The Part II of Conjoint FHKCFP/ FRACGP Examination finally came to an end. As a trainer, noting only 30% passing rate, I cannot help feeling disappointed. This feeling was stirred up into a tempest in my mind after reading an article by Dr Richard Yu titled "why do family medicine trainees jump boat?" dated on 14/12/2007 in Hong Kong Economic Journal (信報). I have a burning sense to share with you my thoughts and feelings.

Why is the passing rate so low? Is the standard too high to be satisfied? Is the FM College trying to build an ivory tower or an icon for trainees to worship but not to be reached? Or is our quality of training not matching the examination standard?

I have been in the FM training programme for 6 years. As an ex-trainee, a junior trainer and examiner, I have witnessed changes in FM Conjoint and Exit Examinations. The College had showed much effort in trying to change the Conjoint Examination into a more objective one assessing a wider knowledge base and a larger variety of skills of trainees. The pains and efforts of the College are undeniable. The icon and ivory tower built under the old format is now being pulled down bit by bit. The new format is heading through a right track. Therefore if it is not the problem about standard and examination format, it must be something wrong with the training quality.

I regret to admit this is true. Being a doctor trained under the public setting, it took me no effort to realize that there had been big gaps between what I was taught and what I have to practice. So it has been again a battle between idealism and pragmatism. This is nothing new or unique to the FM specialty. However, after so many years, why have these gaps been getting wider? Have we not tried hard enough to narrow these gaps? Who should be responsible?

Are the trainees not up to standard? Or are the trainees not competent enough to be trained? It is not uncommon to come across trainees who do not know about injecting trigger finger after months of orthopaedic rotation; or trainees who do not know bedside treatment for haemorrhoid after surgical training; or trainees who do not know about IUCD insertion after gynaecology rotation. Are the hospital-based trainers too busy to teach trainees? Are they not aware of the skills trainees should acquire during the rotation? Is the FM College not providing enough guidance to our trainers and trainees? Is our medical system being too defensive especially in medico-legal aspect to teach new skills to FM trainees? Should the College help to open up new channels in the community (e.g. Family Planning Association, Maternal and Child Health Centre or even private practice attachment) to maximize training opportunity? There seems to be no simple answer. I think specialists of different disciplines should think hard to reflect on their own knowledge on FM practice. Of course, it is also the FM College's responsibility to make them understand FM more. It would be too naive to blame a single party for all the problems.

In order to improve the training quality or outcome, what else can we do? Should the College lower the virtues and standards of FM in order to pass more trainees so that they will stay in the specialty? But what is the use of salt if it loses its saltiness and what is the use of light when it doesn't shine? Should trainees and trainers be more examination orientated and more strategic in the training programme? But what is our purpose in practising FM in a way that is not believed to be? Should healthcare administrators stop adding quantities to primary healthcare frontline at the expense of qualities? What is the use of promoting patients' right and quality healthcare when we are not providing one? Should healthcare profession and reformers recognize the need of a FM based healthcare system and therefore allowing some space and nourishing ground for the growth of the specialty? What can we expect from the training quality when trainees are not nurtured in a right medium? Do we expect to train a 5-star chef at a fast-food shop setting? Is it time for us, especially FM doctors to think about our role in upholding the training quality?

Each sector has its own dilemma. It is time to pull ourselves together to clarify the future of our specialty. In the coming years in this era of health care reform, it is time for all parties in the health care profession to think about the future training in FM.

I would like to take this opportunity to thank Dr Yu for his courageous opinion about current FM. Some pressure on us is always good in order for us to grow.