Undergraduate family medicine education: The starting point for strong primary care in Hong Kong

Julie Y Chen 陳芸, Esther YT Yu 余懿德

HK Pract 2022;44:95-97

‘Family doctors for all’ - a dream among family doctors in Hong Kong, is finally coming true. At the “Hong Kong Policy Address 2022,” Chief Executive John Lee affirmed the role and need of quality family doctors in maintaining a sustainable and cost-effective healthcare system.¹ To alleviate the overreliance and burden on public hospitals, the main focus of the health care development will lie on the establishment of a prevention-oriented and community-based system: A Primary Health Care Blueprint will be published within this year, and an authority for management of health care services in both public and private sectors, and a family doctor system in collaboration with the private sector will be set up. A three-year Chronic Disease Co-Care Pilot Scheme will be launched, in which residents who are regarded as high risk for hypertension and diabetes mellitus will be referred to family doctors for further screening and management.

The importance of primary health care has long been recognised by the World Health Organization as the road to ‘health for all’ since 1978.² As the ‘gatekeepers’ in disease prevention and management, especially deciding on referral to secondary and tertiary care^3,4, family doctors play a crucial role in protecting health and maintaining effective utilisation of medical services.⁴ To support the upcoming primary health care development locally, a high demand for well-trained family doctors can be anticipated. In particular, to sustain its development and manpower needs in the long run, support for quality undergraduate medical education in family medicine is essential.

Medical students are our future

Medical students are the core upstream resource that can be better tapped to help primary care grow and thrive. There are currently over 3300 medical students across the two Hong Kong medical schools with around 250 entering internship each year and prepared to select training streams towards the career of their choice. In the next few years, this number will steadily increase with at least 300 students graduating from each medical school by 2028. Motivating more students to select family medicine as their desired career is an ongoing challenge that is also faced by other developed countries where primary care has long been entrenched.

Medical students may enter medical school with a preferred career plan based on their perception of the work of a doctor. This perception may be influenced by experiences with health care and encounters with doctors or particular specialties due to personal or family member illness or through formal or self-initiated attachment to doctors that were formally arranged or through connections with practising doctors. Some have family doctors since childhood who have left a strong impression. However, few students adhere to the initial career plan because these preferences and interests shift as they progress through their studies, affected in part by the curricular experiences in medical school.

Stimulating interest in family medicine in medical school

A recent systematic review of medical student specialty choice found that the most influential reason for selecting a specialty was interest in that specialty⁵ while a ‘best evidence in medical education’ (BEME) systematic review highlighted a direct association between interest in a specialty and career choice.⁶ Wu et al.⁷ arrived at the same conclusion in the local context, demonstrating that interest was the strongest reason for final year Hong Kong medical students to select a specialty. Her study showed that the strongest predictor for selecting family medicine was that it was perceived to be a discipline that provided adequate opportunity to work with patients.

Interest in family medicine can be nurtured at an early stage by early exposure and learning in family medicine. Most family medicine learning takes place during the clerkship years with senior students immersing themselves in clinical learning. However, early clinical exposure during the first and second years of medical school, the pre-clerkship years, can be an opportune time to have a positive influence by showing students the knowledge and skills of a family doctor in action and help students to understand the role of primary care within the healthcare framework. It can also help to change potentially negative perceptions that family medicine is easy and not intellectually challenging by exposing students to FM role models and mentors who can demonstrate the breadth and variety of knowledge needed in FM to diagnose, problem-solve, manage uncertainty and provide holistic care.

Early generalist placements during the pre-clerkship years have been associated with increased likelihood of selecting family medicine training after graduation.⁸ These placements were longitudinal, lasting weeks, and included mostly elective opportunities that allowed flexibility in scheduling including over the summer holidays. Longer pre-clerkship placements had a stronger association with FM specialty choice. These features reflected some of the characteristics of other undergraduate medical education pathways that have had a positive influence on medical students to select primary care careers⁹ such as enabling students to learn in the real-life practice context, learning over time (repeated episodic exposure or in a continuous block), and fostering professional relationships between students and family medicine doctors through quality role modelling or mentorship.

Similarly, in the senior years of medical school, primary care specialty choice was shown to correlate with having a mandatory FM clerkship.¹⁰ There was also a positive correlation with clerkships of longer duration and higher quality, those with a wider scope of primary care practice, and those that took place within a medical school culture supportive of primary care.

Recognising the integral teaching role of family doctors in the community

To implement and sustain pre-clerkship programmes and clerkships that possess the features that promote interest in FM, a dedicated network of community family doctors is essential to partner with university-based family medicine teachers. Academic family doctors are effective in introducing the principles of FM and teaching the basic clinical skills that underpin patient-centred care but equally important are the enthusiastic, skilled family doctors in the community and in general outpatient clinics who are the key to demonstrating the potential and promise of family medicine. These teaching partners are integral to the team but predominantly work on goodwill. To achieve the best practice in FM teaching with adequate longitudinal exposure in early years as well as more intensive teaching in the clerkship years, community family doctor teachers need to be remunerated and remunerated appropriately for taking up this crucial responsibility. Local professional and licensing bodies should actively encourage all doctors to teach as a core responsibility, in line with the role of a medical practitioner as ‘educator’ as stated in the Medical Council of Hong Kong publication ‘Hong Kong Doctors’,¹¹ and to recognise them meaningfully.

'By choice not by chance'¹² is an extensive collaborative work led by Professor Val Wass and sponsored by the United Kingdom (UK) Medical Schools Council and the NHS Health Education England. It sought to investigate how medical schools can help address the problem of recruitment into general practice that exists even in the UK with its very welldeveloped GP-led health care system. GP attachments are recognised as the core mode of learning for medical students and among the recommendations was the need for adequate resourcing to ensure that GPs can have protected time to teach without compromising patient care in their own practices. The report suggests that current funding systems, processes and guidance for funding undergraduate teaching must be made fit-for-purpose to ensure the quality and quantity of learning for medical students. Furthermore, it highlights that the General Medical Council in ‘Good Medical Practice’ emphasises the role of a doctor as a teacher (http:// www.gmc-uk.org/guidance/) and that GP colleges and professional societies should collaborate with medical schools in underscoring the importance of contributing to undergraduate education to their membership.

Conclusion

The promise of support to strengthen primary care in Hong Kong is exciting but will require more family doctors to meet the manpower needs. Undergraduate family medicine education is well placed to stimulate interest in family medicine among future doctors at an early stage by demonstrating the intellectual challenge, diversity and rewards of primary care practice and therefore shape the direction of medical students’ careers towards primary care. It is necessary to have innovative funding models to support learning real-life family practice from family doctors in the community and professional reward mechanisms to recognise the essential role of family doctors to teach. The individual and collaborative efforts of practising primary care doctors, academic departments, medical schools, professional bodies and government are all vital to support undergraduate FM education in Hong Kong leading to a vibrant and sustainable primary healthcare system for our patients.

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