamours for more accountability and better responsiveness to public issues and community needs in the University Governance, I appeal to the Council of the University of Hong Kong to pass an unprecedented resolution that the Governing Body of the University issues an explicit directive to the Faculty of Medicine, through its Dean, to "upgrade the existing Unit of General Practice/Family Medicine to a major Specialist Department headed by a Chair Professor or Professors as a matter of urgency and as soon as possible".
I sincerely hope that the above may stimulate discussions within the College and evoke comments from fellow members of the profession.
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tre behind the radical and drastic changes in the Medical Faculty, I take the liberty of enclosing herewith an article by Prof Tony Dixon entitled: "Medical Education: The Next Revolution" published in the Journal of the Hong Kong College of Family Physicians in March 1997 explaining the rationale for the change (Appendix V), and another article jointly by Prof Dixon and Prof S P Chow, the then Dean of the Faculty, entitled: "Medical Education at the Hong Kong University: Changes and Challenges" published in the Chinese Medical Journal in June 1997, describing in detail the completely revamped curriculum and the new system of teaching in the Faculty of Medicine (Appendix VI). These reforms revolutionized medical education in Asia, for which the University should be proud. I understand that CUHK only started to follow suit years later. I also took the occasion of being invited to Beijing in October 2002 as the Keynote Speaker at the international "Presidents' and Deans' Forum", to which was invited the Presidents and Deans of major medical schools and universities around the world as well as the Presidents and Deans of all medical schools in China, held in conjunction with the celebrations of the 90th Anniversary of Beijing University, to advocate the adoption of these reforms by medical schools in China, and by others who cared to listen.