Family doctors, serving as the first point of professional contact for patients, are inevitably first to identify probable cases of coronavirus disease 2019 (COVID-19) among the many patients presenting with respiratory symptoms each day.1 Family doctors in Hong Kong have experience in dealing with the severe acute respiratory syndrome (SARS) epidemic in 20032 3 and the H1N1 pandemic in 2009.4 5 However, their preparedness in handling another outbreak of a novel infectious disease has not been explored. Furthermore, Hong Kong has a dual-track healthcare system in which 70% of primary medical care, especially acute episodic care, is provided in the private sector where practice settings and resources vary and differ from those of public clinics.6 7 8 Family doctors play a crucial role in the community to offer first contact and coordinated care for patients, and their preparedness, perceptions, and attitudes towards COVID-19 are particularly important to inform future strategies for responding to epidemics. Hence, the Hong Kong College of Family Physicians (HKCFP) conducted an online survey among its members to evaluate preparedness and to identify clinic-related challenges of private and public family doctors who were providing primary care services during the early phase of the evolving COVID-19 outbreak in Hong Kong.

All family doctors who are HKCFP members were invited to complete an online survey. The structured questionnaire (online supplementary Appendix 1) comprised 20 questions. Twelve closed-ended questions assessed the effects of the COVID-19 outbreak (at the time of the survey, the World Health Organization had not announced it as a pandemic) on clinical services and the preparedness of the responding family doctors, such as changes in infection control practice. An open-ended question invited respondents to express their concerns towards the COVID-19 outbreak and suggest measures that would facilitate their clinical practice. The last seven questions collected demographics of the respondents. The survey questions were modified from a previous survey for primary care doctors in Hong Kong and Canada9 10 and pilot-tested by a panel of experienced academic family doctors and HKCFP Research and Executive Committee members. Invitation e-mails and short message service reminders were sent to target participants between 31 January 2020 and 3 February 2020.

Descriptive statistics were used to summarise the characteristics of the respondents. Respondents were stratified by their practice sector (ie, public vs private). The differences in the effects of the COVID-19 outbreak on the clinical practices, clinic service, and infection control practices between public and private family doctors were evaluated by Pearson Chi squared test. Thematic analysis was performed on the respondents’ free comments and suggestions. The responses were reviewed independently by two investigators and consolidated into themes. Inconsistencies were resolved by discussion between the two investigators to reach consensus on a common theme. The consolidated themes from the respondents’ suggestions and concerns were further stratified by respondents’ practice sector using descriptive statistics.

All significance tests were two-tailed and those with a P value of <0.05 were considered statistically significant. The statistical analysis was executed by Stata (Version 16.0; StataCorp LLC, College Station [TX], US).

Since the survey was initially conducted to examine the needs and preparedness of frontline family doctors who are members of the HKCFP during the early phase of COVID-19 outbreak in Hong Kong, ethics approval was obtained from the Survey and Behavioural Research Ethics Committee of The Chinese University of Hong Kong subsequently for data analysis and presentation.

The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist for cross-sectional studies was used in the drafting of this article.11

Of 1589 HKCFP members invited to complete the survey, 491 (31%) provided a complete and valid response (Table 1). Of the respondents, 393 (80%) had attained higher qualifications in Family Medicine. Among the respondents, 236 (48%) worked at public primary care clinics operated by the Hospital Authority or Department of Health, and 242 (49%) worked in the private sector, half of whom were solo practitioners. The ratio of public to private sector respondents was approximately 1:1.

The vast majority of the respondents (n=482, 98%) continued to provide clinic services although most of their clinic practices (n=428, 87%) had been affected by the COVID-19 outbreak (Fig 1, online supplementary Appendix 2). Significantly a higher proportion of private than public family doctors reported reduced clinic service demands during this outbreak (n=111 [45%] vs n=60 [24%], P<0.001). Half of the surveyed family doctors adjusted non-acute consultation services and/or reduced consultation time. As of 4 February 2020, over 140 patients with suspected severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection had been encountered by 70 (14%) surveyed family doctors; one public family doctor reported a patient who was subsequently confirmed to have SARS-CoV-2 infection. Among the surveyed family doctors, 310 (63%) perceived needs for more training on how to deal with the COVID-19 outbreak. At time of the survey, to assist clinical decision making for diagnosing COVID-19, guidelines from the Centre for Health Protection or the Hospital Authority were used by public family doctors more frequently than by private family doctors (n=143 [58%] vs n=98 [40%], P<0.001). Conversely, 195 (80%) of the surveyed private family doctors encountered problems in stocking personal protective equipment (PPE).

Nearly all respondents wore masks during consultations (n=490, 99%) and washed hands between or before patient encounter (n=486, 99%) [Fig 2 and Supplementary Appendix 2]. A greater proportion of public than private family doctors insisted patients wear masks during consultations (n=210 [85%] vs n=165 [67%], P<0.001) and routinely screened patients’ body temperatures (n=211 [86%] vs n=183 [75%], P=0.002). In contrast, a greater proportion of private than public family doctors cleaned work surfaces with antiseptics at least once a day (n=223 [91%] vs n=200 [81%], P=0.002) and installed air purifiers (n=71 [29%] vs n=35 [14%], P<0.001).

Of the respondents, 159 (32%) answered the open-ended question, among which 135 (85%) suggested measures to be instituted by government and/or local health authorities to facilitate frontline family doctors to respond to the COVID-19 outbreak (Table 2). A significant proportion of respondents (n=52, 39%) appealed to the government, health service providers and/or professional bodies for securing adequate supply of PPE, especially surgical masks, for frontline healthcare workers as well as the general public. There was a strong call (n=49, 36%) for more effective public health policy to contain the outbreak, such as border control and/or quarantine measures for returning residents and travellers to reduce imported cases. Two respondents (1.5%) had expectations for better coordination between the public and private sectors with respect to role delineation and resource allocation, for example, setting up a Primary Care Authority to maximise efficiency and effectiveness of scattered primary healthcare delivery locally. Some family doctors (n=9, 7%) advocated for the introduction of designated clinics and requested availability of rapid diagnostic tests. A few respondents (n=8, 6%) stressed the importance of public education on infection control practice and reporting accurate travel and contact history during consultation.

Nineteen respondents (4%) expressed personal concerns that were consolidated into six themes (Fig 3 and online supplementary Appendix 3). The major concern was the risk of SARS-CoV-2 infection, as a result of the lack of PPE, consultation with an asymptomatic patient with SARS-CoV-2 infection, or dishonest patients with unreliable history. Owing to the lack of rapid tests and/or PPE, two private family doctors (11%) worried that they would be unable to provide clinic services, resulting in public healthcare system overload. Three respondents (16%) raised concerns about the need to handle and/or clarify “fake news” (ie, misinformation).

The vast majority of surveyed family doctors were committed to discharging their duties in the early phase of the COVID-19 outbreak despite clinical uncertainties, psychological distress arising from infectious risk to self and family, and corresponding significant effects on clinical services. Only 2% of the surveyed private family doctors had closed their clinics, compared with 8% during the SARS epidemic in 2003.9 These figures were also much lower than reported absenteeism rates of healthcare workers during influenza pandemics.12 13 14 In the 2009 H1N1 pandemic in 2009, 59% of local primary care doctors reported higher demands in clinical services.4 In contrast, in the present study, 25% of public family doctors and 45% of private family doctors reported reductions in clinical service demand. Different from an influenza outbreak when primary care doctors are tasked with providing confirmatory diagnostic tests and antiviral treatment, rapid diagnostic tests were not readily accessible in the primary care setting at time of our survey, and treatments for COVID-19 were available only in hospital settings. Patients with highly probable SARS-CoV-2 infection were sent directly to hospital isolation wards for further management. Patients suspecting themselves to have SARS-CoV-2 infection presented in large numbers to emergency departments instead of primary care clinics. Local citizens were also strongly encouraged to practise social distancing, especially avoiding areas of high contact risk, including clinics.15 Patients with other non-urgent health needs might opt to delay their clinic visits. Nevertheless, family doctors encountered probable SARS-CoV-2 infection, especially patients with milder, non-specific respiratory symptoms and with less clear travel and/or contact history. Thus, family doctors needed to remain vigilant in identifying suspected cases in the community during this period, while providing continuing care to other patients with unrelated medical conditions, mental health support for patients affected by the outbreak and educating healthy patients.

Although the mode of transmission of COVID-19 was not clearly understood in the early phase of outbreak, almost all surveyed family doctors readily adopted standard droplet and contact precautions, including wearing facemasks during consultation and washing hands before and/or between seeing patients as recommended by the Centre for Health Protection of Hong Kong.16 Wearing facemask during consultation became a common practice among family doctors in Hong Kong since the global outbreak of SARS.4 9 17 Conversely, hand hygiene practices of family doctors were less consistent and varied between 45% before the H1N1 influenza epidemic4 to 70% during SARS in 2003.9 In the present survey, 99% of family doctors reported washing their hands before patient encounters during the current outbreak, which has been proven more effective than facemask wearing alone in limiting the transmission of respiratory infections.18 19 The practice of other recommended infection control measures differed between public and private family doctors, reflecting practical challenges in their implementation. A particular infection control challenge for local small-sized clinics would be the required isolation of patients with suspected SARS-CoV-2 infection, where an extra single isolation room with or without negative pressure, or even a designated isolation area >1 m from the rest of the waiting area, was often unavailable.16 To protect other patients from possible cross-infection in clinics, respondents adjusted non-nonacute patient appointments, shortened consultation times to avoid crowding of patients in the clinic, or divert patients to other clinics. Despite the variations, these infection control measures might be contributory to the zero-infection rate observed among primary care providers in Hong Kong at the time of the survey.

Many respondents considered public health policies and interventions in response to the COVID-19 outbreak to be important. There has been an escalation of infection control responses to the COVID-19 outbreak, especially wearing of facemasks, in the healthcare20 and community settings.21 Consequently, an acute shortage of facemasks was experienced by respondents, similar to the situation observed in the US.22 Echoing the viewpoints of Australian general practitioners towards influenza pandemic management, family doctors from Hong Kong also considered that government and health authorities should be responsible for ensuring steady supply of PPE to frontline healthcare workers and/or the public.23 A few surveyed family doctors commented that they would cease to provide clinical service if PPE became unavailable, owing to the high infection risk. Moreover, a large proportion of respondents advocated for border controls and quarantine measures to limit cross-border transmission.24 Subsequently, border controls and mandatory quarantine were implemented on people arriving from mainland China in early February 2020,25 and extended to travellers from most regions around the globe in March 2020.26 These measures may have contributed to the relatively slow rise in the number of confirmed COVID-19 cases in Hong Kong.

Some private family doctors requested the introduction of designated fever clinics for the public, so that high-risk patients presenting with fever and/or respiratory symptoms could be diverted to a designated location and managed appropriately. Such arrangements would be particularly important for protecting the many small private clinics which lack the capacity to properly isolate high-risk patients. Designated clinics were successfully implemented in Hong Kong during the 2009 H1N1 pandemic5 and in China and the US during the current COVID-19 outbreak.1 22 Unfortunately, local citizens opposed these clinics owing to a fear of COVID-19 transmission in the neighbourhood. Instead, designated doctors were assigned to attend high-risk or febrile patients in certain public primary care clinics. However, the arrangement was not clear to the public nor frontline private family doctors and symptomatic patients continued to seek care from private family doctors. Despite repeated calls for coordinated care or clear role delineation of family doctors between public and private sectors at times of outbreak, this has still not been achieved.5 9

This study had two key strengths. First, our survey was conducted in the early phase of the COVID-19 outbreak, thus the survey rapidly captured the early effects of an emerging outbreak on primary care services and reflected the clinic preparedness and needs of frontline family doctors in Hong Kong. Second, our study covered family doctors from both public and private sectors, allowing for comparison between the two sectors. Possible service gaps in the current dual-track primary healthcare system could be readily identified to inform policy makers.

A major limitation of this study was the low response rate, attributable to the relatively short survey period. Although our response rate (31%) was lower than previous similar surveys among family doctors in Hong Kong during SARS (75%) and H1N1 pandemic (42%), the crude response rate was higher (n=491, vs 137 and 126, respectively). However, our respondents included only approximately 10% of the doctors listed in the Primary Care Directory.27 Also, only HKCFP members and fellows were targeted in this survey. Hence, the sample might not be representative of all primary care physicians in Hong Kong. Lastly, as an observational study, reporting bias existed.

Family doctors from both public and private sectors in Hong Kong reported willingness and preparedness to provide primary, continuous, and whole-person care to the community from the early phase of the COVID-19 outbreak. Despite limitations in clinic physical settings and potential for PPE shortages, most family doctors adopted standard precautions and effectively protected themselves and the public from cross-infection. Nevertheless, there is an obvious need for health authorities to improve role delineation and coordination between private and public primary care services and to provide relevant support during an outbreak, so that family doctors can continue to play their various roles in the community under the current dual-track primary healthcare system.

Concept or design: SYS Wong, EYT Yu, WLH Leung.
Acquisition of data: SYS Wong, EYT Yu, WLH Leung.
Analysis or interpretation of data: All authors.
Drafting of the manuscript: All authors.
Critical revision of the manuscript for important intellectual content: All authors.

All authors had full access to the data, contributed to the study, approved the final version for publication, and take responsibility for its accuracy and integrity.

All authors have disclosed no conflicts of interest.

We would like to thank The Hong Kong College of Family Physicians (HKCFP) Research and Executive Committee members who have contributed to the design of questionnaire and review of the draft, including Dr Angus Chan, Dr David Chao, Dr Catherine Chen, Dr Lap-kin Chiang, Dr Billy Chiu, Dr Cecilia Fan, Dr Ho-lim Lau, Dr Jun Liang, Dr Shuk-yun Leung, Dr Lorna Ventura Ng, Professor Martin Wong, and Dr William Wong; and Miss Erica So, Miss Crystal Yung, and Miss Angel Fung who provided administrative support for the study. We would also like to thank all the participating family doctors who responded promptly to this survey.

This research has not been presented in any academic conference or published previously. Part of the findings from the survey was disseminated through a local press release on 10 March 2020.

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

This study was approved by the Survey and Behavioural Research Ethics Committee of The Chinese University of Hong Kong (Ref SBRE-19-578).

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