Knowledge and Understanding of the term 'Family Doctor'
Almost all participants had heard of the term 'family doctor' (except a few elderly participants of lower SES in the 'no family doctor; group). Participants' descriptions of what a family doctor is or does generally matched most of the accepted concepts of a family physician, i.e., care that is first contact, continuous, comprehensive, coordinated, and orientation to the patients' context (patient-centred) [
13]. Unsurprisingly, this was especially true of those in the group with a family doctor but even those in the 'no family doctor' group generally at least knew of the concept.
"You will go to see that doctor for all diseases. And you can ask him questions if you have problems, and he will explain to you. Other ordinary western doctors will not do that. They will just talk to you around 3 sentences and you will have to leave then. They will not be in such a detailed manner. Family doctor is different. They are in more details. You can ask them questions on diseases and they will explain to you in detail." [23, no regular doctor]
Their information about family doctors came from a variety of sources, including the media. Several participants believed that a family doctor is a regular doctor to whom the whole family will go, and who has a close relationship with the family, almost like a 'family member'. Some felt that a family doctor would also be on-call 24 hours a day and be prepared to do home visits whenever requested.
Who should have a family doctor?
There were a diverse range of views on who should or could have a family doctor. Those with a family doctor felt that the family doctor model was appropriate, irrespective of age and type of condition. These participants were mainly of higher SES (see Table
1).
"I think I need a family doctor...I think that the health histories of mine and my ex-wife can influence our son, therefore I think if there's a doctor who can understand our health histories, all the better as he can have a clearer picture...I think this kind of doctor is very important, and there's such a need to have this kind of doctor, not only the doctor can have a clear picture on our health backgrounds, but we as a family can know how to prevent some diseases." [[
7], has family doctor]
However, many participants who did not currently have a family doctor (either having a regular doctor who is not a family doctor or no regular doctor) and were mainly of lower SES than those with a family doctor (see Table
1), saw a family doctor as something of a 'luxury item' for the wealthy and not within the financial reach of the bulk of the population in Hong Kong.
"Seeing family doctors need money; and if you have money, then it's good. I cannot afford if I need to pay $1000 or $2000 every month. If I have money, of course I will go to find those family doctors. Even if I don't have any problems, I will go to them as well to ask questions. The most important thing is economy." [[
17], has regular doctor]
Who can be a family doctor?
There was a majority view among participants (irrespective of whether they had a family doctor or not) that the family doctor model was only possible in the private sector and not feasible in the public healthcare sector. This was largely because of the perceived pressure on the public system including issues of access, lack of personal continuity, and time constraints.
There was very limited knowledge among participants (irrespective of whether they had a family doctor or not) about training or qualifications in family medicine, and the concept of a family doctor was not solely limited to general practitioners or family physicians. For two participants who classified themselves as having a family doctor, their family doctors were specialists in paediatrics and dermatology. There was no evidence that their understanding or expectations of a family doctor differed substantially from those with a specialist family physician as a family doctor. Most participants also believed that TCM practitioners have the potential to be family doctors.
"TCM practitioners are more willing to spend time listening to your problems. They will ask you many questions. From my experience, most TCM practitioners are really willing to spend time explaining about their prescription in details, and willing to understand our body status...they will explain your body situation in details, and they are willing to talk to you. I know the training of a TCM practitioner is much longer than the training of western medicine doctors, and some of them are doctoral graduates. Therefore, I think not only their qualification is better, but they know more about how to communicate with patients...I think TCM practitioners can become family doctors, because they also receive all-rounded training." [[
18], with regular doctor]
Views on the Current Primary Care System
The Public Primary Care system
The vast majority of participants were currently attending the public healthcare system (specialty outpatient clinics or general outpatient clinics) for their chronic diseases irrespective whether they had a family doctor or not. Reasons for this included issues of cost, consistency, informational continuity, prescription duration, quality, trust, access to specialists and allied health professionals (in-house referrals) and access to tests and investigations. For many (including those with a family doctor), they simply viewed the public system as the appropriate place to have their chronic disease managed.
"First, of course it is the economic concern. It's really very cheap. Also, if you need to have a surgery, or if you have any sudden changes in your disease, I think the equipment of public hospitals is better and more advance. But of course, the most important concern is finance. If you need to have more tests, then the fees will be more expensive in the private sector." [[
13], with family doctor]
"It's better to go to public hospitals for chronic conditions, because hospitals are on a larger scale and so have better equipment like ECG and more senior doctors with better qualification and more experience. I trust hospitals more in this case. They have been following up my situation and so they don't need to redo the blood tests or other tests, because they have the records. If I switch to private doctors, then I will need to redo the blood tests and other tests as well as spending time to wait for the results. It's time consuming." [19, with a regular doctor]
There were thus many reasons for using the public system and advantages to 'getting into the system and staying there' with numerous disincentives to 'leaving the system'. This is not to say that participants were uncritical of the public healthcare system. Access, waiting times, a lack of interpersonal continuity, short consultations, and poor attitude of doctors were commonly cited as problems. It was also clear from participants' accounts that many factors conspired to keep them in the public healthcare system, including recommendations by their private doctors, and ongoing internal referrals with no effective linkage to the private sector.
The Private Primary Care System
Private primary care doctors were generally regarded as being mainly for acute illnesses, rather than for chronic disease management. Participants expressed a general lack of trust in the private sector, particularly among those who did not have a family doctor. Reasons for this included cost of consultations and prescriptions, ineffectiveness of treatments, concerns about lack of training and knowledge, and suspicions about being overcharged in terms of unnecessary drugs and investigations. Many participants voiced concerns about the government's planned healthcare reforms, and possible public-private partnerships between the HA and the private GP sector. Cost was a major concern for many, especially those on lower incomes, but issues of quality assurance also figured highly.
"But I am worried about the quality. I am afraid that these family doctors are not as knowledgeable as the public doctors. You know, we have many diseases, so it's more troublesome. If you just have a cold and flu, then of course it's easy and every doctor can treat you. But if you say heart problems, I am afraid that family doctors are not capable and they may not have such expertise. I still think that public doctors are better to follow my chronic diseases." [25, no regular doctor]
Barriers and Incentives to Adopting the Family Doctor Model
There were five main themes identified; cost, perceived need, choice, relationships, and quality issues.
Cost
For many interviewed cost was a major barrier, especially for those who did not have a family doctor, which generally reflected income level and SES; those on higher incomes were less concerned about costs personally (for themselves and their family) whereas those on lower incomes were greatly concerned.
"Many people are still struggling on how they can pay the consultation fees, so how can they have the ability to talk about family doctors?" [20, with regular doctor]
"I think family doctor is a very extravagant thing. I think family doctors will be very expensive...It will cost you several hundred for a single visit. It's really a waste. I think it's really a waste to spend several hundred dollars on seeing doctors for the things that you can do by yourself. We are in lower class and several hundred is too expensive for us...." [25, no regular doctor]
However, the relationship with cost was not entirely straightforward. There was a view expressed by some participants that 'good things can't be cheap', i.e., high quality family medicine should be expensive:
"I just think that if a family doctor has good expertise, then he should not be cheap. Cheap things should not be good, as I have experienced this before." [25, no regular doctor]
Perceived need
A second barrier to the adoption of the family doctor model was the perception by many participants of the lack of need. Many of those without a family doctor simply saw having one as something unnecessary, irrespective of financial issues:
"It's not a money problem. Because I don't think I have the need to have one. Not every family needs a family doctor. If you and your children are healthy, what's the need of having a family doctor? If your children have many diseases, then you may need to have one... It's not necessary for one to have a family doctor if he just merely suffers from a cold and flu occasionally." [19, with regular doctor]
"There's no such need at the moment. I don't have too much sickness... I think going to hospital is good enough... There is no such need. I don't need a [family] doctor to follow my case closely." [28, with no regular doctor]
Conversely, some others did perceive the need for family doctors, which was related to perceptions of risk and concurrent diseases and to a large extent current or past experience of having a family doctor. For some, the incentive to have a family doctor came from positive experiences of family doctors overseas, in countries with well-developed primary care systems.
"I think I need a family doctor. Migrating to Canada was really the changing point. My ex-wife and my son also saw that family doctor in Canada...therefore after coming back to Hong Kong, I also hope that I can have the same doctor to follow my whole family's health, which I think it is good to my son and to myself....I think this kind of doctor is very important, and there's such a need to have this kind of doctor, not only the doctor can have a clear picture on our health backgrounds, but we as a family can know how to prevent some diseases." [[
7], with a family doctor, the first experience of family doctor was in Canada]
Choice
The right to choose a doctor was a common theme which was related exclusively to the private sector. Participants strongly defended their right to choose a doctor (or doctors), in order to find the 'right match'. 'Doctor shopping' was regarded as a way to assert choice in order to find a good doctor. Thus a potential barrier to the adoption of the family doctor model was the concern that the government might limit choice by imposing restrictions; although financial incentives or subsidies on the one hand were seen as an incentive to moving to a family doctor model, many also wanted reassurance that the 'right to choose' would not be diminished.
"Family doctors should be something like options and choice, and should not be a mandatory thing, because many people are very conservative and don't want other people know too much about them, even though they are doctors." [[
10], with family doctor].
"If the government assigns a family doctor to a patient, then I cannot know whether this doctor really suits me." [[
13], with a TCM practitioner as family doctor]
Interestingly, most felt that this 'right to choose' simply did not apply to the public healthcare system. Although in principle they would prefer to be able to see a doctor of their choice in the public system, and be able to form a long-term relationship with that doctor, in practice many felt this was simply impossible.
Doctor-patient relationship
A related barrier to adopting the family doctor model was the issue of the doctor-patient relationship. Many participants had concerns about the attitudes of doctors in Hong Kong. Many quoted examples of commonly being rushed in consultations, with little time to ask questions, gain information, and so on:
"It's really rare to see a doctor who can spend 5 minutes on a patient, and I think its standard to finish a patient in one minute. Probably, they still haven't seen your face but have started to type your record and prescription. They will then ask you whether you need a sick-leave certificate. That's it. Everyone is in a rush. Patients are in a rush, and the doctors are in a rush. Therefore, it's really difficult to have a family doctor in Hong Kong." [20, has regular doctor]
"It is not easy to get a good doctor who is willing to spend time and have the patience to listen to you. I don't know where I can find such a doctor. Most doctors are very busy in 'rushing cases'." [[
18], has regular doctor]
Conversely, an important incentive to having a family doctor was the possibility of forming an enduring therapeutic relationship. There were numerous potential advantages associated with this, such as effectiveness, efficiency, holistic support, empathy, respect, trust, confidence, health promotion and self-care support. However, many felt that a therapeutic relationship with a family doctor would take a long time to develop; that is the relationship had to be developed and nurtured over a period of years. This was irrespective of the doctors training, qualifications, or certificates. Respect and trust had to be earned through contact and experience, and the patient's judgement of the doctor's skills by their own personal evaluation of honesty, integrity, and effectiveness of care.
Although participants generally viewed the long-term therapeutic relationship with a doctor as a positive factor, one participant felt that 'being too familiar' with a doctor could be a barrier.
"Maybe I am too familiar with him and have seen him for a long time, so I don't dare to tell him, or I don't feel comfortable psychologically to tell him the truth if his medication fails. It's quite contradictory. Of course it's good to have a doctor whom you have seen for a long time. But if his medication fails, I don't dare to tell him honestly... I don't dare to tell him, because he may think that I feel suspicious with his medication, though I have seen him for a long time. I am afraid that the doctor will have such feeling. Some doctors are better because they will really tell you that you have to go back to switch to another medication if this medication cannot work for you. You will feel less embarrassed to go back. But if the doctor told you that "it's okay for you to take this medication", then how can you go back and tell him the medication fails? I think this is really embarrassing." [27, no regular doctor]
Quality issues
A further theme which acted as a barrier to having a family doctor was the issue of quality. Many participants were concerned that private family doctors were not adequately trained or skilled to deal with chronic diseases. Some felt that only specialists could look after specific chronic conditions, and therefore family doctors had to be specialists in the patient's particular disease.
"I will find a specialist as my family doctor for my heart problems and not just a GP... I do not expect there's a doctor who can follow all my diseases - it seems that he's not a specialist al all; I just expect that I can follow the same doctor in internal medicine, and the same doctor in ENT [ear, nose and throat]...I think there is no single doctor can be all-rounded. An ENT specialist will just have titles on ENT. They do not have cardiology titles. I think this is a barrier. Just like I have heart and ENT diseases; but others may have even more different types of diseases which may involve many specialties, then how can you find a doctor who can treat all these diseases?" [[
13], TCM as family doctor]
"I think for specialty problems, family doctors are incapable in dealing with them... Of course only the specialists can deal with specialty problems. Family doctors cannot, so of course it's better to search the specialist by myself if I think it's a specialty problem... Family doctors only deal with minor diseases, they are not specialists. If I need specialist treatment, I still have to see the specialists no matter how far they are." [26, no regular doctor]
Qualifications and certificates were rarely used by participants as criteria on which to judge if a doctor was suitably qualified to deal with chronic diseases. Indeed the issue of trust was not simply related to knowledge, but was also intimately related to perceptions of the doctors' ethics and values. Even for those participants who believed that further training for family doctors should be required, they felt the training should focus on holistic and humanistic skills as much as medical skills.
"But training can just teach you about the skills; whether you can do well as a family doctor depends much on your personality. Medical skills are not important for family doctors, but what's more important is that whether they can motivate a patient to tell the real health situation to them, and so they can help you thinking about the possibilities to treat your problem. It's really based on trust. The main function of family doctors is not for treatment, but he is the one that you can trust and he can give you medical advice. I think what the subject or training can teach mainly concerns about the skills, but it is still impossible for them to become family doctors if the environment does not allow." [20, with regular doctor].
Finally, some participants said they did not know how to find a family doctor in Hong Kong.
"In Hong Kong, I just have the impression that you don't know where you can go when you are sick - the only place that you can go is the doctor whom is convenient to you. Otherwise, you can only go to public clinics. I don't know if Hong Kong has family doctors. Maybe there are some family doctors, but I cannot know, and I don't know any sources that I can know whether there are family doctors here... I do not have the information of how to get a family doctor from any people. I can ask my friends for recommendation about a good acupuncturist, but no friends have ever recommended me about a family doctor, because people do not have the concept of family doctor." [21, with a regular doctor, past experience of family doctor in Australia].
Summary of similarities and differences between views of participants with a family doctor and those with no family doctor
In summary, there were similarities and differences in the perceptions, knowledge, and understandings of the family doctor model between the participants who had experience of a family doctor (family doctor group) and those with no experience (regular doctor/no regular doctor groups) as shown in table
2. In general, most participants had a reasonably accurate knowledge of the family doctor model, participants in both groups equated it with the private sector, all participants felt TCM practitioner had the potential to be family doctors, and participants in both groups generally felt that chronic disease management was best done by the public system.
Table 2
Differences and similarities between informants with and without family doctors
Knowledge of family doctor model of care | √√√ | √√ |
Family doctor can only be in private sector | √√√ | √√√ |
Family doctor can be TCM doctor | √√√ | √√√ |
Chronic disease management best done in public sector | √√√ | √√√ |
Family doctor offers holistic care and therapeutic relationship | √√√ | √ |
Family doctor is essential to health needs | √√√ | XXX |
Family doctor is costly | √ | √√√ |
Choice and quality key issues | √√√ | √√√ |
Those with a family doctor valued the holistic approach and the therapeutic relationship that developed over time, and felt that they and their families needed a family doctor. Those without a family doctor saw the potential benefit of such a relationship, but felt that having a family doctor was a 'luxury' rather than a 'need'. Cost was a concern, especially for those without a family doctor (who were of lower SES), as was trust in quality of care. All groups valued the preservation of choice which came with the private sector. These views on family doctors were not obviously related to gender or age, and therefore the fact that those in the 'no regular doctor' group were somewhat older on average and mainly female (Table
1) did not seem to account for these findings. The main factor associated with having a family doctor or not (and hence the specific views related to that) was SES, which was generally higher in those with a family doctor (Table
1).