By the late 20th century, traditional teaching methods in postgraduate medical education were considered inadequate for preparing doctors to navigate modern healthcare systems, thereby posing risks to patient safety. This realisation led to a global shift towards competency-based medical education.1 2 3 The Hong Kong Academy of Medicine (HKAM) identifies seven key competencies essential for contemporary medical practitioners, namely, professional expertise, interpersonal communication, teamwork, leadership, professionalism, academia, and health promotion. The achievement of proficiency in these areas requires novel approaches to teaching and learning.

Traditional postgraduate medical education is often centred around two main principles: the transmission of knowledge and the ‘see one, do one, teach one’ model. Although knowledge acquisition is essential, mere memorisation of facts and information does not lead to excellence in medical practice. Effective education requires more than the delivery of information. It involves selecting content aligned with learning objectives, organising and presenting material in ways that reflect how people learn, and fostering motivation to engage with the material.4 It had been demonstrated that knowledge acquisition alone does not result in expertise.5 Individuals may successfully recall information and perform well on examinations, but they often encounter difficulties when addressing real-life clinical problems. The application of knowledge is critical, and hands-on clinical experience is invaluable. However, the tasks encountered in postgraduate medicine are more complex and challenging than those in traditional apprenticeships, rendering the ‘see one, do one, teach one’ method insufficient. Teaching methods that provide support and promote a deeper understanding of material are necessary to develop true expertise in medicine.6 The importance of such teaching methods underscores the critical need for faculty development—commonly referred to as training for trainers—which involves acquiring new skills and knowledge while undergoing a shift in mindset.

Faculty development is central to the successful implementation of competency-based medical education. It includes activities undertaken by healthcare professionals to enhance teaching, leadership, research, and scholarly abilities in both individual and group contexts.7 This emphasis on faculty development was highlighted in the Position Paper on Postgraduate Medical Education, published in 2023.8 The Hong Kong Jockey Club Innovative Learning Centre for Medicine (ILCM), established by HKAM, was created to modernise postgraduate medical education in Hong Kong. Initially focused on simulation-based medical education, the ILCM has since broadened its scope to address all aspects of postgraduate medical education.9 Recognising the importance of faculty development, the ILCM has assumed a leading role in advocating for this concept within the medical community. To advance these efforts, the ILCM formed the Faculty Development Workgroup (the ‘Workgroup’), which includes representatives from all 15 Colleges under HKAM, to collaborate on faculty development initiatives.

To ensure that faculty development in postgraduate medical education is competency-based, the Workgroup conducted a literature review to identify existing frameworks and identified seven relevant models.10 11 12 13 14 15 16 After careful deliberation, the frameworks proposed by Hesketh et al12 and the Academy of Medical Educators16 were deemed the most comprehensive and appropriate for adaptation to the local context in Hong Kong.

Steinert7 defines faculty as all individuals involved in teaching and educating learners across the educational continuum (eg, undergraduate, graduate, postgraduate, and continuing professional development), leadership and management within universities, hospitals, and the community, as well as research and scholarship in the health professions (eg, communication sciences, dentistry, nursing, and rehabilitation sciences). Based on this definition, the Workgroup delineated four categories of faculty within the framework: trainers, examiners, supervisors of training, and collegial leads in medical education within each College of HKAM. The initial phase of development focused on creating the Framework for Faculty Development of Trainers, which outlines the key competencies required for trainers. This framework facilitates the identification of individual learning needs, supports effective delivery of course content, and guides the evaluation of outcomes of the faculty development programme.17

The Workgroup adopted the three-circle model to classify learning outcomes proposed by Simpson et al.18 This model categorises competencies into core tasks, approaches to tasks, and professional identity, ensuring that trainers perform their roles effectively while approaching these roles with appropriate attitudes and professionalism (Fig).18

The Framework for Faculty Development of Trainers17 was approved earlier this year by the Education Committee and the Council of HKAM (Fig). In the future, the ILCM will design and implement training workshops guided by the following principles19:

Evidence-informed educational design

Relevant content

Experiential learning with opportunities for practice and application

Opportunities for feedback and reflection

Intentional community building

Moreover, a recent systematic review has highlighted key principles for effective faculty development that extend beyond workshops and individual teaching effectiveness. These principles include strengthening participants’ identities as educators, promoting recognition of educational excellence and leadership development, and fostering communities of practice to support ongoing learning and skill refinement.20 This comprehensive approach reflects the learning process for clinical skills, which requires practice, feedback, and continuous development in the workplace. Therefore, effective faculty development will require sustained support from HKAM and collaboration with stakeholders across all Colleges to ensure that faculty continue to advance their skills after completing workshops.

Faculty development is essential for the advancement of postgraduate medical education in Hong Kong. By equipping trainers with the appropriate competencies and skills, the framework ensures that doctors in training receive high-quality education and mentorship, ultimately enhancing patient care and outcomes within the healthcare system.6

All authors have contributed equally to the concept, development and critical revision of the manuscript. 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 declared no conflicts of interest.

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

1. Kohn LT, Corrigan JM, Donaldson MS, editors. To Err Is Human: Building a Safer Health System. Washington (DC): National Academies Press; 2000.

2. Institute of Medicine (US) Committee on Quality of Health Care in America. Crossing the quality chasm: a new health system for the 21st century. Washington (DC): National Academies Press (US); 2001.

3. Whitehead CR, Austin Z, Hodges BD. Flower power: the armoured expert in the CanMEDS competency framework? Adv Health Sci Educ Theory Pract 2011;16:681-94. Crossref

4. Swanwick T, Forrest K, O’Brien BC, editors. Understanding Medical Education: Evidence, Theory, and Practice. The Association for the Study of Medical Education (ASME); 2019. Crossref

5. Dreyfus SE, Dreyfus HL. A five-stage model of the mental activities involved in direct skill acquisition. Operations Research Center, University of California, Berkeley; 1980.

6. So HY. Postgraduate medical education: see one, do one, teach one…and what else? Hong Kong Med J 2023;29:104. Crossref

7. Steinert Y. Faculty development: core concepts and principles. In: Steinert Y, editor. Faculty Development in the Health Professions: A Focus on Research and Practice. Innovation and Change in Professional Education, 11. Dordrecht [NY]: Springer; 2014: 3-25. Crossref

8. So HY, Li PK, Lai PB, et al. Hong Kong Academy of Medicine position paper on postgraduate medical education 2023. Hong Kong Med J 2023;29:448-52. Crossref

9. Chen PP, So HY, Lo JS, Cheng BC. Modernising postgraduate medical education: evolving roles of the Hong Kong Jockey Club Innovative Learning Centre for Medicine in the Hong Kong Academy of Medicine. Hong Kong Med J 2023;29:480-3. Crossref

10. Skeff KM, Stratos GA, Bergen MR, Regula DP Jr. A pilot study of faculty development for basic science teachers. Acad Med 1998;73:701-4. Crossref

11. Harden RM, Crosby J. AMEE Guide No. 20: The good teacher is more than a lecturer—the twelve roles of the teacher. Med Teach 2000;22:334-47. Crossref

12. Hesketh EA, Bagnall G, Buckley EG, et al. A framework for developing excellence as a clinical educator. Med Educ 2001;35:555-64. Crossref

13. Molenaar WM, Zanting A, van Beukelen P, et al. A framework of teaching competencies across the medical education continuum. Med Teach 2009;31:390-6. Crossref

14. Milner RJ, Gusic ME, Thorndyke LE. Perspective: toward a competency framework for faculty. Acad Med 2011;86:1204-10. Crossref

15. Srinivasan M, Li ST, Meyers FJ, et al. “Teaching as a Competency”: competencies for medical educators. Acad Med 2011;86:1211-20. Crossref

16. Academy of Medical Educators. Professional standards for medical, dental and veterinary educators (fourth edition). 2022. Available from: https://www.medicaleducators.org/write/MediaManager/Documents/AoME_Professional_Standards_4th_edition_1.0_(web_full_single_page_spreads).pdf. Accessed 1 Nov 2024.

17. Hong Kong Academy of Medicine. Framework for Faculty Development Part 1: Trainers. September 2024. Available from: https://www.hkam.org.hk/sites/default/files/PDFs/2024/HKAM_Faculty%20Development%20Framework_Part%201.pdf?v=1729586789500. Accessed 20 Sep 2024.

18. Simpson JG, Furnace J, Crosby J, et al. The Scottish doctor—learning outcomes for the medical undergraduate in Scotland: a foundation for competent and reflective practitioners. Med Teach 2002;24:136-43. Crossref

19. Steinert Y, Mann K, Centeno A, et al. A systematic review of faculty development initiatives designed to improve teaching effectiveness in medical education: BEME Guide No. 8. Med Teach 2006;28:497-526. Crossref

20. Steinert Y, Mann K, Anderson B, et al. A systematic review of faculty development initiatives designed to enhance teaching effectiveness: a 10-year update: BEME Guide No. 40. Med Teach 2016;38:769-86. Crossref

Women’s health differs from men’s health not only in biological and gender-specific aspects but also in societal and psychological dimensions, making it a crucial component of public health. The health of women and girls is particularly important because they often face disadvantages and vulnerabilities due to discrimination in many societies. In recent years, increased awareness of gender-specific health issues has underscored the need for comprehensive strategies to address women’s health concerns, including reproductive health, cancer prevention, and care for elderly women. This editorial provides an overview of the unique health challenges faced by women in Hong Kong throughout various stages of life and examines interventions designed to improve health outcomes for women.

Reproductive health is fundamental to women’s overall well-being, encompassing all aspects of the reproductive system and its functions.1 Health issues may arise at any stage of life, from menarche (the onset of the first menstrual period) to menopause. Multiple pregnancies, defined as the simultaneous presence of more than one fetus (eg, twins, triplets, or higher-order multiples), involve serious health risks.2 3 The perinatal mortality risk can be up to 7 times higher in twin pregnancies than in singleton pregnancies; risks increase further in triplet and quadruplet pregnancies.2 Since the introduction of assisted reproductive technology in 1978, the prevalence of multiple pregnancies has risen worldwide.2 A retrospective study analysing medical records from a university tertiary obstetric unit in Hong Kong showed that the prevalence of multiple pregnancies increased from 1.41% in the first decade (2000-2010) to 1.91% in the second decade (2010-2019).2 Despite this increase, the total mortality rate for multiple births significantly decreased, from 25.32 per 1000 births to 13.82 per 1000 births. This improvement has been attributed to advancements in antenatal care, enhanced treatment options, and reductions in preterm births.2 These findings highlight the importance of continued research and targeted interventions in reproductive health to achieve better outcomes for women and infants.

Additionally, postpartum haemorrhage (PPH), a life-threatening condition characterised by excessive bleeding, is significantly more common in women with multiple pregnancies than in those with singleton pregnancies.4 A retrospective cohort study revealed a substantially elevated risk of severe PPH among women with twin pregnancies, particularly those who were obese, had conceived via in vitro fertilisation, or presented with placenta previa.4 Special attention must be given to pregnant women with these risk factors, including proactive preparations for the management of severe PPH to mitigate the risk of mortality. Enhanced monitoring and targeted interventions are essential for efforts to improve outcomes in this vulnerable population. Psychological morbidity is also frequently observed in pregnant women, particularly those experiencing threatened miscarriage.5 In a cross-sectional study of women in their first trimester, 48.4% to 76.7% reported distress.5 Notably, women with a history of miscarriage exhibited higher stress scores relative to those without such a history.5 6 Thus, early identification of women requiring additional psychological support, facilitated through psychometric instruments, is critical for improvements to maternal psychological well-being, which is also associated with better fetal outcomes.5

Moreover, pregnant women tend to be more vulnerable to communicable diseases such as coronavirus disease 2019 (COVID-19), more concerned about severe complications, and more fearful of vertical transmission to neonates; these tendencies impose additional psychological stress.7 8 According to a cross-sectional survey conducted in Hong Kong from 28 July 2020 to 13 August 2020, 83.1% of pregnant women expressed substantial concern about contracting COVID-19 during pregnancy, 70.5% feared intrauterine viral infection of their fetuses due to maternal COVID-19, and 84.3% opposed the ban on husbands accompanying their wives during labour and delivery.7 Governments and healthcare professionals should enhance public education to increase awareness of COVID-19—related complications during pregnancy, enabling women to approach the situation with informed perspectives and reducing unnecessary stress.7 The provision of universal screening for pregnant women, a widely supported approach, represents another intervention to alleviate the burden of disease.7

In addition to health concerns during pregnancy, infertility remains a major reproductive health issue for women, affecting nearly one in six adult women worldwide.9 Although advancements in fertility preservation technologies have enabled many patients to conceive their own biological children, some individuals have been unable to undergo the ovarian stimulation required for oocyte or embryo freezing, including prepubertal girls who are ineligible for the procedure.10 Ovarian tissue cryopreservation serves as an ideal option for preserving fertility in these cases.11 An in vivo study of nude mice demonstrated that grafted ovarian tissues remained viable after ovarian tissue cryopreservation and subsequent transplantation, supporting the implementation of this approach in Hong Kong.11

Cancer is a leading cause of death among women, and breast cancer is the most prevalent type in Hong Kong.12 13 Early detection through risk-based screening programmes is essential for reducing breast cancer–related morbidity and mortality.14 15 In Hong Kong, the Cancer Expert Working Group on Cancer Prevention and Screening has reviewed and updated its breast cancer screening recommendations, introducing slight changes for women at moderate risk.12 Women aged 44 to 69 years with increased breast cancer risk (eg, family history, benign breast disease, reproductive history, early menarche, high body mass index, and physical inactivity) are advised to consider biennial mammography screening after consulting their physicians.12

Advanced treatment plays an equally important role in managing breast cancer.16 Neoadjuvant chemotherapy (NAC), administered before definitive breast cancer surgery, reduces tumour size and facilitates surgery for patients.17 Insights from a 12-year review of the Hong Kong Breast Cancer Registry demonstrated the effectiveness of NAC, supporting its application in patients with stage II or higher disease, as well as those with human epidermal growth factor receptor 2–positive (non-luminal) or triple-negative breast cancers.16 The use of NAC in Hong Kong nearly doubled during the 12-year period, increasing from 5.6% in 2006-2011 to 10.3% in 2012-2017.16

Early prevention of cancer through human papillomavirus (HPV) vaccination plays an indispensable role in women’s health. Human papillomavirus vaccination is a safe and effective method for preventing cervical cancer, as well as other HPV-related cancers, including cancers of the anus, vulva, vagina, penis, and oropharynx.18 To improve vaccine coverage, the promotion of a gender-neutral vaccination programme within the school-based childhood immunisation framework is essential. A cross-sectional online survey in Hong Kong revealed that only 12.5% (63/503) of parents had consented to vaccination for their daughters.18 Parental misconceptions regarding vaccine safety and the ideal vaccination age represent major barriers that must be addressed to increase HPV vaccination coverage among children.18

As women age, they encounter unique health challenges, including an increased risk of osteoporosis, cardiovascular disease, and cognitive decline. Pelvic organ prolapse (POP) is a common health issue, reported by nearly 10% of the Chinese population.19 Increasing evidence supports surgical treatment over vaginal pessaries as a definitive intervention for POP. A recent multicentre retrospective study showed that POP surgeries were safe and effective for women aged ≥75 years in Hong Kong.20 Additionally, there is a need to emphasise the importance of the Hong Kong Reference Frameworks in managing chronic diseases among elderly women.21 These frameworks provide evidence-based, standardised guidelines for primary healthcare professionals to assist patients in preventing and managing conditions such as diabetes mellitus, hypertension, and common musculoskeletal disorders.21

In summary, the growing recognition of women’s health as a critical component of public health requires a comprehensive, evidence-based approach to implementing effective interventions that address the unique challenges faced by women at various life stages. This editorial has outlined prevalent health issues among women in Hong Kong and worldwide, emphasising the need for a multidimensional framework that integrates prevention, early detection, and effective treatment. Such an approach is essential to improve women’s health outcomes in the future.

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.

The authors acknowledge the literature search and review assistance of Mr Zehuan Yang, Research Assistant at the Jockey Club School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong.

1. Global Perspectives on Women’s Sexual and Reproductive Health Across the Lifecourse. Cambridge International Law Journal; 2018.

2. Lau SL, Wong ST, Tse WT, et al. Perinatal mortality rate in multiple pregnancies: a 20-year retrospective study from a tertiary obstetric unit in Hong Kong. Hong Kong Med J 2022;28:347-56. Crossref

3. Sherer DM. Adverse perinatal outcome of twin pregnancies according to chorionicity: review of the literature. Am J Perinatol 2001;18:23-37. Crossref

4. Kong CW, To WW. Risk factors for postpartum haemorrhage in twin pregnancies and haemorrhage severity. Hong Kong Med J 2023;29:295-300. Crossref

5. Ip PN, Ng K, Wan OY, Kwok JW, Chung JP, Chan SS. Cross-sectional study to assess the psychological morbidity of women facing possible miscarriage. Hong Kong Med J 2023;29:498-505. Crossref

6. Farren J, Jalmbrant M, Ameye L, et al. Post-traumatic stress, anxiety and depression following miscarriage or ectopic pregnancy: a prospective cohort study. BMJ Open 2016;6:e011864. Crossref

7. Lok WY, Chow CY, Kong CW, To WW. Knowledge, attitudes, and behaviours of pregnant women towards COVID-19: a cross-sectional survey. Hong Kong Med J 2022;28:124-32. Crossref

8. Dashraath P, Wong JL, Lim MX, et al. Coronavirus disease 2019 (COVID-19) pandemic and pregnancy. Am J Obstet Gynecol 2020;222:521-31. Crossref

9. World Health Organization. 1 in 6 people globally affected by infertility: WHO. Last modified April 4, 2023. Available from: https://www.who.int/news/item/04-04-2023-1-in-6-people-globally-affected-by-infertility. Accessed 12 Dec 2024.

10. Dolmans MM, Donnez J. Fertility preservation in women for medical and social reasons: oocytes vs ovarian tissue. Best Pract Res Clin Obstet Gynaecol 2021;70:63-80. Crossref

11. Chung JP, Chan DY, Song Y, et al. Implementation of ovarian tissue cryopreservation in Hong Kong. Hong Kong Med J 2023;29:121-31. Crossref

12. Tsang TH, Wong KH, Allen K, et al. Update on the Recommendations on Breast Cancer Screening by the Cancer Expert Working Group on Cancer Prevention and Screening. Hong Kong Med J 2022;28:161-8. Crossref

13. Huang J, Chan PS, Lok V, et al. Global incidence and mortality of breast cancer: a trend analysis. Aging (Albany NY) 2021;13:5748-803. Crossref

14. Duffy S, Vulkan D, Cuckle H, et al. Annual mammographic screening to reduce breast cancer mortality in women from age 40 years: long-term follow-up of the UK Age RCT. Health Technol Assess 2020;24:1-24. Crossref

15. Henderson JT, Webber EM, Weyrich MS, et al. Screening for breast cancer: evidence report and systematic review for the US Preventive Services Task Force. JAMA 2024;331:1931-46. Crossref

16. Chan YH, Kwok CC, Tse DM, Lee HM, Tam PY, Cheung PS. Preoperative considerations and benefits of neoadjuvant chemotherapy: insights from a 12-year review of the Hong Kong Breast Cancer Registry. Hong Kong Med J 2023;29:198-207. Crossref

17. Shien T, Iwata H. Adjuvant and neoadjuvant therapy for breast cancer. Jpn J Clin Oncol 2020;50:225-9. Crossref

18. Lam EW, Ngan HY, Kun KY, Li DF, Wan WY, Chan PK. Awareness, perceptions, and acceptance of human papillomavirus vaccination among parents in Hong Kong. Hong Kong Med J 2023;29:287-94. Crossref

19. Pang H, Zhang L, Han S, et al. A nationwide population-based survey on the prevalence and risk factors of symptomatic pelvic organ prolapse in adult women in China—a pelvic organ prolapse quantification system-based study. BJOG 2021;128:1313-23. Crossref

20. Wong D, Lee YT, Tang GP, Chan SS. Surgical treatment of pelvic organ prolapse in women aged ≥75 years in Hong Kong: a multicentre retrospective study. Hong Kong Med J 2022;28:107-15. Crossref

21. Health Bureau, Primary Healthcare Commission. Reference Frameworks. Available from: https://www.healthbureau.gov.hk/phcc/main/frameworks.html?lang=2. Accessed 24 Nov 2024.

Healthcare for vulnerable populations, including but not limited to children, women (particularly during pregnancy), older adults, individuals with underlying long-term conditions, and those facing structural barriers associated with lower socio-economic status, remains one of the most formidable challenges in health protection and promotion worldwide. The advent of coronavirus disease 2019 (COVID-19) has exacerbated the vulnerability of these groups, placing them at greater risk of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and worse health outcomes.1 Global data indicate that COVID-19 has disproportionately affected these vulnerable groups, driven by a complex interplay of biological factors, social determinants, and overstretched healthcare services.2

A substantial body of evidence demonstrates the harmful and long-lasting consequences of COVID-19 on the development of children and adolescents, encompassing physical health, mental well-being, academic performance, and socio-emotional skills, both directly and indirectly.3 A recent review of the literature revealed that adolescents, children from ethnic minority backgrounds or lower-income families, and those with obesity were more susceptible to SARS-CoV-2 infection.4 While COVID-19 generally presents as a milder or moderate illness in children compared to adults, due to fundamental differences in immune responses, continued surveillance—such as wastewater monitoring and universal or pooled testing—remains critical to managing the spread of infection within communities.4 Serious conditions, although fortunately rare, require preparedness and response efforts from frontline paediatricians and intensivists to provide optimal respiratory support. A framework for airway management procedures has been proposed, based on a comprehensive system incorporating respiratory pattern monitoring, spontaneous respiration oxygenation, apnoeic oxygenation, manual ventilation, and scavenging to reduce the risk of healthcare-associated transmission.5 Case reports have described adolescent patients presenting with rare conditions, such as laboratory-confirmed SARS-CoV-2 infection with chilblain-like lesions6 and paediatric multisystem inflammatory syndrome temporally associated with SARS-CoV-2 after recovery from COVID-19.7 Both cases suggest that paediatricians should remain vigilant for potential symptoms and signs to enable timely diagnosis and mitigate transmission risks.

Although vaccination has proven effective in reducing the severity of COVID-19 and providing protection against post—COVID-19 conditions, increasing concerns persist regarding the knowledge gap on long-term efficacy and potential adverse events associated with COVID-19 vaccines.4 8 Gut microbiota may play an important role in the immune response to vaccination, offering a promising avenue for management of vaccine-related adverse effects. A pilot study in Hong Kong demonstrated the safety and tolerability of a microbiota-derived health supplement among children aged 5 to 17 years.8 This supplement, administered prior to COVID-19 vaccination and continued for 7 days post-vaccination, showed potential for alleviating vaccine hesitancy among parents and children.8

The impacts of COVID-19 on the dramatically increased use of digital tools in school education have also attracted considerable public attention, partly due to mitigation strategies such as school closures and restrictions, which have affected at least half of the global student population.9 Despite rapid advances in virtual learning technology and home-schooling platforms, the prolonged reliance on remote or distance learning in response to the COVID-19 pandemic poses profound risks to the cognitive and social development of adolescents. These risks arise from the absence of physical interactions with peers and teachers during the transition to adulthood.9 Such effects may be more pronounced in children and youth with behavioural or intellectual disabilities who rely on special education support services. In resource-constrained settings or among low-income families, effective education time is often substantially reduced due to inadequate access to electronic devices and limited internet connectivity, thereby exacerbating academic inequality. Addressing this challenge may require sustained government investment in community-based, targeted socio-technical interventions to close the social class achievement gaps and reduce the digital divide.10

Excessive screen time resulting from increased reliance on digital media has led to a range of public health concerns, including asthenopia and vision impairment. A clinical assessment of visual acuity among school-aged adolescents in western rural China revealed a significantly higher prevalence of asthenopia and worsened vision impairment during the COVID-19 pandemic compared with the pre-pandemic period.11 The striking progression of vision impairment highlights the urgent need for policymakers to develop system-level strategies and tailored guidelines aimed at promoting healthy screen time practices. Such measures are essential to address the increasing incidence of eye problems among students in the post—COVID-19 era, where digital media is deeply embedded in nearly every aspect of adolescents’ daily lives.

Coronavirus disease 2019 also posed multiple challenges throughout pregnancy because pregnant women infected with the virus faced a higher risk of severe illness relative to their non-pregnant counterparts.12 Additionally, they may experience exacerbation of COVID-19 symptoms due to reduced lung capacity associated with fetal growth and immune suppression during pregnancy.13 Although compelling evidence indicates that rigorous public health measures effectively mitigate the spread of SARS-CoV-2,14 pregnant women often exhibited high levels of anxiety about contracting COVID-19, largely due to their vulnerable immune status.15 This widespread anxiety may arise from perceived risks of pregnancy complications, fears of vertical transmission to the newborn, and uncertainties regarding delivery and breastfeeding practices in the event of infection.15 These observations highlight the importance of ensuring enhanced laboratory support for universal screening and providing adequate personal protective equipment. Emotional support is equally important. Satisfaction with maternity care can be achieved through partner companionship during labour.15 A multidisciplinary approach involving expert teams has proven essential in providing optimal care.12 However, changes to childbirth companionship and peripartum services during the COVID-19 pandemic frequently fell short of pregnant women’s expectations, potentially leading to negative psychological consequences such as heightened antenatal anxiety and emotional disturbance.16 Guidelines and decision-making in obstetric practice must balance infection control measures with the peripartum needs of women; the nulliparous group requires additional attention.

Older patients with COVID-19 are considered among the most vulnerable groups during the pandemic because advanced age and co-morbidities are well-documented risk factors for mortality.17 Clinical findings have supported frailty screening as a reliable predictor of clinical deterioration and adverse outcomes in older patients upon hospital admission.17 Furthermore, older adults were more likely to remain at home during the pandemic, with limited access to recreational activities or social support, while facing an increased risk of elder abuse.18 Tackling these issues may require government-led legislation and integrated social welfare services to reduce vulnerability to abuse and neglect among older adults, particularly those residing in long-term care facilities.19

A recent global review examined national plans and policies on maternal, newborn, child, and adolescent health services, as well as health services for older people across 110 countries.20 The findings revealed a significant knowledge gap, particularly regarding the absence of specific activities, monitoring indicators, or resource allocations aimed at mitigating potential service disruptions in the COVID-19 response and recovery plans. The insights gained from clinical management during this pandemic will undoubtedly inform the development of policy interventions and guide future interdisciplinary research to enhance preparedness for emerging and unforeseen public health challenges, ultimately improving health outcomes for vulnerable populations.

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 declared no conflict of interest.

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

1. World Health Organization. Considerations for COVID-19 surveillance for vulnerable populations. Manila: World Health Organization; 2021.

2. World Health Organization. COVID-19 and the social determinants of health and health equity: evidence brief. Geneva: World Health Organization; 2021.

3. Irwin M, Lazarevic B, Soled D, Adesman A. The COVID-19 pandemic and its potential enduring impact on children. Curr Opin Pediatr 2022;34:107-15. Crossref

4. Wurm J, Ritz N, Zimmermann P. COVID-19 in children: evolving epidemiology, immunology, symptoms, diagnostics, treatment, post covid conditions, prevention strategies, and future directions. J Allergy Clin Immunol 2024 Nov 15. Epub ahead of print. Crossref

5. Leung KK, Ku SW, Fung RC, et al. Airway management in children with COVID-19. Hong Kong Med J 2022;28:315-20. Crossref

6. Wong JS, Wong TS, Chua GT, et al. COVID toe in an adolescent boy: a case report. Hong Kong Med J 2022;28:175-7. Crossref

7. Chua GT, Wong JS, Chung J, et al. Paediatric multisystem inflammatory syndrome temporally associated with SARS-CoV-2: a case report. Hong Kong Med J 2022;28:76-8. Crossref

8. Chow CM, Cheong PK, Hu J, Ching JY. Can a microbiota-derived health supplement mitigate adverse events after COVID-19 vaccination in children? Hong Kong Med J 2023;29:542-4. Crossref

9. Leung KK, Hon KL, Ip P, Ng DK. COVID-19 and children: potential impacts and alleviation strategies. Hong Kong Med J 2023;29:443-7. Crossref

10. Golden AR, Srisarajivakul EN, Hasselle AJ, Pfund RA, Knox J. What was a gap is now a chasm: remote schooling, the digital divide, and educational inequities resulting from the COVID-19 pandemic. Curr Opin Psychol 2023;52:101632.Crossref

11. Ding Y, Guan H, Du K, Zhang Y, Wang Z, Shi Y. Asthenopia prevalence and vision impairment severity among students attending online classes in low-income areas of western China during the COVID-19 pandemic. Hong Kong Med J 2023;29:150-7. Crossref

12. Nana M, Hodson K, Lucas N, Camporota L, Knight M, Nelson-Piercy C. Diagnosis and management of COVID-19 in pregnancy. BMJ 2022;377:e069739. Crossref

13. Ahmed AK, Sijercic VC, Sayad R, et al. Risks and preventions for pregnant women and their preterm infants in a world with COVID-19: a narrative review. Vaccines (Basel) 2023;11:640. Crossref

14. Leung HH, Kwok CY, Sahota DS, et al. Effects of strict public health measures on seroprevalence of anti- SARS-CoV-2 antibodies during pregnancy. Hong Kong Med J 2022;28:294-9. Crossref

15. Lok WY, Chow CY, Kong CW, To WW. Knowledge, attitudes, and behaviours of pregnant women towards COVID-19: a cross-sectional survey. Hong Kong Med J 2022;28:124-32. Crossref

16. Hui PW, Seto MT, Cheung KW. Behavioural adaptations and responses to obstetric care among pregnant women during an early stage of the COVID-19 pandemic in Hong Kong: a cross-sectional survey. Hong Kong Med J 2022;28:367-75. Crossref

17. Tam EM, Kwan YK, Ng YY, Yam PW. Clinical course and mortality in older patients with COVID-19: a clusterbased study in Hong Kong. Hong Kong Med J 2022;28:215-22. Crossref

18. Shea YF, Ip WC, Luk JK. Comparison of the pattern of elderly abuse in Hong Kong before and after the COVID-19 pandemic. Hong Kong Med J 2022;28:502-3. Crossref

19. Gardner W, States D, Bagley N. The coronavirus and the risks to the elderly in long-term care. J Aging Soc Policy 2020;32:310-5. Crossref

20. Czerniewska A, Sharkey A, Portela A, Drapkin S, Mustafa S. National COVID-19 preparedness and response plans: a global review from the perspective of services for maternal, newborn, child and adolescent health and older people. BMJ Glob Health 2024;9:e013711. Crossref

Hepatitis B virus (HBV) infection is an important public health issue. Hong Kong’s universal HBV immunisation programme for newborns began in 1988.1 This programme consists of administering hepatitis B immunoglobulin (HBIg) to infants born to hepatitis B surface antigen (HBsAg)–positive mothers, along with the first dose of the HBV vaccine at birth. The second and third doses of the vaccine are typically given in Maternal and Child Health Centres at 1 and 6 months, respectively. Notably, the proportion of HBsAg-positive pregnant women has steadily decreased in recent years, from 5.2% in 20162 to 2.4% in 2023 (unpublished data). Despite a 99.8% HBsAg screening rate among antenatal women, together with 99.5% coverage for both HBIg and HBV vaccinations in newborns of HBsAg-positive mothers,2 a local study3 of 641 HBsAg-positive pregnant women showed that the overall mother-to-child transmission (MTCT) rate remained 1.1%, indicating immunoprophylaxis failure. To align with the World Health Organization’s (WHO) goal of eliminating viral hepatitis as a public health threat by 2030,4 and specifically to achieve the WHO target of <0.1% HBsAg prevalence among 5-year-old children by that year, further reduction of MTCT of HBV has been targeted by the multidisciplinary Steering Committee on Prevention and Control of Viral Hepatitis, established in 2018 and chaired by the Director of Health and the Chief Executive of Hospital Authority.5 As an obstetrics representative on the Steering Committee, the first author had the opportunity to present a literature review for use in formulating the action plan. Three strategies were considered: (1) maintaining the current approach of administering HBIg and HBV vaccinations to newborns of HBsAg-positive mothers, (2) conducting another randomised controlled trial on the use of tenofovir in further prevention of MTCT of HBV, and (3) implementing a universal programme to use tenofovir for this purpose. Although two major randomised controlled trials,6 7 both published in The New England Journal of Medicine, appeared to reach conflicting conclusions, the MTCT of HBV rates were zero in both the Mainland China study6 (n=92, per-protocol) and the Thailand study7 (n=147). The safety of tenofovir in pregnancy has also been established. Rebound increases in alanine aminotransferase after tenofovir discontinuation were mild in most cases (acute hepatic exacerbation, defined as alanine aminotransferase elevation of >300 IU/L, occurred in 6% of the tenofovir group vs 3% of the control group7). The administration of antivirals to HBsAg-positive pregnant women with high HBV DNA levels has been recommended by the American Association for the Study of Liver Diseases, European Association for the Study of the Liver, Asian Pacific Association for the Study of the Liver, and Advisory Committee on Immunization Practices.5 Despite these recommendations, the WHO had not made any recommendations by 2018. The Steering Committee ultimately decided to proceed with option 3.5

All HBsAg-positive pregnant women with an HBV viral load >200 000 IU/mL will receive an early referral to the corresponding hepatology clinic under Hospital Authority to discuss starting tenofovir (tenofovir disoproxil fumarate; United States Food and Drug Administration pregnancy category B8) by 28 weeks of gestation to further reduce the risk of MTCT of HBV. This programme began as a pilot at Queen Mary Hospital and Prince of Wales Hospital in the first quarter of 2020; it was expanded to Pamela Youde Nethersole Eastern Hospital, Kwong Wah Hospital, Queen Elizabeth Hospital, Princess Margaret Hospital, United Christian Hospital, and Tuen Mun Hospital in the third quarter of 2020.5 In this issue of the Hong Kong Medical Journal, Cheung et al9 published the 2024 Hong Kong College of Obstetricians and Gynaecologists guideline on antenatal screening and management of hepatitis B to prevent MTCT, summarising current clinical practices in Hong Kong. This evidence-based guideline aligns with the core strategy of reducing MTCT risk in the Hong Kong Viral Hepatitis Action Plan 2020-2024.10 Additionally, the guideline addresses important issues such as immunoprophylaxis failure, antenatal management, and the indications for and duration of continued antiviral treatment after delivery. We strongly encourage our readers to incorporate the recommendations of the Hong Kong College of Obstetricians and Gynaecologists into their clinical practice.

Between September 2020 and December 2022, a total of 2151 HBsAg-positive pregnant women attended Hospital Authority antenatal clinics.11 Among them, 328 (15.2%) had a high viral load (HBV DNA >200 000 IU/mL) and were referred to hepatologists, and 314 (95.7%) of these pregnant women attended hepatology clinics. After consultation with hepatologists, most women (n=292, 93.0%) accepted tenofovir prophylaxis.11 Among those who refused tenofovir after consultation, common reasons included concerns about potential side-effects on the fetus and fears of hepatitis flare-ups after postpartum discontinuation of tenofovir.11

A key aspect of outcome assessment is post-vaccination serology testing, which will be performed in infants after they complete the full course of vaccination. Infants born to HBsAg-positive mothers will be recruited from Maternal and Child Health Centres and referred to the Hong Kong Children’s Hospital for blood tests. We anticipate favourable results, confirming the elimination of MTCT of HBV in Hong Kong by 2030!

Both authors contributed equally to the development of the manuscript. Both 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.

Both authors have declared no conflicts of interest.

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

1. Wong VC, Ip HM, Reesink HW, et al. Prevention of the HBsAg carrier state in newborn infants of mothers who are chronic carriers of HBsAg and HBeAg by administration of hepatitis-B vaccine and hepatitis-B immunoglobulin. Double-blind randomised placebo-controlled study. Lancet 1984;1:921-6. Crossref

2. Department of Health, Hong Kong SAR Government. Surveillance of Viral Hepatitis in Hong Kong: 2022 Report. 2023. Available from: https://www.hepatitis.gov.hk/english/health_professionals/files/hepsurv22.pdf. Accessed 8 Oct 2024.

3. Cheung KW, Seto MT, Kan AS, et al. Immunoprophylaxis failure of infants born to hepatitis B carrier mothers following routine vaccination. Clin Gastroenterol Hepatol 2018;16:144-5. Crossref

4. World Health Organization. Global Hepatitis Report 2017. Geneva: Global Hepatitis Programme; 2017. Available from: http://apps.who.int/iris/bitstream/10665/255016/1/9789241565455-eng.pdf?ua=1. Accessed 27 Sep 2024.

5. Leung WC. Use of tenofovir in further prevention of mother-to-child-transmission of hepatitis B virus. Hong Kong Med Diary 2020;25:11-5.

6. Pan CQ, Duan Z, Dai E, et al. Tenofovir to prevent hepatitis B transmission in mothers with high viral load. N Engl J Med 2016;374:2324-34. Crossref

7. Jourdain G, Ngo-Giang-Huong N, Harrison L, et al. Tenofovir versus placebo to prevent perinatal transmission of hepatitis B. N Engl J Med 2018;378:911-23. Crossref

8. United States Food and Drug Administration. Prescribing information: tenofovir disoproxil fumarate tablets, for oral use. Revised 2017. Available from: https://www.accessdata.fda.gov/drugsatfda_docs/pepfar/078800PI.pdf. Accessed 9 Oct 2024.

9. Cheung KW, So PL, Mak LL, et al. 2024 Hong Kong College of Obstetricians and Gynaecologists guideline on antenatal screening and management of hepatitis B for prevention of mother-to-child transmission. Hong Kong Med J 2024;30:400-8. Crossref

10. Department of Health, Hong Kong SAR Government. Hong Kong Viral Hepatitis Action Plan 2020-2024. 2020. Available from: https://www.hepatitis.gov.hk/doc/action_plan/Action%20Plan_Full%20Version_PDF_en.pdf. Accessed 8 Oct 2024.

11. Tsui WM, Leung WC, Kung KN, Lai CH. Antiviral prophylaxis for the prevention of mother-to-child transmission of hepatitis B virus. Hospital Authority Convention 2024 poster presentation F3_3.34. Available from: https://d1j0dbg7fhovrj.cloudfront.net/assets/haconvention2024/filemanager/images/1712735576F_P3.34_TSUIWaiManVivien.jpg. Accessed 27 Sep 2024.

In Hong Kong, 50% to 60% of the population consulted traditional Chinese medicine (TCM) practitioners at least once in their lives notwithstanding the wide availability of services from Western medicine (WM).1 A study has shown the concomitant use of TCM and WM by 25.9% of patients in Hong Kong.2 There is a need for better integration clinically and legally, especially when both WM and TCM practitioners are uncertain of their liabilities if any medico-legal incidents arise during co-care. Application of various common-law elements of negligence (duty of care, standard of care, causation and foreseeability) would help to develop deeper insights into how liabilities would fall on different parties.

When a patient comes to consult a practitioner, WM or TCM, a doctor-patient relationship is arguably already established. If a patient is under the co-care with prescriptions of both TCM and WM, who owes the duty of care to the patient? A three-pronged test can be used to determine the duty of care3:

the proximity (sufficient close) in the relationship between the claimant (patient) and the defendant (practitioner);

damage being reasonably foreseeable; and

whether the court considers it fair, just and reasonable to impose a duty of the given scope upon the defendant practitioner.

Who has the closest relationship with the patient claimant for a particular management? For instance, a patient consulted a WM doctor for back pain with no significant abnormalities detected, and the patient was advised bed rest, with sick leave certification and analgesia if needed. The patient then consulted a TCM practitioner and was prescribed some herbal medicine to take regularly. The patient also took analgesia, and s/he developed an allergic reaction. Who should owe a greater duty of care? Likewise, a patient consulted TCM for health maintenance with a prescription of TCM supplements. The patient then had a bad cough and was diagnosed with bronchitis by a WM doctor, who prescribed a course of antibiotics. The patient developed severe diarrhoea. Which practitioner owed a greater duty of care?

It is the submission of the authors that in the back pain case, the TCM practitioner may have had a closer relationship with the patient claimant upon initiation of regular treatments. The TCM practitioner should ask firstly whether the patient has been prescribed any medication. In the bronchitis case, the WM doctor may have had a closer relationship and should enquire about any concurrent medication including supplements. The patient claimant then bears the burden of proof with respect to whether the medication is likely to cause damage (causation). The defendant practitioner could defend against the claimant’s allegations with scientific evidence. If the best available evidence has not revealed any significant adverse drug interaction, the court may not see it “fair, just and reasonable” to impose a duty on the defendant practitioner (reasonable standard of care).

In WM, the Bolam test is applied, where a doctor is “not guilty of negligence if he has acted in accordance with a practice accepted as proper by a responsible body of medical men skilled in that particular art”.4 Traditional Chinese medicine practitioners hold themselves as practitioners specialised in treatment of certain health conditions, and they might use methods not in perfect line with WM practices, and patients look for TCM because they prefer not to receive WM, should the Bolam test also apply, or should TCM follow its own specific standard of care?5 Let us consider three cases to provide some insights.

In the United Kingdom, Abdur Shakoor was treated by Situ, an herbalist (TCM practitioner) with 5 years’ experience in China possessing both a traditional “medicine” and “modern” medical qualifications, but no British professional medical qualifications. Situ prescribed a course of Chinese herbal remedies for Shakoor’s lipoma.6 Shakoor got very ill and died of liver failure. Post-mortem examination found that his liver contained Bai Xian Pi (白蘚皮), or Dictamnus dasycarpus, which could be hepatotoxic as published in western journals. The judge concluded that as long as the herbalist has complied with the United Kingdom’s laws, not prescribing substances prohibited or regulated by statutes, and taking steps to keep abreast of pertinent information in TCM textbooks and periodicals, this would fulfil the standard of care of a reasonable herbalist.6

In Singapore, Lim Poh Eng,7 a TCM practitioner, was charged criminally negligence in having caused grievous harm to a patient by prescribing colonic washouts without proper training in the procedure and use of equipment, and without any understanding of the risks and complications involved. Lim was convicted after trial and failed on appeal to argue that the standard of negligence in criminal cases should be higher than the civil standard. The High Court ruled that a TCM practitioner embanking on management without prior knowledge and training can be found negligent.

Practitioners providing TCM or complementary and alternative medicine for management should provide evidence to create a hypothetical standard of care, otherwise the same standard will apply as WM. A United States case, Gonzalez,8 provides a legal reference. Dr Gonzalez (defendant doctor) initiated a cancer treatment including pancreatic enzymes, specific diets, vitamin and mineral supplements, animal organs extracts, and coffee enemas. Such departure from good and accepted medical practice was a proximate cause of the claimant’s injuries. If the treatment risks and the alternatives had been appropriately given, a reasonably prudent person in the claimant’s position would not have agreed.

The Bolam4 test can still be applied to TCM/complementary and alternative medicine, in accordance with the standard of care provided by responsible TCM practitioners skilled in that particular field. This is particularly important for the ‘but for’ test to prove causation: “but for the defendant’s negligence, would the claimant suffer injuries?” In a claim, the claimant bears the burden of proof, and the defendant doctor can adduce expert opinions to rebut. In the United Kingdom case Wilsher v Essex,9 a junior doctor mistakenly inserted a catheter into a vein instead of an artery in a preterm baby for oxygen monitoring and excess oxygen was given, which may be a possible cause of blindness but not a definite cause. So, the claim failed in causation. The damage must not be too remote or unforeseeable as in Goodwill,10 where a doctor did not owe a duty of care for contraceptive advice to the person having sexual relationship in future after vasectomy.

Healthcare practitioners can refer to the basic doctrine of bio-medical ethics to avoid medical mishaps.11 Identification of the ‘material risk’ in adopting ‘patient-centred’ care, particularly after the leading judgement of Montgomery12 in the United Kingdom Supreme Court, would enable both WM and TCM practitioners to understand why patients seek alternative treatments in line with the principles of autonomy and also justice and fidelity,13 acting for the best interests for patients. However, patients should understand the limitations that practitioners of TCM and WM might not fully comprehend the practices on other side. They can only advise on the benefits of treatment of their own specialities as well as the potential harmful effects (beneficence and non-malfeasance). It is the authors’ submission that it is not fair, just and reasonable to ask WM doctors to be liable for any harmful effects of treatment under TCM and vice versa.

There is also concern of liability of referring patients from each side. The basic principle is whether the alternative therapeutic options are generally accepted within the medical community and a referral to a medical specialist usually does not attract malpractice liability, so referring doctors ought to know, through reasonable inquiry, the credentials of the practitioner to whom they refer.14 Another concern is vicarious liability if the TCM practitioners are employed by or affiliated with an institution. A key factor is the degree of control that Chief Medical Executives, usually WM doctors, have over TCM practitioners. United Kingdom court cases provide good references. In Barclays Bank, the Supreme Court held that the bank was not vicariously liable by having referred its employees to doctors for pre-employment check if an employee was subsequently sexually harassed by a doctor referred.15 In Christian Brothers, the Supreme Court discussed the test of control that “[m]any employees apply a skill or expertise that is not susceptible to direction by anyone else in the company that employs them. Thus, the significance of control today is that the employer can direct what the employee does, not how he does it.” (para 36).16 Chief Medical Executives can only control that their TCM practitioners comply with law and regulations, but not how those practitioners consult with patients. This is particularly important when a complaint is filed against a Chief Medical Executive regarding the performance of a TCM practitioner.

When patient is under co-care of a TCM practitioner and a WM doctor, there should be clear delineation of the duties and standard of care in those particular circumstances. Regulatory bodies should examine causation under co-care to determine issues of liability. If a WM/TCM practitioner embanks on management under other’s domain, the standard of care required is that of an ordinary skilled person exercising and professing to have the special skill as in Lim7 and Wilsher9 (the House of Lords held that a junior doctor owes the same duty of care and standard of care as a qualified doctor). Structured inter-professional education and research can drive integration with better understanding of the clinical science of each other.17 18 With the integrated Chinese-Western Medicine Programme executed by the Hospital Authority for cancer care, stroke, and low back pain since 2014, an integrated healthcare framework should be shared among the key stakeholders to ensure patient safety for definition of clear professional boundaries and roles.

All authors have contributed to the concept, review and analysis of literature and critical revision of the manuscript for important intellectual content. A Lee is responsible for the first draft. 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.

Content in this presentation is intended solely to provide general discussion concerning medico-legal perspective of Integrated Chinese and Western Medicine. It is not intended as legal or medical advice. Legal or medical advice should be obtained from qualified legal counsel or other professionals to address specific facts and circumstances and to ensure compliance with applicable laws and standards. This paper is written in personal capacity of the authors and the opinions expressed therein do not represent the organisations which they work for or affiliated with.

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

1. Wong W, Lam CL, Bian XZ, Zhang ZJ, Ng ST, Tung S. Morbidity pattern of traditional Chinese medicine primary care in the Hong Kong population. Sci Rep 2017;7:7513. Crossref

2. Leung GK, Wong SW, Ng GK, Hung KN. Concomitant use of Western and Chinese medicine treatments in neurosurgical patients in Hong Kong. Chin J Integr Med 2011 Jul 30. Crossref

3. Caparo Industries plc v Dickman [1990] UKHL 2 (House of Lords).

4. Bolam v Friern Health Management Committee [1957] 1 WLR 582 (Queen’s Bench).

5. Raposo VL. Complementary and alternative medicine, medical liability and the proper standard of care. Complement Ther Clin Pract 2019;35:183-8. Crossref

6. Estate of Shakoor (deceased) v Situ (t/a Eternal Health Co) [2001] 1 WLR 410; All ER 181 (Queen’s Bench).

7. Lim Poh Eng v Public Prosecutor [1999] 1 SLR(R) 428 (High Court).

8. Charell v Gonzalez [1997] 173 Misc.2d 227; 660 N.Y.S. 2d 665 (N.Y. Sup.Ct.1997) (Supreme Court of New York).

9. Wilsher v Essex [1988]. AC 1074 (House of Lords).

10. Goodwill v British Pregnancy Advice Service [1996] 7 Med LR 129 (Court of Appeal).

11. Beauchamp TL, Childress JF. Principles of biomedical ethics. Oxford (Great Britain): Oxford University Press; 1989.

12. Lee A. ‘Bolam’ to ‘Montgomery’ is result of evolutionary change of medical practice towards ‘patient-centered care’. Postgrad Med J 2017;93:46-50. Crossref

13. Tarvydas VM, Cottone RR. The Code of Ethics for Professional Rehabilitation Counselors: what we have and what we need. Rehabil Couns Bull 2000;43:188-96. Crossref

14. Cohen MH. Legal and ethical issues in complimentary medicine: a United States perspective. Med J Aust 2004;181:168-9. Crossref

15. Barclays Bank plc v Various Claimants [2020] UKSC 13 (Supreme Court).

16. The Catholic Child Welfare Society and others v Various Claimants (FC) and The Institute of the Brothers of the Christian Schools and others [2012] UKSC 56 (Supreme Court), UK (“Christian Brothers”).

17. Chiu SW, Sze TO. Revival or innovation? Chinese medicine at the crossroads of professionalization in Hong Kong. SSM–Qualitative Research in Health 2021;1:100004. Crossref

18. Perharic-Walton L, Murray V. Toxicity of Chinese herbal remedies. Lancet 1992;340:674. Crossref