Common symptoms like headache, abdominal pain or dizziness may have a wide spectrum of causes ranging from self-limiting to potentially lethal disorders. Sometimes it is not feasible or even possible to make a definitive diagnosis before treatment is provided. During consultation, general practitioners tend to make a ‘tentative diagnosis’ based on their clinical judgment and treat as such. This management strategy may sometimes be more cost effective and at the same time may offer a faster way to resolve the problem.¹ According to Heneghan et al (2009), diagnostic stages used by general practitioners in primary care can be divided into three stages,² namely: the initial diagnostic hypothesis; refining the diagnosis and defining the final diagnosis. On many occasions, diagnostic labels could not be given after the initial consultation even though it may be possible to make a spot diagnosis if distinctive diagnostic features are present.

During this era of flooding information through the internet, patients may match their symptoms with disorders before they seek a doctor’s opinion and at times would tell doctors what they think they are probably suffering from. With a hypothesis in mind, doctors usually adopt the Murtagh’s process³ to refine the diagnosis and decide on the probability taking into consideration the symptoms, signs, and own experience of patients with similar presentations. It was stated that only less than fifty percent of cases can be given a definitive diagnosis without further investigations.² Under these circumstances, management strategies that are commonly used by general practitioners include ‘therapeutic trial’ to confirm or refute the ‘tentative diagnoses’ before embarking on expensive and/or invasive investigations or direct referrals. Another strategy often used by general practitioners is the use of time especially when presenting symptoms are vague or of short duration. Adopting this strategy could allow more time for obvious diagnostic features to appear allowing the attending doctor to make a diagnosis with more certainty. There are few guidelines/ rules about the algorithms of managing patients with symptoms in the local primary care setting. Concrete evidence to show that utilizing such strategies is advantageous in balancing cost and management of common symptoms are lacking. There are a number of articles in this issue of the Hong Kong Practitioner, calling on doctors to be aware of management strategies in several areas.

One of the articles introduced a new approach to treat benign paroxysmal positional vertigo (BPPV). Anyone who had suffered from vertigo would know that this symptom is very scary causing a lot of anxiety especially when the attacks are frequent and treatment appeared ineffective. The ability to provide quick relief together with appropriate explanation would certainly allay patients’ anxiety and avoid unnecessary referrals to specialist that may create additional fear to our patients.

Another article is about a patient with a rare disorder, superior mesenteric vein thrombosis, who presented with abdominal pain, which is a very common symptom in the general practice setting. The author reminded us about the possibility of a rare yet potentially lethal condition that presented with a not so sinister symptom at the early stage of disease process. This demonstrated the usefulness of the Murtagh’s process. At the same time, it is important to remind patients to return for reassessment if the symptoms become more severe or fail to subside within an estimated time frame.

The delicate balance between unnecessary referral, and timely referral to save lives, is exactly the skills that a family physician should acquire to ensure the best of care for our patients.

An interesting finding in one of the articles was that there was a high prevalence of anxiety and depressive symptoms amongst all patients attending the out-patient clinics, irrespective of whether they have hypertension and/or diabetes or not. Physiological state and presence of illness had been shown to be a source of stress for patients and the response to such stress depends on the patients’ perception of their problems.⁴ It has been reported that the degree of stress response in terms of anxiety and depressive symptoms depend on the appraisal of the stress event and the individual patient’s sense of control,⁵ that is, the ability to cope. For patients with chronic illness such as hypertension or diabetes mellitus, their mental health may not be significantly affected if their condition is well under control and if they are not suffering from any physical discomfort. On the other hand, other patients attending the clinic with other ailments that they do not know what they are suffering from, such uncertainties would result in an increase in their anxiety level. These authors rightly pointed out that social support is extremely important for patients suffering from chronic illness. It has been shown that both instrumental and emotional support is beneficial to the emotional health of these patients.⁶ Since most people in Hong Kong do not need to worry about basic needs, it is time for us to look into the population’s mental health at large and our target outcome for treating patients is not only ‘free from physical symptoms’ but to lead a better life with physical, psychological and perhaps even spiritual wellbeing. Family physicians have an important role to play in coordinating patients’ care in all these aspects. 

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INFORMATION FOR AUTHORS

Circulation and Content

The Hong Kong Practitioner is published quarterly by The Hong Kong College of Family Physicians.

The Journal is indexed in EMBASE/Excerpta Medica as ‘HK Pract’. It has a circulation of 4000, distributed to all members and some non-members of the College, academic institutions as well as private subscribers in Hong Kong and overseas.

The aim of the journal is to promote the development of quality family medicine/general practice in Hong Kong and the region, by publishing editorials, original articles, update reviews, letters to the editor, and self-assessment materials.

Manuscript Criteria - General

Papers submitted for publication should fulfill the following criteria:

1. Manuscript to be accompanied by covering letter, signed by all authors stating that it is original and no part of it has been submitted for publication elsewhere and identifying any possible conflict of interest, and the contribution of each author.
2. Typed in double line spacing with 3cm margins.
3. Submission of manuscript should be the preferred Microsoft Word (DOC) format, and sent to “carmen@hkcfp.org.hk” with one printed copy of the manuscript to the Editor.
4. List of full names (both in English with Western name(s) first, then Chinese names hyphenated or initials, and then family name and if applicable in Chinese characters) with a maximum of six authors, giving basic and higher qualifications and current appointment of each.
5. A maximum of four qualifications will be included for each author. All qualifications should be identified and include name of awarding body or institution.
6. The principle author should give his or her address for correspondence.
7. Authorship details should be on a sheet separate from the main text to assist in sending papers ‘blind’ to referees. Spelling should conform to the Oxford Dictionary.
8. Abbreviations should be spelt in full when first used.
9. Generic names of drugs must be used. Proprietary names may be used in parentheses on the first occasion if necessary.
10. SI units should be used, with traditional units in parentheses.
11. Tables and illustrations should be on separate sheets and clearly labelled. The titles should enable interpretation without reference to the text.
12. Photographs should be labelled on the reverse.
13. References should conform with
    the Vancouver style as used in this journal, and must be clearly numbered in the correct order in the text. Journal titles should be abbreviated to Index Medicus Style. List all authors and/or editors up to three; if more than three, list the first three and et al.
14. While a liberal policy is adopted in matters of controversy, no personal attacks, explicit or implied, are permitted.
15. Attempts at self advertising or unwarranted promotion of particular drugs or procedures will lead to rejection of the article.
16. Ten copies of reprints will be provided free to the authors if requested. Additional copies may be purchased and should be ordered when the proofs are returned.
17. All articles described in this Information for Authors are peerreviewed. At least one of the reviewers will be a family physician.
18. All articles are subject to editing.
19. Correspondence should be addressed to the Editor, The Hong Kong Practitioner, The Hong Kong College of Family Physicians, 7th Floor, HKAM Jockey Club Building, 99 Wong Chuk Hang Road, Hong Kong.

Copyright

Authors assign copyright of all articles to the journal. However 10% of any article may be used elsewhere without permission.

Categories of Articles

Original Research Papers

Papers on original research relating to primary care in Hong Kong are particularly welcome.

They should be set out in a standard format with an Introduction giving background and objectives; Method giving details of subjects, study design and measurements, interventions, outcomes, and statistical methods; Results; Discussion; Conclusions; References; and Acknowledgements.

Papers should be between 1,500 and 3,500 words in length. Graphs and tables should be limited to six and references to 40.

A structured summary of up to 200 words should be set out under the headings of Objective, Design, Subjects, Main Outcome Measures, Results, and Conclusions. Up to five keywords should be given to aid index cross-reference.

Educational Update Articles

They should be relevant to the Family Physician who is trying to keep up to date with recent advances in primary care.

Articles should be between 1,500 and 3,500 words, and structured with a summary, introduction, and main body of article with appropriate subheadings.

Graphs and tables should be limited to six and references to 40.

Discussion Papers

Papers on topics and issues of relevance to primary care are welcome. They should present a hypothesis or problem,

and offer a way of solving it or a solution for discussion. They should be between 1,500 to 3,500 words, and structured with a summary, introduction, and main body of article with appropriate subheadings.

Case Reports

These articles should be up to 1,500 words reporting cases of particular interest, difficult management, unusual presentations or outcomes, carrying a useful message to other doctors; with no more than one table or illustration and five references.

Letters to the Editor

Letters should be up to 500 words with no more than one table or illustration and five references.

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References