Family medicine training - What have we not taught our trainees?*

K Choi 蔡堅

HK Pract 2005;27:20-22

In the old format of the conjoint examination, the log diary would usually tell the examiners who was a trainee with a supervisor and who was a Category 2 candidate. A non-trainee candidate in family medicine, who might even be a specialist in another field, might submit a diary exposing his inadequacies as a family doctor. A candidate with a higher diploma in family medicine from an overseas university through a correspondence course might reveal that he practiced preventive medicine by doing CBC, LFT, RFT, Lipid profile, VD screening, urinalysis, stool examination, x-ray chest and ECG for all those who asked for a health check up or all those whom he convinced to have one. Examiners would know his deficiencies in family medicine and also that he had never had a supervisor. Medicine is derived from the words "to teach". When I applied as a trainer about 3 years ago, I just wanted to teach. Now that the project of employing private family medicine specialists to help out in the public sector is coming to an end despite the Secretary of Health, Welfare and Food's reply in the Legislative Council that training in family medicine is limited by the availability of trainers, I must acknowledge the input by the College and Dr Donald Li who transformed the dream into reality. In one earlier meeting with other supervisors and the Hospital Authority administrators, I declared that the role of the supervisors should be to teach good family medicine, to assist trainees to take examinations, and to facilitate them to become viable general practitioners in the private sector when they exit from the public sector. This last role is most important since the new Secretary for Health, Welfare and Food has announced that his vision for the Health Care System of Hong Kong is based on a strong team of private primary care doctors whom he labelled family doctors. I perceive family doctor as one trained in the principle and practice of family medicine and providing holistic care to his patients. Dr C H Leong in a speech to graduates of Hong Kong University on the first of December 2004 referred to these doctors - the superior doctor heals the nation, the middle doctor deals with the person, the inferior doctor treats the disease. 『上醫醫國，中醫醫人，下醫醫病』 I hope we as trainers are producing the middle doctors to provide holistic care for the patients, and not organ specialists dealing with disease only. It may be too difficult to produce superior physicians who create policies, but they are often labelled as vociferous.

While the Secretary's idea of a family doctor may not coincide with ours, it is important to examine our own products and find out whether they are satisfied with our supervision. Unfortunately, there has not been any assessment of this kind by the College up to now. We have assumed that those who are Fellows or those who completed the training programme are good enough. We have assumed that providing them with CME or CPD will keep them on the right path and the right track. Are we correct?

Let us look at the first scenario. A 76 year-old lady limped into the office of a public hospital clinic complaining of a troublesome running nose and postnasal drip. She was on paracetamol for osteoarthrosis of the knees and also mentioned nocturia up to 3 times each night. The doctor prescribed chlorpheniramine and promethazine and sent her on her way.

I suggested checking for visual acuity, balance, postural BP drop, time up and go, and functional reach to assess the possibility of falls if antihistamines were to be prescribed and asked the doctor to review the necessity for the prescription. If antihistamines were needed, could there be alternatives. Even if non-sedating alternatives were not available in the public clinic, should the patient be informed and given the choice to purchase the better alternative if it was deemed necessary. Should the reason for nocturia be explored - infection, cystocoele, atrophic vaginitis etc. and should her home environment be assessed - How far is her bed from the toilet? Would she need a commode? In fact, she used a bedpan. This is what holistic care is all about and this is what I hope my trainees will model after.

Even the media agreed that patients may have to pay for quality treatment. On 5 March 2001, the Editorial of SCMP wrote: "If people want unrestricted access to the most modern drugs and medical technologies, they will have to be prepared to pay for them through insurance schemes or mandatory saving plans. If not, they will have to be content with the restrictions of the tax-funded system. In health care, as in most other things, nothing comes free". I hope that my trainees learn to give patients options.

Another scenario follows. A 50 year-old lady with Helicobacter pylori gastritis complained of dyspepsia despite a week's triple therapy. She had frequent colic and diarrhoea. The 5th year resident suggested a prescription of a proton pump inhibitor that the patient would have to buy outside. The patient pleaded that her husband was unemployed and she could not pay for the medications. The doctor laughingly asked "do you want me to buy for you?"

To the young resident who will be migrating to the private sector, I advised that some remarks are uncalled for and may entice complaints. Instead of dispensing medicine which trainees are keen to do, tackling the problem using the bio-psycho-social model would probably pay off more dividend - the lady's financial embarrassment and her husband's unemployment were legitimate reasons for the symptoms of irritable bowel syndrome rather than gastritis. Should we explore whether she was depressed? The consultation is the most important component of each clinical encounter, and making use of the bio-psycho-social model to review each case makes us different from the organ specialist, and trainees should take this to heart. Sometimes it is more important to use our heart to manage a patient, not just our eyes and our minds and our computers.

His next patient was a 60 year-old man with hypertension complaining of tinnitus. Examination was normal. The tinnitus actually dated back 10 years. The patient was sent away with betahistine 6 mg tds for 4 days. Again the unasked question was why now, after 10 years? (actually he could not sleep recently) and the inappropriate practice was to dispose of the patient with a drug which was not needed and which was not useful when prescribed at this dose for 4 days only. Professor SW Tang of the Psychiatry Department of Hong Kong University put it very nicely - "the good doctor manages while the poor doctor treats".

The last patient, whom I sat in with, complained of left lower quadrant pain and loose stool. A rectal examination confirmed mucus in the stool. No query was made as to the concern of the patient who actually had an appointment in 2 weeks' time for colonoscopy in another hospital. The patient was sent away with a note detailing the findings of the rectal examination and he was told that he must attend for colonscopy at all cost without any reason being given. It was obvious that further uncertainty and anxiety was instilled after the consultation.

Another trainee who completed the programme joined a doctors' group. The records supplied by his group had limited space for properly recording vaccination, genogram and past health. A 35 year-old receptionist saw him for dyspepsia and sore throat. She had a child who recently developed chickenpox. Communication was good and symptomatic treatment was provided. Sick leave was issued. However, periodic health examination was not discussed or offered and the essence of a good family medicine consultation which he used to offer was gone.

His current interest lies with the use of expensive and potent drugs that his competitor cannot afford, such as Telfast and Singulair. Another young Fellow who started his practice using the College record also competes by using a lot of medications not available in his former public practice - Zomig, Plavix, Lipitor, Approvel, Harnal, Reminyl, Nexium, Telfast D, Propecia, Proscar. His books, charts, and drug samples were all over the examination couch. He visits Elderly Homes and treats geriatric patients for minor ailments. He practices family medicine but has difficulty in making ends meet despite his long hours and efforts.

I picked up Paracelsus's remark from Professor Tang's lecture which should prove useful to my young friends: "All substances are poisonous, there is none which is not a poison. The right dose differentiates a poison and a remedy".

The quality of our doctors was actually reported by the Harvard Team. Commissioned by the Health and Welfare Bureau in 1997 to look at the health care system of HKSAR, they reported that "the quality of health care is highly variable" and "there is considerable evidence of widespread sub-standard medical practice....". Witch-hunt stemmed from the report. Actually, variability amongst doctors is invariable from the day students enter medical school, some with many more distinctions than his classmates. Amongst the graduates there are those with honour and distinctions and those with pull-up pass. Will training and CME make all doctors identical? I have my reservations.

A young Fellow who completed the programme and joined a NGO clinic phoned me two months ago and yelled help. His clinic nurses had dispensed the wrong medications to his patients. He did not know what to do. He was not aware that he should check the medications himself. He did not know that he could change the clinic practice himself as a new employee. He had not been taught how to deal with this situation.

I asked another Fellow, his wife, what they wanted to know. Here is a list that supervisors should consider teaching their trainees:

1. How much to charge?
2. How many days of drugs to prescribe?
3. How to choose a clinic practice site?
4. How to employ staff?
5. How to discharge staff?
6. How to prevent theft in the clinic?
7. How to do proper book-keeping?
8. How to make an annual report to the IRD?
9. How to remain in harmony with your neighbouring colleagues?
10. How to choose a laboratory?
11. How to set up a practice?
12. . How to decorate a clinic - who to call?
13. How to recognize your worth? A young trainee who completed training and acquired the DCH was employed for 45k while another who passed the conjoint with DCH and PDCG for 80k. How should a young doctor negotiate his salary?
14. Is FM the right choice, the right career for me?
15. How can I find time to relax, enjoy the sun and the sea, have babies, raise a family?
16. What prospects are out there for me?
17. Where will I be 20 years from now?

All these questions are best answered by a clinical supervisor from the private sector and trainees should have all the answers before they exit from the public sector.

A successful trainee who passed the examination phoned me for advice. He went to familiarize himself with the practice of someone he will be working for. He was alarmed with the amount of codeine-containing cough mixtures and antibiotic being used and asked me how to cope and whether he should change his style. I quote Star Wars. "The Force be with You, do not defect to the Dark Side, young Skywalker". I made use of Dr Donald Li's Presidential Message: "By providing the best quality of service, we will command a much deserved reward. Trainees are apprentices and may have to bear some hardship for now but the future is bright for qualified family physicians. Acquire the proper skills and attitude and you will soon find that you have a good following of patients. Financial reward will also follow. Do not buckle under pressure and temptation; there is no shortcut to success". I pray that Dr Li is right.

I would like to thank my friends and mentors who taught me family medicine, Dr L F Chan, Dr Nat Yuen, Dr Y T Wun, Dr Cynthia Chan, Dr Cindy Lam and Dr T P Lam. I am most grateful to all my trainees for enduring my idiosyncrasies during the last few years. I learnt more from them than the other way around. I appreciate what John Chamberlain said "To teach is to touch a life forever". I would like to encourage all my young friends with a quote from the past "here I am not so much striving to teach as I am encouraging you to learn". Thank you all for giving me this opportunity to express my feelings for my trainees. Good luck, God bless and Merry Christmas.