Of all the roles of the primary care doctor, the "gatekeeper" role is probably the one that arouses most confusion, ambiguity and misunderstanding, and for good reasons too. The word is not one in common usage and certainly most people in Hong Kong have never heard of it. Such confusion over the meaning of words is not uncommon. For example, the term "free radicals" means quite different things to chemists and to counter terrorist experts. Similarly, a "unionized compound" could mean an uncharged chemical or a building that has become a member of a labour union.

I went to a seminar a while ago and the speaker who was introduced as an experienced family physician mentioned the word "gatekeeper" when describing the role of the primary care doctor but when he tried to explain it in Chinese, he actually used the Cantonese term for "goalkeeper". He has obviously confused the less commonly used word with the more familiar "goalkeeper". This is probably the worst possible interpretation of the primary care doctor's role.

A goalkeeper is a player in sports whose sole mission is to prevent the ball from entering the goal. Applying this without modification to the healthcare setting, one comes up with the mental picture of footballs, which symbolize patients, flying from all directions towards the goal, which symbolizes secondary healthcare. And the primary care doctor, as "goalkeeper", swings his arms around, desperately keeping patients out of secondary healthcare. This interpretation immediately creates several problems. Firstly, in this scenario, patients and doctors are oppositional in position and the nature of the doctor-patient relationship becomes one of competition. Secondly, any patient who manages to "slip" into secondary care represents a failure on the part of the doctor. Nothing can be further from the truth!

It is far better to describe the gatekeeper as someone on the road who directs lost travellers to different gates according to their needs and destinations. The relationship between the traveller and gatekeeper then becomes one of trust and the decision-making process becomes one of collaboration. This is a much more accurate description of the primary care doctor"s role.

Out of the many varied meanings of the word "gatekeeper", it is interesting to note that in the very popular computer game "Final Doom", the Gatekeeper is actually a large, powerful demonic creature that controls access to the interdimensional Gate of Hell.¹ It is not hard to imagine the facial expression on a teenage computer game enthusiast when his family physician tells him that "I am the Gatekeeper"!

Going back to the question we started off with, "What does the word "gatekeeper" mean?" The answer, and problem, is, it means different things to different people. If the word is to be useful to anyone, it should be clearly defined every time it is used.