The changing jigsaw puzzle of good medical practice in primary care

Lau Ho Lim 劉浩濂

HK Pract 2019;41: 89-90

Providing good medical care in family medicine is like putting together pieces in a jigsaw puzzle to reveal the holistic picture, a challenging yet rewarding experience to all concerned, and the further you get in your career as a family physician, the deeper you will appreciate it is no easy task at all.

There are some simple guides, e.g. Guidance on Good Medical Practice from the General Medical Council, UK ¹, for doctors, but these guides usually focus at the personal level. In our daily work as a family physician, however, we know we need to understand not just ourselves, but also our patients, the healthcare system and medical models in which we practise, all being pieces of the jigsaw puzzle in question, and all influencing the quality of medical care we offer.

In a medical journal on family medicine there are mainly two kinds of articles: those that aim to cover a particular field of knowledge in the discipline and those that aim to conceptualise, define or re-define it. In this issue of The Hong Kong Practitioner, we have both of these two kinds of articles, focusing on different levels of knowledge and offering insight into different building blocks of our jigsaw puzzle.

Adapted from her 2019 Dr Sun Yat Sen Oration at the Hong Kong College of Family Physician’s Conjoint Fellowship Conferment Ceremony, Prof Amanda Howe elucidated three principles of modern times – identity, humanity and equity.² They point very nicely to the roots of the WONCA Tree which defines the core competencies of the general practitioner/family physician - attitude, science and context.³ The three principles explained in detail by Prof Howe also set the scene for future development of the discipline of family medicine.

Nowadays chronic illnesses dominate much of the clinical work of the family physician. Two of these common chronic health problems Editorial are addressed in two articles in this issue. Chau and Wong studied the attitudes and knowledge among GOPC doctors in Kowloon West Cluster in Hong Kong about obstructive sleep apnoea.⁴ Their finding of low confidence among these doctors in managing obstructive sleep apnoea is important in the design of our vocational training in future. Lau et al examined the current knowledge and acceptance of same stage bilateral knee replacement (SSBKR) among prospective joint replacement candidates in a local Joint Centre⁵ and provided evidence to help inform future patient education. These two studies on attitudes and knowledge are important in ensuring good medical care because it has been found that “knowledge, bias and uncertainty” is one of the three domains of factors that contribute to poor medical care.⁶ These two articles also reinforce the current emphasis on understanding both the doctor and the patient in order to foster fruitful shared decision-making⁷ and a good doctor-patient relationship.

Prof Rodger Charlton took a wider, macroscopic look at the doctor-patient consultation and his discussion paper on new models of primary care in the UK⁸ shows how our jigsaw puzzle is never static. As medicine has been changing constantly since its beginnings, with the advent of digital consultation trying to replace the well-tried face-to-face consultations in the UK, he argued that a new model of primary care is emerging. This model needs to address questions such as security and privacy of electronic health records⁹, effective information-sharing, patient needs and ideals and risk to patient safety behind this façade of easy access to medical attention. Currently there is limited adoption of e-consultations with many questions requiring further research to answer them.^10,11 However, it may lead to fundamental changes to the pieces of our jigsaw puzzle of good medical practice in primary care in future. We have to equip ourselves for a potential paradigm shift.