At thirty, I established my stand 三十而立

Gene W W Tsoi 蔡惠宏

HK Pract 2007;29:482-483

Our 2007 Conjoint Examination has just been completed smoothly in early November which involved well over 100 Fellows in the various segments of the OSCE. I am in a bit of a rush to write this commentary for two reasons.

First of all, I send my heartiest congratulation to our own College for her 30th Anniversary. It is time for "old timers" to get together for a good reunion and to recollect how we have cut through the bush and set our feet firmly amongst the medical profession in Hong Kong. I salute their selfless contributions to serve the College in the past three decades. However, it is also time for younger generations of members and fellows to see how they would like the future of the College to be shaped. As Chairman of the Board of Vocational Training and Standards, my thought is naturally directed towards training and standards. If we preach about "patient-centred" care, should we not practise the same? But are those young doctors our patients? Or should we treat them as consumers because they have to pay training fees to our College and how can we "serve them to their satisfaction"? And what is the meaning of "satisfaction" in this context?

Secondly, I would like to introduce the first certificate course to be organized by BVTS on the Leicester Assessment Package (LAP) for consultation skill training to our members and fellows. This is in connection with the questions which I brought up in the previous paragraph. LAP is developed by Professor Robin Fraser in UK and has been one part of the Exit Examination required to obtain the Fellowship in Family Medicine of the Hong Kong Academy of Medicine. Over the years, "mortality rate" is notoriously high in this segment. There are a lot of reasons being suggested for the high failure rate. One of the reasons I believe is that trainees were not trained in that way in the basic training setting and it is hard to apply LAP in their practice within two years after passing the Conjoint. Hence few performed well in the examination. Nonetheless, there have gradually been changes and improvement compared to a few years ago. Some of the trainers are starting to use LAP to train basic trainees.

Another reason in the high failure rate I believe is the lack of standardisation of our FM Clinical Supervisors. The criteria for the appointment are rather primitive. There is no requirement for them to receive any formal training before they start to train our trainees. Also, there is no stipulation as to what method they should use in training trainees. The LAP is a very complex and well-structured tool for training and assessment of consultation skills. The "39 steps" is a super-condensed version of the book "Clinical Method" written by Professor Fraser. The method may not be totally accepted within the academic circle, but at least there are some explicit criteria and targets to be achieved in terms of training and assessment. Our College has adapted LAP as part of the Exit assessment, but we have never clearly spelt out that it could also be used as the training standard when appointing clinical supervisors.

In October this year, I was among the College delegates who went to Sydney for the RACGP ^50th Anniversary and Annual Scientific Meeting. I attended a Keynote Lecture given by Professor Per Fugelli from Norway. The plenary delved into the history of general practice through Professor Fugelli's experience with healers and GPs* and his research into the relationship GPs have with their patients. He believes, "the concern of the state of general practice is unfound. General Practitioners, known as healers in the past, are extreme survivors close to the scorpion and the crocodile - remarkably adaptable and sustainable species. Molecules come and go. Technologies come and go. Colleges even come and go. General practice endures, as long as the world goes on. Loyalty and priority should always be with the individual patient."¹

To me, the content of the lecture is highly stimulating. Workshops and various sessions followed the lecture and one of the sessions was "Meet the keynote speaker". A group of about 25 quite senior GPs and educators participated, including Dr Beth Jane and me, who were among those enthused about Professor Fugell's lecture. We joined into a more close and interactive exchange of feelings about present day general practice and education of future general practitioners. There was a deep sense of worry or even pessimism within the group about the future of our discipline, in the technology dominated professional world, surrounded by the other specialists and ultra-specialists. How and what should we do to train our next generation of GPs to face the challenges from the increasingly demanding patients and specialists of other fields? Could we stand up and defend the core value and principles of our discipline? I jotted down the following points expressed by the participants:

1. There is no longer a partnership relation between GP and patients; continuity had been devalued.
2. We have noticed fragmentation and de-personalisation in present day practice.
3. Professor Fugelli believed that when health is in danger, it is man's instinct to search for TRUST, which is most important for GPs.
4. GPs should be freedom fighters, to bring out the true facts and point out the wrong practice in the medical profession, so that our patients will be freed from the technology dominated world.
5. Professor Fugelli also believed that GPs should be pragmatic, personal, generalist doctors.
6. Professor Fugelli advocated that GPs should be proud of themselves as "Master of Imperfection". We live in a world of imperfection, and there is so much uncertainty in the GP's practice. We do not deserve to be seen as "Jack of all trade, master of nothing".
7. To accept God's will, the song "Che Sara Sara - whatever will be, will be."
8. Reject the demand for zero risk. There is no Heaven on Earth.
9. Research in GP should be to support the core value of GP's postulated outcome.
10. Persevere with coordination, continuity, and care for patients.

I have echoed at the end of the session by a quote of Confucius. Confucius said: 子曰
"At fifteen, I aspired to learning. 吾十有五而志于學
At thirty, I established my stand. 三十而立
At forty, I had no delusions. 四十而不惑
At fifty, I knew my destiny. 五十而知天命
At sixty, I knew truth in all I heard. 六十而耳順
At seventy, I could follow the wishes of my heart without doing wrong." 七十而從心所欲不踰矩
Do you find similarity with the above synopsis?
I hope this article will provide stimulation in a reflective frame of mind, thoughts about the future of our College, direction in education, training, assessment, research, standard of practice, our position in the medical profession, and the role in the society. Good luck and good health friends!

*GPs is the term commonly used in Australia and UK as abbreviation for either "General Practice" or "General Practitioners".