H.K.U. MEDICAL FACULTY IN DEFAULT
A Demand for a Full and Independent Department of Family Medicine

by

Dr. Peter C.Y. Lee, KStJ, JP,
MBBS, LLD(HKU), FHKCFP, FRCGP, MCFPC, FRACGP, FHKAM(Family Medicine), LLD(Birm.U),
Founder President, H.K.C.F.P.
Past-President, World Organization of Family Doctors (WONCA)

As the person who introduced the Discipline of General Practice/Family Medicine into Hong Kong in 1973, I can claim to have achieved some measure of success by founding the Hong Kong College of General Practitioners (now the Hong Kong College of Family Physicians) in 1977. The driving force behind my self-imposed mission to nurture and vigorously promote this Discipline of Family Medicine and the raison for my perseverance in pursuing this course of action for the last 25 years is my firm belief and resolute conviction that the Science of Medicine must be sustained by and pampered with the Art of Medicine, and that the "Human Face of Medicine" with its care and concern for the individual must be evident at all levels of care. Otherwise, to the lay person, the treatment of disease becomes an argotic puzzle and its outcome a technical solution, where the patient and the family play no part and are kept completely in the dark.

This unsatisfactory and negative type of medical practice was routine in the bygone days of the 19th/early 20th Century when the general level of education of the populace was low and doctors were revered as demigods. It is therefore sad and even tragic to witness in Hong Kong similar situations to this day in the 21st Century. The emergence of an army of well-trained family physicians would be just the right cure for the condition. To achieve this ideal, we need a competent and influential College of Family Physicians (which we are proud to have) backed by the staunch academic support of a strong and potent Department of Family Medicine (which we pathetically and tragically lack) in the Faculty of Medicine.

It is therefore incomprehensible that whilst the Hong Kong Government, after years of hesitation, became finally convinced that integration of medical services is in the best interest of the community, and through its proxy, the Hospital Authority, had since 1998 started to implement the process of intensive and strenuous training of family physicians, with the result that today no fewer than 450 Hospital Authority doctors are undergoing training in family medicine programmes in public hospitals throughout Hong Kong under the auspices and supervision of the Hong Kong College of Family Physicians, the HKU Medical Faculty is still blind to this modern trend and continues to dogmatically cling to the 19th Century mentality of relegating the Discipline of Family Medicine to a lowly status of being just a "unit" in the Department of Medicine!

Fortuitously, the University's own routine 5-yearly review of the Faculty of Medicine was conducted recently, and the Report of its findings was submitted to the HKU Council. This Review Report together with the Response from the Medical Faculty were among the Council papers for the 24th June Meeting of Council. As a member of the University Council, I was privy to these documents. After careful scrutiny of the papers, I submitted my own paper to the Council to register my displeasure and abhorrence of the obvious obduracy of the Faculty to continue to pursue the policy of downgrading and suppressing the Discipline of Family Medicine of the past decades, and to request the University Council to direct the Medical Faculty to review its priorities as a matter of urgency by upgrading the existing "unit" of Family Medicine to a major Specialist Department as soon as possible.

To put more pressure on the Medical Faculty to change its ways, I submitted another paper to the Ordinary Meeting of HKU Convocation at its Meeting on 11th July to make use of this Forum to point out to all graduates and academic staff of the University, irrespective of faculties or disciplines, the reasons why the Discipline of Family Medicine must be elevated to a full Department headed by a Professor or Professors to provide better academic support to the College of Family Physicians and to produce graduates who can better serve the community. At the same time, the paper is to request the Standing Committee of Convocation to invite the Medical Faculty to justify and explain its actions of the past decades of deliberately downgrading and suppressing the Discipline of Family Medicine.

Whilst my submission to the University Council is the property of the University, my paper to Convocation is in the public domain. I therefore take the liberty and pleasure to share its contents with my colleagues in the College as well as all colleagues in the profession in the hope that such wide dissemination of the authentic true facts of the matter will help to force the hands of those in authority to change the system of medical education to make it more relevant to the needs of the society and the community for the betterment and benefits of the people of Hong Kong.

Reproduced hereunder is the compendium of my paper to the Standing Committee of HKU Convocation for your perusal and information:-

In going through the Report of the Medical Faculty Review, you will find accolades and acclamations in glowing terms for the Faculty's notable achievements and impressive accomplishments over the years, for which all of us should feel very proud. However, if you dig deeper into the document, you will discover that all the "First-rate and Outstanding Attainments" are only in terms of "the Science and Technology of Medicine". The benevolence, the humanity, the compassion and goodwill of a caring and attentive doctor, which represents "The Human Face of Medicine", is conspicuous by its absence. It is very sad for me to have to say that this Bastion of Medical Distinction, this Citadel of Academic Excellence, this Medical Faculty of ours, is a "Colossus of Scientific Medicine", - but with no heart and no soul!

The Review of the Medical Faculty chronicled mainly hospital or hospital-related activities and duties, but made little or no mention of functions or undertakings in the community or community-connected missions or jobs. But what annoyed and irked me most was that under the heading, "Direction of the Faculty: Vision and Mission", the section covering undergraduate programmes stated inter alia, and I quote: "In curriculum development, the Faculty should take more account of feed-backs from the major employer, the Hospital Authority". Any one who is an alumnus of a Medical Faculty whose Vision/Mission gives the impression that the Faculty produces doctors only for the sake of finding employment in the Hospital Authority, to the exclusion of needs of the community and benefits to its people, would be deeply humiliated and mortified!

When the Scott Team from Australia was invited to Hong Kong by the then Medical and Health Services Department to find a solution to the problem of severe hospital over-crowding in 1985, Dr. K.L. Thong, the then Director of Medical and Health Services (DMHS), representing the government at that time, instead of giving the experts a free hand to advise on the overall medical and health needs of Hong Kong, severely restricted their ambit by limiting their purview to hospitals only. That the Australian Team was not happy with such stringent restrictions on their mandate could be perceived by the way they presented their Final Report, which recorded grudgingly that: "This report is concerned with the provision of medical rather than public health services and facilities", and then went further to reveal pathetically that: "In actual fact, the terms of reference are even more specific, in that they relate to the delivery of medical services in hospitals. This gives a prime focus on the major centres of medical services in hospitals, rather than giving equal attention in the review to work outside hospital, in, for example, clinics or other decentralized activities, such as community nursing". This sort of distorted, lop-sided, unbalanced, off-target and out-of-context straitjacketed constrain in the terms of reference to the Australian Team was the fatal mistake that gave rise to and created the Hospital Authority.

From the very beginning of the public debate on this issue in 1985, I was very much against the concept of the Hospital Authority. Fortuitously, the year coincided with the period (1985-1990) when the Hong Kong Basic Laws were being drafted. As a member of the Basic Law Consultative Committee, I told everyone who cared to listen, up to and including high officials from both the Beijing and Hong Kong Governments, that the Hospital Authority could not be financially sustainable, and that it would end up to become a "Black Hole", incessantly sucking public funds without end. I even suggested that the creation of the Hospital Authority would be akin to an "economic time-bomb" being left behind by the departing Colonial Powers, either intentionally or unintentionally, for the unwary HKSAR Government in 1997, straddling the administration with a no-win situation - to persevere invites bankruptcy, and to abort incites riots and social unrest!

However, as a medical practitioner, my biggest objection was that its establishment would have a disastrous and devastating effect of completely segregating primary from secondary/tertiary care. We must bear in mind that it was universally recognized that hospital-based health care systems which places heavy emphasis on medical technology and expertise have little impact on overall health, but result in an unsupportable drain on human and financial resources. Furthermore, cognisance must be taken of the fact that more than 50% of the graduates will become general practitioners. The effects of dislocation of General Practice and hospital specialists care go further than merely to limit the quality of primary care, but the resultant overcrowding of hospital in-patient services adversely affects the efficiency, quality and cost-effectiveness of secondary/tertiary care. General practice teachers are usually required to assume a much broader mandate to deal with issues such as primary care, diagnostic process, medical ethics, social/family/sexual problems, psychological illness, patient communication and compliance, doctor-patient relationship, terminal illness and bereavement, etc. These are issues of paramount importance at all levels of care, but which are not taught coherently or systematically at any other point in the medical undergraduate system except in the general practice department. All developed countries around the world fully recognize that an expert and efficient primary health care delivery system is absolutely essential for an efficient secondary and tertiary care health system, and the first priority of their medical schools in allocation of resources is to energize and pep-up the Department of Family Medicine/General Practice and its sub-specialties as the bases on which to built a good all-round and fully-integrated health delivery service which is cost-effective and which the community can afford. I warned the authorities that for Hong Kong to run counter to these world trends to establish a Hospital Authority, when the rest of the world is otherwise engaged, would be the biggest mistake of the Century for Hong Kong. My pleas fell on deaf ears, and the rest was history.

I hate to say: "I told you so!" Even though it happened over ten years ago, it is still appropriate at this point for me to state with conviction that when the Scott Team from Australia was in Hong Kong at the Government's invitation in 1985, the Australian "Family Medicine Programme for Private Practising General Practitioners", funded by their Federal Government since 1973, was already 12 years down the road and had been proved to be successful in dramatically reducing the number of hospital beds per thousand population by simply upgrading medical standards of their practising General Practitioners. It is therefore quite conceivable to postulate that if only our then Government Officials (in 1985) were to have the vision and wisdom to give our Australian Visitors a free hand to review the "Total and Comprehensive Healthcare Needs of Hong Kong", instead of applying the blinkered vision and myopic mentality of typical civil servants 「頭痛醫頭，腳痛醫腳」 to restrict the purview of the team of Australian Experts to "Hospital Services Only", there would have been NO Hospital Authority today.

Lest there be any misunderstanding, I must absolutely and categorically deny that I had ever harboured any animosity or ill-feeling towards the Hospital Authority. The fact that the Hospital Authority was blunderingly and disastrously created was not its fault; and one must admit that, on the whole, it had performed well as a corporate entity. I must also give Dr. E.K. Yeoh, the former Chief Executive Officer of the Hospital Authority, top-marks for being the first to advocate "Seamless Health Care" several years ago in an attempt to palliate the awkward dilemma. I am also gratified that five years ago, the Hospital Authority executed a complete U-turn by reversing its former policy of totally ignoring family medicine. Whereas, since time immemorial, trainee posts in family medicine in public hospitals were unheard of, hospital vacancies specially earmarked for vocational training in family medicine were first offered in 1998. Since then, such posts increase rapidly in numbers. Today, a staggering total of 346 young doctors are being trained in family medicine programmes throughout the territory. As if to put the official stamp of approval to such drastic change in government policy, the Secretary of Health, Welfare and Food, Dr. E.K. Yeoh, as the Orator in the traditional Hong Kong College of Family Physician's "Dr. Sun yat-sen Oration" at its 25th Anniversary Ceremony on 22nd March 2003, spoke on the theme: "Medicine without the medicine", highlighting the important role played by family physicians in the health delivery system in Hong Kong today.

It is pertinent to record at this point that for the past quarter-century, I spared no efforts to exhort, prod and persuade the Faculty to place more emphasis on the teaching of General Practice/Family Medicine to medical students because of its crucial importance in the context of the Hong Kong environment and its significance in the health delivery system in Hong Kong. Since over 70% of out-patient attendances of the community are in the hands of General Practitioners in the private sector, better trained front-line doctors are not only good for the people, but will also relieve the pressure on instrumental to induce the College to donate HK$100,000 to the H.K.U. Faculty of Medicine for hospital beds, and hence help contain the high health costs. In 1982, as the then President of the Hong Kong College of General Practitioners, I was the establishment of the "HKCGP Professorship in General Practice" in the Medical Faculty as a means to stimulate academic development of the Discipline. Not sensing any progress after a lapse of 10 years, I approached the Hong Kong University authorities in 1992 to propose the topping-up of the senior lectureship post to full professorial status by financing the cost difference, and to name the new Chair of General Practice in honour of the Father of Modern China and Founder of the Republic of China. I was grateful that HKU Council accepted my offer, and the "Dr. Sun yat-sen Chair of General Practice" was thus conceived in 1995, and Prof. Tony Dixon became the first "Dr. Sun yat-sen Professor of General Practice" in the University of Hong Kong.

Reverting back to the Faculty's own ill-advised statement concerning the need for the Faculty "to take more account of feed-backs from the major employer, the Hospital Authority" in curriculum development, does the Faculty not realise that the Hospital Authority had since 1998 made a complete about-face in regard to its previous policy of completely ignoring family medicine and has today 346 Hospital Authority doctors being trained in family medicine programmes in public hospitals? That is why I find it so difficult to comprehend the rationale of the Medical Faculty's decision to abolish the "Dr. Sun yat-sen Chair of General Practice" after the retirement of Prof. Tony Dixon one year ago in the context of, and in direct contradiction to, the Hospital Authority's policy change five years ago in regard to Family Medicine. To make matters worse, the senior lecturer post, which was left vacant on Prof. Dixon's departure, was not filled during the past year, resulting in manpower resources in our Family Medicine Unit being even worse off than before 1995 when I personally injected a total amount of $1.5 million to the University (spread over three years) to top-up the post. The abolition of the Chair not only reflects most adversely on the public image of the University, but is also an insult to the good name of Dr. Sun yat-sen, particularly in respect to the circumstances in our University where there are already far too few precious little memorabilia around the campus to honour our national hero and our most famous alumnus.

It appears to me therefore that the HKU Medical Faculty is still living in the past, if not trundling in reverse, concentrating only on teaching students and doing research on subjects relating to hospital and specialist care in its ambition to achieve idealistic elitism, and wilfully neglecting the education of undergraduates in fields of primary and ambulatory care. At the "World Conference on Medical Education" on the theme "The Changing Medical Profession" in 1993, Prof. Henry Walton, the President of the World Federation of Medical Education, and his colleagues, in partnership with the World Organization of Family Doctors (WONCA), of which I was President, produced an important document, "The Edinburgh Declaration", which uncompromisingly proclaimed that medical education must be made relevant to people's needs, and that the teaching of primary care should be an important component.

For all these reasons, I respectfully request the HKU Standing Committee of Convocation to consider dispatching to the HKU University Council appropriate resolution or resolutions to rectify the situation in terms like:

That Convocation is of the opinion that the Community of Hong Kong and its people could be better served if the emphasis on health delivery be shifted to primary and ambulatory care; and,

As a foot-note, I take the opportunity to reproduce hereunder a E-mail message just received (2nd July at 1:30 p.m.) from Dr. Stephen Foo:-

"Your vision in this paper is to be much commended. Agree totally with you in regard to the short-sighted policy of the Medical Faculty in the neglect of our discipline in undergraduate teaching. In the recent orientation course of new family medicine trainees employed by Hospital Authority on 28 June, only 80 of the 300 of competing applicants were recruited to join our programme, leaving quite a number disappointed. The family medicine training programme is getting more popular. The majority of them are genuinely interested to take up family medicine as their careers. It would facilitate the post-graduate training if the trainees have been given a wider exposure in this discipline in the undergraduate period. For your information, the updated number of trainees now in the programmme is 450, outstriping those of all other disciplines in Hospital Authority.

S. Foo."

Dr. Stephen Foo is the Immediate-Past President of the Hong Kong College of Family Physicians and concurrently one of the College's Clinical Supervisors for the Hospital Authority's postgraduate family medicine training programmes. The above was his spontaneous response to my 24th June paper to the University Council and was completely unrehearsed. His 2nd July update was most revealing in that it more than substantiated what I said in this present paper. The indisputable fact that there are now 450 trainees in Hospital Authority's family medicine programme confirmed my conjecture that the Hospital Authority had executed an about-face in its corporate strategy by earnestly pursuing E.K. Yeoh's vision of "Seamless Health Care", which is tantamount to "total integration" of primary and secondary/tertiary medical services, and which places heavy reliance on intensive and strenuous training of family physicians. This exposes the duplicity and perfidy of the Medical Faculty when their "Review" document explicitly stated that the Faculty "should take more account of feedbacks from the major employer, the Hospital Authority" in the curriculum development of their undergraduate programmes. How can medical education operate in isolation from medical practice or from society?

May I suggest that the Standing Committee of Convocation requests the Medical Faculty to justify and explain their actions.

Date of Submission: July 3, 2003