The evidence of primary care linking to better healthcare has been accumulating ever since researchers started to distinguish primary care from other aspects of the health services delivery system.¹ It has been demonstrated that health is better wherever there are primary care physicians and the people receiving care from primary care physicians are healthier. The characteristics of primary care are also seen to associate with better health.^2-4

Moreover, when one examines closer when the supply of primary care physicians comes from family physicians (FPs), internists, and paediatricians, only the supply of FPs showed a significant relationship to better health.⁵ It is because the training of FPs is based on not only across clinical boundaries in terms of bodily systems, age or sex, but across that very difficult one - the boundary between medical and social problems.

Family physicians are also equipped with skills in preventive medicine and identification of early risk factors. They need to have the diagnostic skills and be able to use time as diagnostic tool rationally. Therapeutic skills should also include use of the doctor-patient relationship and doctor-family relationship to maximize effectiveness of treatments. The specialty of Family Medicine is breadth rather than depth and this would facilitate the FPs to have deeper understanding of patients' problems from individual perspective to family perspective and also community perspective.

Evidence has shown that preventive interventions are best seen in primary care when they are not related to any one disease or organ system; for example, to be physically active, eating a healthy diet, not to smoke, use seat belts and breastfeeding. The American states with higher number of primary care physicians to population ratio have lower smoking rates, less obesity and higher seatbelt use.^{1, 6-7}

Historically, Hong Kong has not established a certification system for doctors practising in primary care; so we have doctors from many different specialties practising in primary health care. The recent discussion paper on future service delivery model has mentioned that family or primary care doctors can be general practitioners, specialists in various specialties and specialists in Family Medicine.⁸ This is a very warm message and it recognizes the contributions of differently trained doctors in delivering primary medical care. On the one hand we should pay our tribute to our colleagues who have practised in the community as family doctors over the last few decades without having much support and training and using whatever resources they had to equip themselves to deliver quality primary health care. On the other hand we are seeing more and more patients now presenting with problems which cut across different clinical boundaries presenting at early stage of their illnesses. If their problems are not well managed, they would evolve to more complicated illnesses and land up in hospitals.

It is an outdated approach and also unsafe to allow doctors to practise as FPs in primary care setting without acquiring new knowledge and skills in Family Medicine. For the newer generation of doctors, they should all complete the basic vocational training in Family Medicine and be certified to practise. For more experienced doctors who are already specialists of various specialties or have been practising in primary care for long time, they would enhance core skills in Family Medicine by structured postgraduate programmes.

The core skills are ^9-12:

Diagnostic fallacies would occur if FPs make diagnoses just by collection of clinical information in routine fashion. FPs should start off the process by formulation of provisional diagnostic hypotheses, then test the hypotheses by selective collection of clinical information from history, clinical examination and laboratory test looking for positive (confirming) and negative (refuting) evidence. This hypothetico-deductive approach is based on the work of Elstein.¹³ FPs must prepare to revise and test the hypotheses further until it is refined to the point at which management decision is justified. The purely deductive approach can play relatively small role in diagnosing more complex problems in community. The core skills mentioned above are very fundamental for any doctors wishing to play the role as FPs in delivering quality and effective health care.

Hong Kong has only limited numbers of specialists in Family Medicine. Although it is not feasible to have all practising FPs achieve specialist status at present stage, core skills in Family Medicine as discussed above must be attained. Training specialists in Family Medicine is still very important as this group of specialists will be responsible for supervision of new trainees, for taking up senior academic position in Family Medicine or senior position in primary health care practice, and also responsible for standard setting and monitoring. The core skills possessed by an average FP must be clearly defined by senior FPs with substantial experience in education and training. Once this is defined, a registry of practising FPs can then be created, marching towards specialization of Family Medicine for the better health of our population.