Wednesday, June 24, 2015

"You're not a specialist..."

I'm going to say something that I feel should be said:

"Family medicine doctors and general practitioners don't get that much respect, especially in Hong Kong."

So where do I start? Let's begin with my own family. My father has non-alcoholic steatohepatitis or in laymen terms fatty liver. He needs to cut down his fat intake (he already has hypercholesterolaemia or high cholesterol for those who don't know) and also his carbohydrates. He's doing this part adequately through his food intake but he's still drinking alcohol. He drinks about one bottle of beer or one glass of wine per day - not enough to be an alcoholic but he should try to reduce his consumption. I keep telling him that but he keeps saying, "there is no carbohydrate in alcohol" (which there is) or "the alcohol doesn't contribute to my fatty liver" (which it does).

My dad is not the only member of my family who doesn't listen to my medical opinion. My aunt had some blood tests done about two years ago and the results showed she had a blood sugar. I told her to get more blood tests done to see if she actually had diabetes mellitus and whether or not she needed to start medication. She "claimed" she went to see a doctor (not immediately as I suggested) and "claimed" she was told she just needed to control her diet. So what has she got know? Diabetes mellitus, and she is now on medication. 

It doesn't stop there with my aunt. My grandmother was admitted to hospital with confusion a while back and was diagnosed to have neurosyphilis. She had her treatment and when the internal medicine doctor thought she was stable and there was nothing else to do, the doctor discharged her back to her family medicine doctor in the general out-patient clinic to continue her follow up. She said, "why do I have to get sent back to my family doctor? He can't take care of me." When I heard that, it took me all of my willpower not to shout at her for disrespecting my fellow doctors.

I think my grandmother's attitude sums up the view of family doctors in Hong Kong. We are not considered to be specialists, despite that we have our own society which regulates our professional training and examinations. Every time I say I'm a doctor, the first question I'm asked is, "which hospital are you working at?" When I say I'm not working in a hospital but a general out patient clinic, the next question is, "When you have finished working in the clinic, what are you going to specialise in?" It doesn't help that the medical body in Hong Kong doesn't regulate the professional training of doctors that stringently. Once you have finished your internship in Hong Kong, you are allowed to set up your own clinic and do whatever you want, without any prior or current training. At least in the UK and Australia the system is more regulated. So general practitioners (that is what people in Hong Kong call doctors who practise family medicine in private) can prescribe and investigate whatever they want, in contraindication to their medical education, practice guidelines or current medical evidence - as long as the patient is willing to pay for these measures. This situation leads to over-prescription of drugs, unnecessary investigations, patient confusion and doctor shopping.

Patients just consider family doctors as dispensers of drugs. Frequently in my consultations, I'm asked for medication for cold symptoms, eyedrops, antacids and pain killers. They expect me to prescribe them these drugs without any questions. When I do ask them questions about serious symptoms that I have to exclude, some of the patients look at me with the expression "Of course I don't have those symptoms, are you stupid?"

They also consider family doctors as stepping stones to see specialists. I'm often asked, "Can you write me a referral letter to a specialist?" This question just displays the view that family medicine doctors are not able or competent enough to handle your medical complaint. I wish there was a secret code we can use when write a referral letter to specialists to say, "All they want is a opinion from a 'specialist'. Just give them the furthest date you can for their initial appointment." 

I had two patients like this the other day (which is why I'm having a mini-relapse of my depression and calling sick off work). Firstly there was a young nurse (A NURSE) who asked to be referred to a dermatologist (skin doctor) for her eczema on her first consultation with me. She previously had seen another general out patient clinic doctor and was referred to a specialist before, and hadn't receive much treatment. I wrote a "routine" referral to the dermatologist saying she wanted to "be referred to a specialist" - my way of saying to give her low priority. Another patient had presented with De Quervain's tenosynovitis (basically wrist pain) and tennis elbow. She only consulted us once before a few months back and wanted a referral to a specialist. When I asked why she wanted a referral, she just said, "I wanted a specialist's opinion", meaning my opinion was worth JACK SHIT. Then I asked how she expected the specialist to help her, she said "I don't know, he/she is the specialist, I'm asking for his/her opinion, again implying "You can't help me, you're are JACK SHIT." In the end she genuinely said with a hint of contempt, "If you don't want to write me a referral letter, that's fine."

It doesn't help that the Hospital Authority doesn't give us the resources to help our patients. The department has a doctor over from the UK working for one year here and she said our resources are limited - a very narrow spectrum of drugs we can prescribe, we can't order more advanced imaging such as ultrasound, CTs or MRIs and that the waiting time to see a specialist was far too long.

It doesn't help that there is a disdain from specialists about regarding our referrals. They consider are referral letters as having too little or too much information. When the Hospital Authority standardised the referral letter templates for common complaints, the specialists said they don't like the template. I wish I didn't need to write referral letters. I'm only referring if something is needed to be done - to prescribe a medication we don't have in the general out-patient clinic, to investigate a condition with investigations we don't have or to perform a surgery that we cannot do (not that we can do any surgeries at all - not even a basic incision and drainage, another thing I don't like about the rules and regulations governing general out patient clinics). If I write, "Patient asks for a referral to a specialist", that is my code in saying to give this the lowest priority you can.

There are some specialist who think we are not competent in handling cases. One patient was discharged from a specialist clinic to a general out patient clinic for a lung condition. After a few years of being very stable, the family medicine doctor tried to reduce the dosage of the medication as the patient was already taking a lot of medication. Coincidentally the patient had an exacerbation of the lung problem and was admitted to hospital. There was a letter from the specialist clinic saying, "Don't try to adjust the medication. If there is a problem, refer the patient back to us." The lung problem is pretty common and most cases can be handled in the general out patient clinics. The patient was only referred to the specialist as we had exhausted all our drug options and the patient needed a more specialised drug. Basically the specialist was implying we were incompetent and our only job is to prescribe the drugs.

So family medicine doctors don't get any respect from the population, the patients, the Hospital Authority, specialists and even their own family. Are you surprised that I want to leave to somewhere that has a bit more respect from my specialty (Yes, it is a specialty) such as the UK or Australia. I might even Médecins Sans Frontières - at least the target group appreciates doctors more.