Mrs. Yang is a 45-year old bank staff. She started to consult Dr. R, a family doctor practising near her residence 5 years ago. She has been a frequent attendee, consulting about 20 times a year, mainly for minor problems such as diarrhoea and common cold. Over these years, she has become more and more health conscious and often requested Dr. R to refer her to specialists for management of different health problems.

Whenever her cough did not clear within a week, she would consult a respiratory physician. Her frequent diarrhoea and abdominal pain was evaluated with colonoscopy 2 years ago and a gastroenterologist made the diagnosis of Irritable Bowel Syndrome. Symptomatic remedies have been prescribed which helped partially. A gynaecologist has performed pap smear and gynaecological examination annually for her since her marriage. Mrs. Yang started to have irregular menses, frequent palpitation and hot flush at 43. Hormone tests performed were apparently normal. Yet, she perceived herself to be "peri-menopausal" and started taking herbal medicine and soya milk daily. Mrs. Yang also has received manipulative therapy for neck pain, from her boss's chiropractor since early this year. Besides, she has self-medicated with Vitamin C, Omega 3 and Calcium for years. Over-the-counter hypnotic has also been taken few times a week.

Mrs. Yang's company has provided thorough annual medical check-ups and influenza vaccination for every staff. It allows employees to have unlimited access to a comprehensive network of out-patient medical services. Hospital care is also included and she has been admitted for sleep apnoea study, cardiac evaluation and various imaging scans and no positive pathologies were identified.

Mrs. Yang has no habit of smoking or drinking. Her body mass index has climbed up to 28 over the past decade and she rarely exercises. Mrs. Yang's parents have been following up in government specialist clinics for Diabetes Mellitus and both are healthy otherwise. Apart from Caesarean section, Mrs. Yang has not undergone any other operations. Mrs. Yang describes herself as a demanding, neurotic and sociable person. The recent increase in workload has made her exhausted almost every day and she has experienced "blue feelings" quite frequently.

Her relationship with her husband, Mr. Yang and Jason, their 12-year old son, has been fair. Mr. Yang is a fireman and the family has been well-maintained financially. Both Mr. Yang and Jason have no regular family doctor and used to consult government out-patient clinics when needed.

How would you comment on Mrs. Yang's health? Being a high utilizer of medical services, do you think that Mrs. Yang's health needs have been well-addressed? It seems that she has been managed as labels of diseases rather than a person. The emotional, social, functional aspects and disappointingly even the physical aspect of her health have appeared to be sub-optimally managed. Suppose you are going to take up the care for Mrs. Yang as her family doctor, can you do better? How?

Mrs. Yang may represent a group of patients who have physical symptoms which, after extensive investigations, still remain medically unexplained. The term "medically unexplained physical symptoms (MUPS)" is usually used in literature to define these physical symptoms. MUPS can occur in any body system. The commonest symptoms include pain, indigestion, palpitation, cough, dizziness, fatigue and insomnia. Locally, a study in the primary care clinic of the University of Hong Kong showed that MUPS amounted to 20% of all of their consultations.¹ Researches have shown that Chinese patients solely express their emotional problems through physical symptoms.² You may suspect Mrs. Yang is suffering from hidden emotional problems; anxiety, depression or somatoform disorders. To be a good family doctor, an in-depth biopsychosocial assessment should be performed and this usually has to be extended to include her family members. Besides, adequate breath and depth in knowledge across different medical disciplines as well as a compassionate attitude to care for their patients are essential. Different combinations of clinical, communication and management skills have to be flexibly applied to different consultations.³ The strategy of "re-attribution" can be employed to shift the focus of the patient from purely physical to include emotional and social factors and make the link between emotional distress and physical symptoms.⁴ Mrs. Yang has a list of problem needs and the needs should be prioritized and managed. These are not merely diseases such as Irritable Bowel Syndrome, Peri-menopausal Symptoms, Neck Pain, Insomnia, Overweight, work stress and underlying psychological problems but the interaction of these sufferings and her unique illness experience must be seen as a person. A patient-centred integrated care comprising education, negotiation of diagnoses and management, psychological interventions, evidence-based choice of medications, collaboration with other professionals and enlisting family support is required. A trained and committed family doctor should be competent enough to perform all these tasks.

Nonetheless, there are in real life several obstacles we have to overcome together. Or else, the individual family doctor's good will and efforts to help Mrs. Yang may easily be wasted. Like Mrs. Yang, patients with somatisation often demonstrate abnormal illness behaviours.⁵ While we may simply label these patents as "heart sink patients", abnormal illness behaviours should not be considered merely as the result of their personality defects or bad experiences in their upbringing. Rather, all primary healthcare professionals including Traditional Chinese Medicine practitioners, specialists at other levels of healthcare, practice management, healthcare policy, the media and other socio-economical factors may all have unintentionally reinforced these behaviours and their suboptimal health. Concerted efforts to intervene in all these areas are therefore necessary.

Time can be a major obstacle, especially for those practising in busy clinics. Doctors are tempted to use referral or prescription as a quick and customer-need- oriented disposal of their patients. One solution is to employ a more flexible appointment system which can accommodate extended consultations. Others suggested the effective use of the frequent short consultation encounters to break down long consultations into small parts with achievable goals at each visit.

In Hong Kong, primary healthcare has been more diversified than in many developed countries. The standard of care provision by primary care doctors has been commented as being too heterogeneous. This leads to the question about the quality, quantity and the user-friendliness of the available Family Medicine training programmes. Hong Kong College of Family Physicians has developed its structured vocational training programme for Family Medicine trainees for more than 20 years. The programme has been regularly evaluated and has been evolving to meet the changing needs of today's society. For other practising doctors who inspire to practise our discipline, they can join the Diploma courses in Family Medicine organized by our College and several Universities. Participants can acquire the essential core concepts, principles and skills in Family Medicine through these courses. Furthermore, our College would like to encourage all practising primary care doctors to continuously update themselves through different educational activities and to pass our Fellowship examination which may act as objective validation of their efforts. While the individual differences in practices are acknowledged, we must have in the community a significant mass of practising primary care doctors who are applying Family Medicine to their practice. We certainly need more practising doctors to take up Family Medicine training.

Besides, there is a great variety of other practitioners including Traditional Chinese Medicine practitioners and Alternative Medicine practitioners practising in our community. Specialists of other disciplines are also providing certain proportion of primary healthcare to the population. We have to be empathic and understand the innate differences between different professionals. Two way communications should be promoted so that differences can be discussed and compromised. A more balanced or combined management approach may thus become feasible. Apart from communication at the level of patient care, creation of a collaborative multi-specialty research network to share information and study problems such as MUPS is recommended.⁶

Our healthcare system has increasingly emphasized the role of family doctor as gatekeeper and patients with MUPS should be directed to corresponding specialists only when indicated. In reality, without a culture of Family Medicine in our healthcare system, unnecessary investigations, referrals and prescriptions as well as collusion of anonymity will still perpetuate. Much of the taxpayers' money will continue to be used ineffectively. While more and more specialists are appreciating the beauty of collaboration between different levels of healthcare, there is a real need for resources allocation and support from the government in strengthening such system. Besides, the future development of health insurance and financing has to be well-planned so that the balance of different levels of healthcare will be reset healthily.

Doctor shopping, seeking quick fix, self-medication, polypharmacy and non-compliance have been deep-rooted practices in our population. Patient education may be a taxing and challenging task in our short consultations. For years, our College has been striving to correct these practices through promoting the concepts of Family Medicine through different media channels. This will be effective only if more family doctors can step out of their clinics to educate the public in a wider and more influential way. Patients, like ourselves, need time to change. This may be an endless endeavour, but certainly the right route ahead.

Mrs. Yang's case is used here to illustrate the complexity of problems in primary healthcare. There are many more challenges other than patients with MUPS which call for a significant mass of good family doctors to practise in the community. To facilitate these good doctors to practise effectively, we need to have joint effort with our College to proactively promote a Family Medicine culture in our healthcare system among the private doctors as well as in the public sector. As Albert Einstein suggested, "We can't solve problems by using the same kind of thinking we used when we created them."⁷ We have to not only self-improve but also help struggle for a better system good for everyone.

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