Postgraduate medical education (PGME), a mission of the Hong Kong Academy of Medicine (HKAM), is important for the development of competent caring medical practitioners and for efforts to ensure high-quality patient care.1 As the HKAM celebrates its 30th anniversary, there is a need to examine how it must evolve to accommodate changes in the healthcare landscape, diverse patient needs, the increasing complexity of medical practice, and advances in educational practices.2 Despite the limited evidence available regarding PGME, some principles can guide the necessary evolution. Here, I focus on three themes: (1) PGME is situated learning, (2) PGME should be self-directed, and (3) PGME should be competency-based. Considering the space limitations, I provide a broad framework; readers can acquire additional information from relevant articles included in the References.

Postgraduate training in medicine mainly occurs in the workplace through participation in clinical tasks. This training approach can be regarded as a process of apprenticeship after a doctor in training enters a particular specialty or ‘community of practice’ (CoP; discussed in detail below).3 The principles of this learning process include increasing learner engagement in the daily work of the community, professional identity formation, and development of the ability to communicate using the community’s language and act according to the community’s norms.4 Thus, learning is embedded in everyday activities and is no longer considered ‘necessarily or directly dependent on pedagogical goals or official agenda’.4 This mode of learning is consistent with the anthropological concept of ‘situated learning’.

The notion of ‘situated learning’ emerged from the work of Lave,5 who identified distinct differences between learning in a school setting and learning through everyday activities. In a school setting, education focuses on individual learners; it is dominated by cognitivism (ie, information transmission and processing) and behaviourism (ie, shaping of behaviour via reinforcement and punishment). In this context, knowledge is perceived as an ‘inert, self-sufficient, abstract, self-contained, symbolic substance, which is transferred from the teacher to the learner and becomes stored in the learner’s memory for later use’.6 In contrast, proponents of situated learning theory recognise that learning is the active construction of knowledge through social collaborations and a focus on social relationships and interactions, rather than a focus on individual learners. Thus, they view knowledge as a tool. An individual can possess a tool without being able to use it; use of the tool helps to increase the individual’s understanding of the tool and the relevant context (ie, situation). The specific learning that occurs is a function of three factors in the context where that learning occurs: the people in the context, the ‘tools’ used, and the specific activity itself.6

Three decades after Lave published her seminal work, many researchers in health professions education use situated learning theory to guide curriculum design because they recognise its potential advantages.7 Situated learning places learners in realistic settings where socially acquired knowledge is often valued, strategically utilises the learner’s prior knowledge of a particular subject, and (most importantly) increases the likelihood of knowledge application within similar contexts.7 For example, Lave asked adults to determine which of two products in a grocery store was a ‘best buy’. When participants actually went to a grocery store, talked with people in their group, and physically handled various items to compare sizes and shapes, they correctly answered 98% of the math problems involved in the experiment. In contrast, when participants were provided the same math problems in a paper-and-pencil test format, they correctly answered 59% of the math problems.5

As a form of apprenticeship, PGME requires teaching methods that differ from school-based learning approaches. ‘See one, do one, teach one’ is the method used in traditional apprenticeships.3 However, the learning of complex subjects, such as PGME, involves components that are not readily observable, as well as complex relationships and interactions among teachers and learners. Thus, Brown et al8 developed a complementary approach to the traditional teaching model, known as the Cognitive Apprenticeship Model (CAM). The CAM focuses on four dimensions that are present in any learning environment: content, methods, sequencing, and sociology (Table 1).9

Domain knowledge constitutes the explicit concepts, facts, and procedures associated with an area of expertise; this type of knowledge is usually found in textbooks and lectures. Proponents of situated learning theory and CAM argue that a strong grasp of domain knowledge is necessary but insufficient for experts who seek to solve real-world problems. Such experts must also acquire three types of strategic knowledge: heuristic strategies, control strategies, and learning strategies.9

However, strategic knowledge is often tacit; experts may utilise each type of strategic knowledge without conscious awareness of such use. Therefore, apprenticeship teaching methods are designed to provide learners with opportunities to observe, engage in, and discover the strategic knowledge used by experts, within the relevant context. The six teaching methods in CAM can be categorised into three groups. The first three methods—modelling, coaching, and scaffolding—represent the core of traditional apprenticeships. These methods are intended to help students acquire an integrated set of skills through observation (‘see one’) and guided practice (‘do one’). The next two methods—articulation and reflection—are designed to help students focus their observations and gain conscious control of their own problemsolving strategies. The final method—exploration—aims to encourage learner autonomy in terms of implementing expert problem-solving processes and formulating problems.9 I want to emphasise the links between these teaching methods and Kolb’s Cycle of Experiential Learning. Situated learning constitutes experiential learning via participation in clinical tasks. Kolb10 described experiential learning as a transformative process. When learners perform or ‘do’ a clinical task, they transform abstract knowledge into concrete experience. However, learning is only complete when learners reflect on their concrete experience, then transform that experience back into generalised and abstract knowledge to guide future practice.10 When they are ready, learners can independently apply this enhanced knowledge in practice. Kolb’s Cycle supports the purpose of each group of teaching methods in CAM; it also highlights the value of facilitated reflection and feedback in workplace-based learning, including workplace-based assessment.11

The sequence in which clinical tasks are performed affects learning efficacy. Cognitive Apprenticeship Model offers three principles to guide sequencing. First, tasks should progress from simple to complex, requiring increasing amounts of skill and conceptual knowledge. Next, diversity should gradually increase to allow learners to identify conditions in which they should use various skills and strategies. Finally, activities and tasks should progress from a global perspective to a local perspective; thus, learners should build a conceptual map of an activity before considering its details (ie, specific tasks). The establishment of a clear conceptual model of the overall activity helps learners understand the part they are performing, which improves their ability to engage in progress monitoring and develop self-correction skills.9

Lastly, the social characteristics of learning environments (ie, ‘sociology’) can affect motivation, confidence, and orientation towards problems that individuals encounter as they learn. The first element of sociology, which is a core consideration, is ensuring that learners perform tasks and solve problems in an environment that reflects the real-world nature of such tasks. The second element of sociology is intrinsic motivation. Learning environments should be created in manner that enables learners to perform tasks because the tasks are intrinsically related to their goals of interest, rather than because the tasks are driven by extrinsic motivation (eg, earning a good grade or pleasing the teacher). The third element of sociology is the aforementioned CoP, which comprises a group of people who share a passion for something they do and learn how to do it better during repeated interactions; learning may be an intentional or incidental outcome of those interactions. Communities of practice have three key characteristics: a shared domain of interest; engagement in joint activities, information sharing, and relationship building among members; and the development of a shared repertoire of resources for practice.7 Key components of situated learning are relationships among CoP members and engagement in active communication about skills related to their expertise. Full members of the CoP (ie, specialists) provide guidance to doctors in training; they also learn from each other through these interactions. The final element of sociology is cooperation: learners should work together in a manner that fosters cooperative problem solving. There are many ways in which peer learners can help each other to learn; for example, senior learners can guide junior learners in practice, giving and receiving peer feedback, or solving problems together. Learning via collaboration is a powerful motivator and a powerful mechanism for the expansion of learning resources.9 There is evidence that learners can receive diverse benefits from peer-assisted learning.12 Thus, it is important to empower doctors in training via teaching and feedback, rather than waiting until their specialty training is completed.

I will use the Consolidated Framework for Implementation Research (CFIR) model to guide this portion of the discussion (Fig).13 14 The CFIR, a conceptual model for implementing change or intervention, consists of five domains. The implementation process, one of the domains, should be informed by considerations of the other four domains: characteristics of the ‘intervention’, inner setting, outer settings, and individuals involved in the intervention.13

In this discussion, the intervention is the new model of learning: CAM. Damschroder et al13 identified multiple intervention characteristics that may influence the difficulty encountered during implementation. Model complexity and resource implications, particularly in terms of workforce, could be key challenges. Stakeholder engagement via communication is essential to highlight the potential benefits of this new mode of learning. Testing on a small scale and exploring adaptation to the Hong Kong context would also facilitate implementation.13

The implementation of this new mode of learning must be led by an organisation (eg, a college). Leadership, culture, organisational implementation climate, and relevant experiences may affect the implementation of this paradigm shift14; evaluation and management of these factors are potential challenges. Sharing and collaboration among colleges may be useful strategies.

Postgraduate medical education occurs in the clinical setting where challenges can arise from interactions among trainers, doctors in training, the HKAM and colleges, employers, regulators, and patients and the caregivers. Two key challenges in this outer setting are patient safety and the tension between service and training.3 Patient safety concerns have led to a substantial increase in the use of simulation in medical education, based on the rationale that simulated practice accelerates the learning curve while providing a safe environment for skills rehearsal and opportunities to learn from error.3 Simulation should be integrated into postgraduate specialty curricula as a core delivery vehicle to complement workplace-based learning for both individual skill development and interprofessional team-based training.15 The other key issue is that doctors in training and their trainers are both clinic employees; thus, a managed tension exists between service and training, which requires ongoing dialogue among stakeholders to ensure appropriate balance.3

The individuals involved, especially the trainers and doctors in training, are part of the inner setting but regarded as a separate domain under the CFIR. Although PGME is ‘situated’, it does not necessarily indicate that effective methods are used to facilitate situated learning. Most clinical teachers are not trained; they simply use teaching methods that they experienced in schools.16 Therefore, faculty development (discussed in detail below) is essential. Moreover, there has been some discussion regarding colleges in which not many of their specialists are motivated to teach. However, situated learning depends on interactions among CoP members; learning opportunities can only be maximised through the engagement and empowerment of all members. Accordingly, faculty development should not be restricted to a selected group, and the objective of such development should not be limited to the acquisition of teaching skills; it should be oriented towards motivating participants to establish a professional identity in which they serve as a clinical teacher.17 Doctors in training cannot be passive learners in this process. In addition to active participation in clinical tasks, they must actively seek out opportunities (eg, reading medical literature, attending workshops and conferences, and receiving mentorship and guidance from experienced practitioners) to enhance their knowledge and skills, then use those enhancements to improve their clinical expertise. Furthermore, in contrast to the school setting, situated learning is not organised according to a curriculum, especially because clinical encounters are not always predictable. Accordingly, doctors in training must assume responsibility for their own learning.18 However, there is evidence that self-directed learning (SDL) is uncommon among learners in Hong Kong.19 This is the second theme that I will address.

The notion that doctors in training must assume responsibility for their own situated learning is essential to the concept of SDL. The origin of SDL is closely linked to adult learning theory.18 Knowles20 defined SDL as a process in which individuals take initiative (with or without assistance from others) to determine their learning needs, formulate goals, identify human and material resources for learning, choose and implement appropriate learning strategies, and evaluate learning outcomes.

Self-directed learning also requires a paradigm shift. Traditional teaching (ie, pedagogy) is teacher-directed and focuses on content delivery. A major problem with such an educational process is that learners can become accustomed to habitually reinforced patterns of perception, thinking, judgement, feeling, and behaviour; these patterns may lead to inflexible behaviour and a lack of motivation for SDL.21 The direction of adult learning (ie, andragogy) involves engaging learners in an inquiry process. Based on the six assumptions of adult learning (Table 2), Knowles et al22 described a process which teachers can use to facilitate such inquiry (Table 3). It has been argued that SDL is a universally necessary competency in a changing world, particularly for individuals in complex fields such as medicine.21 Indeed, the Accreditation Council for Graduate Medical Education has recommended that doctors in training become self-directed learners, use innovative tools (eg, computerised diaries and portfolios) to evaluate their own learning, and facilitate learning in other individuals.23

More recently, Hase and Kenyon24 expanded the concept of SDL and proposed the notion of heutagogy (ie, self-determined learning) as a learning paradigm for the information age. Although the concept is complex, it can be summarised as follows: modern technology enables explorations of existing knowledge, connections with experts, collaborations with peers, reflections on personal experiences, and the creation and sharing of knowledge. This technology makes learning flexible, allowing learners to learn at their preferred time and in their preferred manner.22 Accordingly, e-learning utilising this technology should be viewed as an approach to re-define the learning experience, rather than as a simple substitute for more traditional learning methods.25 This learning paradigm is relevant to PGME and lifelong learning.

The definition established by Knowles et al22 implies a process to facilitate SDL. However, there is increasing recognition that, in addition to the process component, the construct of SDL has multiple dimensions.18 22 26 Additionally, Ricotta et al26 suggested that the application of SDL in clinical settings would require approaches that differ from classroom methods because of its more rapid pace and the need to consider patient safety. Here, I will address the three dimensions described in two models of SDL in medical education: process, person, and context.18 26

As mentioned above, trainers must utilise appropriate strategies to facilitate the inquiry process. In addition to the process described by Knowles et al22 (Table 3), Sawatsky et al18 and Ricotta et al26 described learning processes in SDL; although the three groups of authors used different terminology in their descriptions, all processes are conceptually similar. The fundamental requirements of strategies to facilitate SDL should focus on learner engagement, emphasise curiosity, support inquiry-based approaches, and promote exploration.26

Self-directed learning is a question of the extent to which learners maintain active control of the learning process.27 Thus, the use of appropriate facilitation processes is necessary but not sufficient to fulfil the goals of SDL. Learners must thoroughly grasp essential learning skills and develop personal attributes necessary to control the inquiry process. Feedback literacy is a particularly important learning skill because reflection and feedback are indispensable components of experiential learning. Carless28 defined feedback as an interactive process in which students interpret and use various inputs to enhance their work. The utilisation of feedback, combined with engagement in actions that close the feedback loop, is an active process. In his model of feedback literacy, Carless28 established three pre-conditions: appreciation of feedback, formation of judgements, and management of affect. Trainers can help foster feedback literacy through strategies such as peer feedback.

The personal attributes of curiosity, perseverance, flexibility, and integrity are prerequisites for individuals who wish to engage in SDL. Motivation is a key factor which energises and connects these attributes.26 The predispositions of doctors in training towards SDL will gradually change as they develop confidence in SDL and gain a more sophisticated knowledge framework.18 Trainers should assess learner readiness and cultivate SDL through the adoption of teaching strategies appropriate for each stage (Table 4).29

The personal attributes described above must be developed in an effective and safe learning environment. Importantly, these attributes may be threatened by approaches that emphasise professional examinations and competition among doctors in training. The cultivation of SDL requires a paradigm shift from a traditionally competitive learning environment to an environment that encourages humility and accepts failure.26 Trainers should establish psychological safety, encourage curiosity, and normalise cognitive dissonance. At the organisational level, a curiosity-focused culture can facilitate learning activities. The acceptance of uncertainty and promotion of inquiry-based approaches help learners to become motivated and prepared to pursue SDL. The creation of an environment that supports SDL development requires new strategies, prioritisation of learner engagement, and encouragement of questioning.26

Building on the above discussion regarding the learning environment and methods necessary for PGME, I will explore the desired outcomes. Although the concept of outcome-based or competency-based education emerged nearly a century ago, its popularisation in medical education began in the 1990s when leaders in the Canadian medical profession observed widespread dissatisfaction in many areas.30 31 They attributed this dissatisfaction to forces such as the availability of medical information on the internet, patient consumerism, government regulations, financial imperatives, litigation, technology, and an overall explosion of medical knowledge; thus, they concluded that medical education could no longer be planned with a focus solely on the latest aspects of medical diagnosis and treatment.31 Modern professional training should create doctors who can accommodate rapid advances in medicine, recognise patient perspectives, appreciate the skills of other health professionals, and work effectively in teams.32 Therefore, training programmes should address clinical skills and knowledge, along with other aspects of clinical competence required among doctors (eg, communication skills, attitude, team working, audit, research, teaching, and SDL).32 The Royal College of Physicians and Surgeons of Canada included seven competencies under the CanMEDS framework.33 34 Similar developments soon followed in other countries.23 35 36 In 2010, the Hong Kong Academy of Medicine published a position statement indicating that the ‘Hong Kong Specialist’ should demonstrate competency in seven broad domains: professional expertise, health promoter, inter-personal communication, team working, academic, manager-leader, and professionalism.37

A common approach to teaching multiple competencies involves dividing them into individual units, then teaching them separately using methods that are appropriate for each competency. Among educationists, this is known as the ‘atomistic approach’, which is difficult to implement because the curriculum is already very full. Moreover, this approach is ineffective in situations that involve complex learning because the competencies are closely related to each other and the whole is more than the sum of its parts—it contains the elements and the relationships among those elements.38 A holistic approach using real-world tasks avoids potential problems regarding compartmentalisation and fragmentation.38 In the setting of PGME, situated learning and CAM are appropriate methods. Accordingly, the three themes discussed here are closely linked together and can be regarded as a single paradigm for modern PGME.

The implementation process of this new paradigm, one of the five domains of the CFIR (Fig),13 14 consists of four strategies based on implementation research and theories: communication, redesign, faculty development, and research.31

The new paradigm is very different from current practice; it is also complex and involves significant resource investments. Successful implementation heavily relies on effective communication to engage stakeholders in both the inner and outer settings. Frank and Danoff31 suggested the use of a social marketing–based communication plan. The framework of social marketing includes concepts of exchange theory, audience segmentation, competition, consumer orientation, and continuous monitoring.39

The Academy and the colleges are responsible for setting educational standards for PGME objectives, training programme accreditation, assessment, professional examinations, and continuing medical education standards; thus, they should redesign the relevant educational standards to incorporate a foundation that involves all competencies.31 This integrative approach would include efforts to align curricular objectives with experiential training in the clinical workplace.40 The incorporation of workplace-based assessment into the curriculum is an example of such integration.41

Steinert42 defined faculty development as all activities that health professionals pursue to improve their knowledge, skills, and behaviours as teachers and educators, leaders and managers, and researchers and scholars, in both individual and group settings. The engagement and empowerment of all CoP members in teaching and learning are prerequisites for implementing community-based medical education via situated learning. Steinert et al17 recommended that the process of faculty development mirror the process of PGME itself: it should utilise SDL and view learning as a process of inquiry through experiential learning, rather than as a process of direct transmission. It should also utilise situated learning theory and view teaching skills as tools to be used in specific contexts, rather than objects that can be acquired. Thus, although workshops may be a useful starting point, there is a need to focus on longitudinal development via faculty development communities.17 As mentioned above, the objective of faculty development should not be limited to teaching skill acquisition; it should include the establishment of a professional identity as a clinical educator, as well as motivation for teaching.17 Similarly, faculty development should promote a culture of change and further development of PGME through innovation, research, and organisational transformation.17 42

Finally, the field of PGME is comparatively new and does not have a strong academic presence. Most of its practical approaches are derived from undergraduate medical education or general education. However, there are some concerns, learning methods, and practices with uniquely ‘postgraduate’ origins.3 Considerable research efforts are necessary to provide evidence that can drive further improvements in PGME, and resources are needed to support such efforts.3 31

Health professionals are expected to possess a diverse set of competencies that fulfil current societal needs. Apprenticeships using real-world clinical tasks can provide effective competency-based medical education. However, the traditional ‘see one, do one, teach one’ approach is inadequate for the complex learning tasks involved in PGME. Instead, learning in this environment involves the facilitation of experiential learning and inquiry, rather than simple content delivery. To achieve this shift in perspective, teaching methods from CAM and SDL must be adopted. The cultivation of SDL requires appropriate context, as well as a CoP with members who possess teaching skills and attitudes that differ from traditional teaching. Faculty development is important for the successful implementation of this new paradigm; it should be grounded in the same principles of experiential learning, situated learning, and SDL. This approach will equip members of the CoP with essential skills, while supporting effective communication and engagement. Moreover, it will cultivate the talent necessary to redesign standards and practices, while encouraging interest and active participation in research efforts to advance PGME.

The author was solely responsible for drafting of the manuscript, approved the final version for publication, and takes responsibility for its accuracy and integrity.

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

The author has disclosed no conflicts of interest.

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Primary care physicians worldwide provide a key point of entry to the healthcare system, and are at the forefront of communicating with the community in the context of vaccination campaign and control of infectious diseases.1 2 Primary care plays a fundamental role in building a resilient healthcare system by ensuring people’s continued access to health promotion, disease prevention, essential treatment, long-term rehabilitation, and supportive care.3 Topics relevant to primary healthcare are an increasingly common sight in international medical journals, including Hong Kong Medical Journal (HKMJ).

COVID-19 (coronavirus disease 2019) has presented an unprecedented dual challenge for primary healthcare in recent years, to respond to the public health threat and simultaneously maintain routine delivery of clinical care and preventive services. A health system’s ability to address the ever-growing care complexity is substantially dependent on the accessibility and coordination of primary healthcare. In Singapore, Public Health Preparedness Clinics, an island-wide network of over 900 primary care clinics and polyclinics, served an epidemiological role through the routine collection of data on community transmission by primary care physicians.4 This approach has added to our understanding of how primary healthcare could contribute to enhancing and tightening disease surveillance. In Europe, primary care physicians coordinate care through active participation in knowledge transfer, integration into crisis management teams, and involvement in strategic responses to the pandemic, which is particularly important for fulfilling shared goals to achieve a high level of resilience.5 Other low- and middle-income settings in Asia have also provided examples of how primary care providers are in a privileged position to utilise a variety of resilience mechanisms including mentor support, peer communication, family encouragement, and community recognition.6

In rural China, there are significant disparities in primary care utilisation among different ethnic minority healthcare providers, together with an association between inadequate clinical competency and poor primary care utilisation. Shi et al,7 writing in HKMJ’s ‘Healthcare in Mainland China’, found that in-service training investments and favourable learning environments are required to develop the capacity and capability required for ethnic minority health practitioners. Meanwhile, concerns have been raised over the difficulties in retaining qualified healthcare professionals in deprived rural communities.8 Furthermore, given the possible widening of inequalities in socio-economic determinants of health, people living in more disadvantaged rural areas are more likely to face poor accessibility of healthcare services and suboptimal physician capacity than that in more affluent urbanised areas as a result of the ‘inverse care law’.9 Previous findings suggested that a lack of physician’s continuing medical education may serve as a notable barrier to satisfactory primary care performance in rural areas.10 These challenges highlight the increasing need for system-wide multisectoral collaboration and partnerships with novel tools to enhance physicians’ engagement in context-specific training and care empowerment.11 Alongside efforts to reconfigure primary care teams to address patients’ barriers to following evidence-based regime and advice,12 improved communication skills are crucial not only in clinical practice but also in public health.13 This will underpin a wider landscape of primary healthcare that incorporates population-wide evidence-based approaches to reducing health inequalities in the context of socio-economic diversity.

From a process of care perspective, there is a greater need for strategies to engage multisectoral efforts to strengthen capacity building within, with and around primary care multidisciplinary teams in joint decision-making and problem-solving.14 Practice-level strategies have been identified in a most recent review of international literature which summarised new approaches to ensure the continuity of regular care provision during the pandemic.15 A novel strategy has been characterised by the integration of digital health (or eHealth) services into practice. These services, which can be delivered via telephone, video consultations, email, text messaging, online portals, or smartphone applications, provide an opportunity to expand seamless access to health services for people in remote areas, and also allow rapid exchange of health information. This enables primary care multidisciplinary teams to respond precisely to specific situations of individuals. With the escalating popularity of wearable devices, digital eHealth platforms, and remote patient monitoring tools, decision support solutions driven by artificial intelligence are beginning to appear in daily primary care, and this will be an exciting growth area in the near future.

Managing care for patients with chronic diseases remains a major challenge in primary healthcare although massive efforts and resources directed to COVID-19 tended to have overshadowed the pandemics of noncommunicable diseases. Low et al16 adopted a constructivist grounded theory design to examine the decision-making experiences of family carers of older people with dementia towards the use of community care services and residential care services regarding a variety of healthcare and illness decisions, including hospitalisation, seeing family doctor, and deteriorating health issues. A deep understanding of patients’ and their caregivers’ decisions about health seeking, daily living, and lifestyle choices will be of critical importance to strengthen the role of primary care practitioners as the gatekeeper to care.

Community outreach is another essential element of primary healthcare that goes beyond clinical care, and the HKMJ’s ‘Healthcare for Society’ section regularly highlights the exemplary work of local doctors and healthcare workers. For example, Dr Ching-choi Lam has made substantial contributions to vulnerable populations across the age spectrum.17 In particular, the Elderly Services Programme Plan provides strengthened community care support for the elderly people to enhance their confidence in living at home and in considering community care as a desirable alternative to residential aged care. This represents a significant paradigm shift in our understanding of how primary healthcare could contribute to tackling the long-term care needs that often arise from multimorbidity, frailty, disability, and dependence to achieve ‘Ageing in Place’. Another example is Dr Yu-cheung Ho, who is dedicated to providing a variety of health-related campaigns and humanitarian work that target poverty and healthcare together.18 The dedication to improve equity in medical services and health outcomes is in line with the ultimate goals of primary healthcare, and support from local healthcare workforce engaging in charitable contributions could further help orient the service delivery to local healthcare needs and priorities.

Primary healthcare will continue to be of paramount value for meeting the healthcare needs of individuals, families, and communities within a larger society. In Hong Kong, with the establishment of the Primary Healthcare Commission and the launch of the Primary Healthcare Blueprint, we are looking forward to concerted efforts among key stakeholders in primary care to create a healthier tomorrow.19

All authors contributed to the editorial, approved the final version for publication, and take responsibility for its accuracy and integrity.

The authors have declared no conflict of interest.

1. Poon PK, Wong SY. Primary care doctors and the control of COVID-19. Hong Kong Med J 2021;27:86-7. Crossref

2. Chau CY. COVID-19 vaccination hesitancy and challenges to mass vaccination. Hong Kong Med J 2021;27:377-9. Crossref

3. World Health Organization. Regional Office for the Western Pacific. Role of primary care in the COVID-19 response. Available from: https://apps.who.int/iris/handle/10665/331921. Accessed 22 Dec 2022.

4. Liow Y, Loh VW, Goh LH, et al. COVID-19 primary care response and challenges in Singapore: a tale of two curves. Hong Kong Med J 2021;27:70-2. Crossref

5. Stengel S, Roth C, Breckner A, et al. Resilience of the primary health care system - German primary care practitioners’ perspectives during the early COVID-19 pandemic. BMC Prim Care 2022;23:203. Crossref

6. Golechha M, Bohra T, Patel M, Khetrapal S. Healthcare worker resilience during the COVID-19 pandemic: a qualitative study of primary care providers in India. World Med Health Policy 2022;14:6-18. Crossref

7. Shi Y, Song S, Peng L, et al. Utilisation of village clinics in Southwest China: evidence from Yunnan Province. Hong Kong Med J 2022;28:306-14. Crossref

8. Yang L, Wang H. Who will protect the health of rural residents in China if village doctors run out? Aust J Prim Health 2019;25:99-103. Crossref

9. Mercer SW, Patterson J, Robson JP, Smith SM, Walton E, Watt G. The inverse care law and the potential of primary care in deprived areas. Lancet 2021;397:775-6. Crossref

10. Dowling S, Last J, Finnigan H, Cullen W. Continuing education for general practitioners working in rural practice: a review of the literature. Educ Prim Care 2018;29:151-65. Crossref

11. Campos-Zamora M, Gilbert H, Esparza-Perez RI, et al. Continuing professional development challenges in a rural setting: a mixed-methods study. Perspect Med Educ 2022;11:273-80. Crossref

12. Wang HH, Mercer SW. Understanding barriers to adherence to optimal treatment of elevated blood pressure and hypertension-insights from primary care. JAMA Netw Open 2021;4:e2138651. Crossref

13. Wang HH, Li YT, Wong MC. Leveraging the power of health communication: messaging matters not only in clinical practice but also in public health. Hong Kong Med J 2022;28:103-5. Crossref

14. Wang HH, Li YT, Wong MC. Strengthening attributes of primary care to improve patients’ experiences and population health: from rural village clinics to urban health centres. Hong Kong Med J 2022;28:282-4. Crossref

15. Matenge S, Sturgiss E, Desborough J, Hall Dykgraaf S, Dut G, Kidd M. Ensuring the continuation of routine primary care during the COVID-19 pandemic: a review of the international literature. Fam Pract 2022;39:747-61.Crossref

16. Low LP, Lee DT, Lam LW. Decision-making experiences of family carers of older people with moderate dementia towards community and residential care home services: a grounded theory inquiry (abridged secondary publication). Hong Kong Med J 2022;28(Suppl 3):S24-7.

17. Tsui M, Cheuk N. Community health advocate from paediatrics to elderly healthcare: an interview with Dr Ching-choi Lam. Hong Kong Med J 2021;27:386-8. Crossref

18. Chan W, Lo A, Wong K. Services make our community a better place to live: an interview with Dr Yu-cheung Ho. Hong Kong Med J 2022;28:415-6. Crossref

19. Pang FC, Lai SS. Establishment of the Primary Healthcare Commission. Hong Kong Med J 2023;29:Epub 6 Jan 2023. Crossref

The primary goals of a health system are generally regarded as the advancement, restoration, and maintenance of health through efforts to ensure coordinated, sustainable delivery of effective, safe, and people-centred healthcare that involves promotion, prevention, treatment, rehabilitation, and palliation.1 High-quality services delivered by motivated healthcare providers are essential for the achievement of effective universal health coverage in countries at all income levels. However, factors that contribute to the quality of healthcare services are multivariate, complex, and interrelated; they cover a wide spectrum of patient-, provider-, organisation-, and system-level enablers and barriers. A previous systematic review demonstrated the negative consequences of physician unwellness on healthcare system outcomes, including but not limited to worse recruitment and retention, reduced productivity and efficiency, suboptimal patient care quality, higher rates of patient nonadherence and dissatisfaction, and increased risk of medical errors.2

In this issue of the Hong Kong Medical Journal, Gao et al3 used standardised patients and questionnaire interviews to examine the extent to which healthcare quality could be attributed to work motivation among village clinicians in 21 rural counties across three provinces in China. The research demonstrated a positive relationship between village clinicians’ internal work motivation and their clinical performance; this association was stronger with incentives and lighter workload (eg, number of patients per month).3 The study adds to a body of previous work published in our section ‘Healthcare in Mainland China’4 by identifying factors associated with healthcare quality in remote and rural areas in China. It also highlights the contribution of physician work motivation to the delivery of high-quality care.

Physicians have a responsibility to meet the needs of people throughout the healthcare system; they also have a responsibility to make evidence-based, sound clinical decisions. Physicians also make substantial contributions to the advancement of medical knowledge and practical skills by conducting well-designed scientific research. For example, research studies focused on coronavirus disease 2019 (COVID-19) are increasingly led by frontline physicians who seek to gain insights regarding disease transmission, risk factors, screening, clinical diagnosis, immune responses, treatment and pharmaceutical prophylaxis, and vaccines.5 The various high-value functions performed by physicians inevitably require continuous dedication, commitment, and passion. Therefore, work motivation and career satisfaction among physicians have received increasing attention over the years, considering their close relationships with healthcare quality.6 There is increasing empirical evidence regarding the multidimensional factors, context, and processes that may influence a physician’s motivation for work; these aspects exert complex effects on the risks of burnout, turnover intention, and job satisfaction.7

Rapid progress in strengthening health systems and service capacity has led to increased clinical responsibilities and job demands on physicians because of increased patient volume, expanded key performance metric indicator targets, and decreased autonomy. Additionally, physician workloads can substantially increase during public health emergencies. For example, the COVID-19 pandemic has presented new challenges that require novel solutions with respect to infection prevention, early recognition, rapid identification, disease control, rehabilitation, and resilience.8 9 10 11 12 These changes have been addressed by research conducted in Hong Kong. A recent territory-wide cross-sectional survey revealed a high prevalence of burnout among physicians who had completed specialist registration within the past 10 years and among residents-in-training, as well as a high level of depression among junior physicians who reported substantial dissatisfaction with their current job positions.13 A review of international literature highlighted the prevalences of sleep deprivation and circadian disorders related to prolonged working hours; these problems affect physician health, leaving physicians vulnerable to significant work-life imbalance, psychological stress, and burnout.14

In remote and rural areas where limited healthcare resource availability remains a recurring key challenge, the achievement of desired health outcomes is dependent on whether physicians can deliver a broad spectrum of person- and family-centred care in the community. Rural physicians play an important role in the delivery of community-based disease prevention and health promotion in response to community healthcare needs. Observational evidence from China suggests that rural physicians with higher workloads tend to deliver less frequent follow-up care; this phenomenon may be explained by reduced initiative and motivation related to the perception of an increased daily clinical workload, particularly among physicians who have not yet achieved clinical proficiency in managing complex encounters.15 The results of a nationally representative survey of physicians in the United States also led to speculation regarding the associations of intrinsic motivation factors with physicians’ career enjoyment, life satisfaction, and clinical commitment.16

Physician attitudes and behaviours with respect to following clinical guideline recommendations are presumed to strongly influence healthcare outcomes. The inability or failure of physicians to initiate or intensify therapy when indicated, despite clear recognition of the problem (ie, ‘clinical inertia’), represents a common and major barrier to efficiency and effectiveness in disease management.17 18 A recent observational study indicated that efforts solely focused on increasing the proportion of tertiary educational attainment among Chinese rural physicians may not directly translate into strong motivation and active commitment to the provision of clinical services, considering the potential for concurrent clinical inertia and workload-related factors.15 Thus, there may be a need for a systematic approach that incorporates the use of facilitators (eg, computerised decision support systems and standardised clinical management protocols), provision of carefully and appropriately designed incentives, and implementation of CME/CPD (continuing medical education/continuous professional development) programmes throughout each physician’s career,18 in addition to the initial medical training.

There remains a vast array of factors to consider when attempting to improve healthcare sustainability and enhance physician satisfaction over time. For instance, practice structure and ownership; relationships with colleagues within and outside the practice; and the content, quantity, and speed of work have been identified as factors that influence physician career satisfaction.19 Some conceptual frameworks may provide useful perspectives, such as the Knowledge-Attitude-Behaviour-Result model, Awareness-Agreement-Adoption-Adherence model, Physician Guideline Compliance model, and Regulatory Focus Theory.18 These frameworks may help to guide interventions that overcome barriers to physician motivation and satisfaction. Multiple randomised clinical trials have been conducted to explore innovative approaches that promote physician well-being. A study at the Mayo Clinic in the United States demonstrated that self-facilitated physician small-group meetings involving reflection, shared experience, and small-group learning produced significant improvements in burnout, depressive symptoms, and job satisfaction.20 As noted in a previous systematic review, physicians with higher levels of career satisfaction are more likely to dedicate their full attention to patients’ healthcare needs and provide better patient care.6

The current findings emphasise the importance of promoting physical, emotional, and spiritual well-being among physicians to ensure empathy and compassion in patient care, while minimising and preventing medical errors and malpractice. Further research concerning the extent to which relationships of physician motivation and satisfaction with healthcare quality vary across levels of healthcare and among medical specialists will be of interest to the readers of the Hong Kong Medical Journal. We also look forward to receiving additional evidence from pragmatic implementation studies that can provide insights regarding optimal strategies for improving physician motivation and satisfaction, particularly in the post–COVID-19 era.

The authors contributed to the editorial, approved the final version for publication, and take responsibility for its accuracy and integrity.

The authors have declared no conflict of interest.

1. World Health Organization. Quality health services: a planning guide. Geneva: World Health Organization; 2020.

2. Wallace JE, Lemaire JB, Ghali WA. Physician wellness: a missing quality indicator. Lancet 2009;374:1714-21. Crossref

3. Gao Q, Peng L, Song S, Zhang Y, Shi Y. Assessment of healthcare quality among village clinicians in rural China: the role of internal work motivation. Hong Kong Med J 2023;29:57-65. Crossref

4. Nie J, Shi Y, Xue H. Why is a special section “Healthcare in Mainland China” so crucial for HKMJ? Hong Kong Med J 2022;28:6. Crossref

5. Wang HH, Chen L, Ding H, Huang J, Wong MC. Scientific research on COVID-19 conducted in Hong Kong in 2020. Hong Kong Med J 2021;27:244-6. Crossref

6. Scheepers RA, Boerebach BC, Arah OA, Heineman MJ, Lombarts KM. A systematic review of the impact of physicians’ occupational well-being on the quality of patient care. Int J Behav Med 2015;22:683-98. Crossref

7. Perreira TA, Innis J, Berta W. Work motivation in health care: a scoping literature review. Int J Evid Based Healthc 2016;14:175-82. Crossref

8. Collins RA, Wei TN, Tang AM, Fan AO, Fung AY. Implementing evidence-based research in the era of COVID-19 and other global health challenges. Hong Kong Med J 2022;28(Suppl 3):S3-7.

9. Lai CK, Lam W, Tsang KY, Cheng FW, Wong MC. COVID-19 pandemic after Omicron. Hong Kong Med J 2022;28:196-8. Crossref

10. Yan BP, Wong MC. Cardiovascular complications of COVID-19: a future public health burden requiring intensive attention and research. Hong Kong Med J 2022;28:199-200. Crossref

11. Huang J, Wang HH, Zheng ZJ, Wong MC. Impact of the COVID-19 pandemic on cancer care. Hong Kong Med J 2022;28:427-9. Crossref

12. Wong MC, Huang J, Wang HH, et al. Resilience level and its association with maladaptive coping behaviours in the COVID-19 pandemic: a global survey of the general populations. Global Health 2023;19:1. Crossref

13. Kwan KY, Chan LW, Cheng PW, Leung GK, Lau CS. Burnout and well-being in young doctors in Hong Kong: a territory-wide cross-sectional survey. Hong Kong Med J 2021;27:330-7. Crossref

14. Stewart NH, Arora VM. The impact of sleep and circadian disorders on physician burnout. Chest 2019;156:1022-30. Crossref

15. Wang Y, Hu XJ, Wang HH, et al. Follow-up care delivery in community-based hypertension and type 2 diabetes management: a multi-centre, survey study among rural primary care physicians in China. BMC Fam Pract 2021;22:224. Crossref

16. Tak HJ, Curlin FA, Yoon JD. Association of intrinsic motivating factors and markers of physician well-being: a national physician survey. J Gen Intern Med 2017;32:739-46. Crossref

17. Phillips LS, Twombly JG. It’s time to overcome clinical inertia. Ann Intern Med. 2008;148:783-5. Crossref

18. Reach G. Clinical Inertia: A Critique of Medical Reason. Paris: Springer-Verlag France; 2015. Crossref

19. Friedberg MW, Chen PG, Van Busum KR, et al. Factors affecting physician professional satisfaction and their implications for patient care, health systems, and health policy. Rand Health Q 2014;3:1. Crossref

20. West CP, Dyrbye LN, Satele DV, Shanafelt TD. Colleagues meeting to promote and sustain satisfaction (COMPASS) groups for physician well-being: a randomized clinical trial. Mayo Clin Proc 2021;96:2606-14. Crossref

Invasive pneumococcal disease (IPD), a major public health problem worldwide (including in Hong Kong),1 2 3 is a severe and potentially life-threatening infectious disease caused by the gram-positive bacterium, Streptococcus pneumoniae.1 2 The clinical manifestations of acute IPD vary among organ systems involved; they include severe and potentially fatal infections such as community-acquired pneumonia, meningitis, and sepsis.2 In Hong Kong, pneumonia has consistently been the second leading cause of death since 20124; it is associated with higher rates of hospitalisation and higher healthcare costs, particularly among older adults.5 6 Despite appropriate treatment, up to 50% of IPD survivors experience long-term complications, including respiratory, cardiovascular, and neurological sequelae.7 Invasive pneumococcal disease is associated with substantial healthcare and economic burdens; thus, it represents an acute public health problem in Hong Kong, particularly amid the coronavirus disease 2019 (COVID-19) pandemic. There is an urgent need to develop effective strategies that can mitigate the potential threat of an IPD outbreak.

Invasive pneumococcal disease has been a statutorily notifiable disease in Hong Kong since January 2015.8 Between 2015 and 2019, the Centre for Health Protection recorded a median of 187 (range: 162-190) IPD cases per year; the emergence of COVID-19 in 2020 led to a dramatic decrease in the number of IPD cases in Hong Kong (Fig 1).3 However, the current IPD burden is severely underestimated because of underdiagnosis, and a high index of suspicion for IPD is a central aspect of differential diagnosis. Because the clinical symptoms of IPD overlap with the symptoms of other respiratory illnesses, inexperienced physicians may experience challenges regarding specimen collection (ie, samples may be inappropriately or inadequately collected); such challenges contribute to the underutilisation of diagnostic tests and underreporting of IPD.

Because S pneumoniae is transmitted by direct contact with respiratory secretions from patients with IPD and from healthy carriers,2 9 public health measures (eg, mask wearing, social distancing, travel restrictions, and quarantine) that were implemented to prevent the transmission of severe acute respiratory syndrome coronavirus 2 also reduced the spread of S pneumoniae; thus, the number of IPD cases has decreased since the beginning of 2020 (Fig 1).3 As Hong Kong emerges from the COVID-19 pandemic, the gradual relaxation of public health intervention measures is expected to result in an increased number of IPD cases. Moreover, seasonality could contribute to a sudden increase in IPD cases because respiratory diseases (eg, pneumococcal infection and influenza) are generally more prevalent during winter and early spring.10 11 Notably, Israel experienced a nationwide outbreak of S pneumoniae serotype 2 between 2015 and 2019, despite the availability of vaccination programmes.12 Such outbreaks highlight the need to formulate effective strategies for early disease prevention.

Two types of pneumococcal vaccines are available to prevent IPD: pneumococcal polysaccharide vaccines (PPSVs) and pneumococcal conjugate vaccines (PCVs). The 23-valent PPSV (PPSV23) contains purified capsular polysaccharide antigens from 23 distinct S pneumoniae serotypes, whereas PCVs—including PCV13, PCV15, and PCV20—contain purified capsular polysaccharide antigens from 13, 15 or 20 serotypes of S pneumoniae conjugated to a nontoxic variant of diphtheria toxin (CRM197), along with aluminium phosphate as an adjuvant.13 14 In contrast to PPSVs, the conjugated complexes contained in PCVs exert long-term protection because they are able to stimulate T-cell-dependent immune response to generate immune memory for the specific S pneumoniae serotypes covered by the vaccine.15 Importantly, clinical trials and real-world evidence have consistently demonstrated the effectiveness of PCV13 in providing serotype-specific protection against IPD.2 13 16 Although IPD can occur at any age, an increased risk of onset is associated with various factors; mortality is substantially higher in children <2 years and adults aged ≥65 years.10 13 In Hong Kong, the current recommendations for pneumococcal vaccination by the Centre for Health Protection prioritise adults aged ≥65 years with high-risk conditions,17 consistent with recommendations from the United States Advisory Committee on Immunization Practices.18 Specifically, pneumococcal vaccine-naïve individuals with high-risk conditions are recommended to receive one dose of PCV13, followed by one dose of PPSV23 at 1 year after PCV13 vaccination.17

Since 2017, the Hong Kong government has provided free or subsidised pneumococcal vaccination to eligible individuals through the Government Vaccination Programme (GVP) and the Vaccination Subsidy Scheme (VSS).19 Despite this governmental support, rates of vaccine uptake and participation in GVP and VSS remain low.19 Concerns regarding vaccine efficacy, poor understanding of the disease, and lack of clarity regarding vaccine schedules are some of the major challenges that limit pneumococcal vaccination among adults in Hong Kong.19 Another limiting factor is vaccine hesitancy related to perceived vaccination burden and fatigue.20

Data from continuous surveillance of pneumococcal serotypes have facilitated analyses of serotypes isolated from the community, which have yielded insights regarding the effectiveness and limitations of pneumococcal vaccination programmes. Since the implementation of pneumococcal vaccination in Hong Kong, the incidence of IPD involving vaccine-covered serotypes has considerably decreased. However, because of low vaccination rates in recent years, PCV13-covered serotypes (including serotypes 3, 19F, and 19A) have been identified in half of all reported IPD cases (Fig 2).3 21 22 23 Importantly, although it is covered by PCV13 and PPSV23, serotype 3 remains a major cause of IPD because its unique polysaccharide capsule resists detection by vaccine-induced antibodies.24 Moreover, the emergence of non-vaccine serotypes (Fig 2; ie, serotype replacement) also poses a public health threat.23 25

Considering the current challenges in Hong Kong, a higher-valency PCV (eg, PCV20) could partly address the potential public health problem associated with serotypes that are not covered by the Hong Kong vaccination programme. The 20-valent PCV provides broader protection against IPD; a single dose contains seven new serotypes, in addition to the serotypes covered by PCV13.26 Phase 3 studies of clinical efficacy have demonstrated that PCV20 is noninferior to PCV13 and PPSV23 across a subset of age-groups, regardless of pneumococcal vaccination history and high-risk conditions.27 28 Importantly, PCV20 can be concurrently administered with influenza and COVID-19 vaccines.26

In October 2021, the Advisory Committee on Immunization Practices recommended one dose of PCV20 alone, or serial immunisation (PCV15, followed by PPSV23), for all PCV/PPSV-naïve adults aged ≥65 years and PCV/PPSV-naïve adults aged 19-64 years with high-risk conditions.26 The implementation of a PCV20 single-shot vaccination programme could be a cost-effective strategy to address the current burden of IPD cases that involve serotypes covered by PCV13 and serotypes unique to PCV20.29 Furthermore, the convenience of a simplified vaccination schedule could improve vaccine uptake.

The government and physicians play key roles in promoting pneumococcal vaccination and improving vaccine uptake, particularly among older adults. Because the perceived low burden of IPD may reduce the rate at which physicians recommend vaccination for their patients,30 there is a need to improve physician awareness regarding IPD and the benefits of pneumococcal vaccines for individuals with an increased risk of IPD.

Continuing medical education programmes for physicians could cover periodic updates regarding the IPD burden in Hong Kong, current pneumococcal vaccine schedules, proper sample collection methods, and appropriate diagnostic tests for confirmation of IPD in patients with relevant symptoms. These initiatives can improve early diagnosis and treatment of IPD, facilitate accurate data collection regarding IPD incidence, and help to manage the underestimated burden of IPD. Additionally, government-led public education campaigns that focus on bridging knowledge gaps with respect to (i) the public health impact of IPD (a vaccine-preventable disease), and (ii) vaccine accessibility through GVP and VSS, could help to overcome vaccine hesitancy and improve vaccine uptake in Hong Kong.

All authors declare no conflict of interest.

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.

Funding for this study was provided by Pfizer Hong Kong. Editorial and medical writing support was provided by Dr Analyn Lizaso from Weber Shandwick Hong Kong, funded by Pfizer Hong Kong.

1. Wahl B, O’Brien KL, Greenbaum A, et al. Burden of Streptococcus pneumoniae and Haemophilus influenzae type b disease in children in the era of conjugate vaccines: global, regional, and national estimates for 2000-15. Lancet Glob Health 2018;6:e744-e757. Crossref

2. Weiser JN, Ferreira DM, Paton JC. Streptococcus pneumoniae: transmission, colonization and invasion. Nat Rev Microbiol 2018;16:355-67. Crossref

3. Centre for Health Protection, Department of Health, Hong Kong SAR Government. Report on IPD. Available from: https://www.chp.gov.hk/en/resources/29/636.html. Accessed 6 Aug 2022.

4. Centre for Health Protection. Death rates by leading causes of death, 2001-2021. Available from: https://www.chp.gov.hk/en/statistics/data/10/27/117.html. Accessed 12 Nov 2022.

5. Li X, Blais JE, Wong IC, et al. Population-based estimates of the burden of pneumonia hospitalizations in Hong Kong, 2011-2015. Eur J Clin Microbiol Infect Dis 2019;38:553-61. Crossref

6. Man MY, Shum HP, Yu JS, Wu A, Yan WW. Burden of pneumococcal disease: 8-year retrospective analysis from a single centre in Hong Kong. Hong Kong Med J 2020;26:372-81. Crossref

7. Brooks LR, Mias GI. Streptococcus pneumoniae’s virulence and host immunity: aging, diagnostics, and prevention. Front Immunol 2018;9:1366. Crossref

8. Hong Kong e-Legislation. Cap. 599 Prevention and Control of Disease Ordinance. Available from: https://www.elegislation.gov.hk/hk/cap599" target="_blank. Accessed Sep 2022.

9. Chan KP, Ma TF, Ip MS, Ho PL. Invasive pneumococcal disease, pneumococcal pneumonia and all-cause pneumonia in Hong Kong during the COVID-19 pandemic compared with the preceding 5 years: a retrospective observational study. BMJ Open 2021;11:e055575. Crossref

10. Centers for Disease Control and Prevention. Epidemiology and Prevention of Vaccine-Preventable Diseases. 14th edition. 2021. Available from: https://www.merle-arbeitsmedizin.de/wp-content/uploads/2022/02/CDC-Pink-Book-Version-14th-Edition.pdf. Accessed Nov 2022.

11. McCullers JA. Insights into the interaction between influenza virus and pneumococcus. Clin Microbiol ev 2006;19:571-82. Crossref

12. Dagan R, Ben-Shimol S, Benisty R, et al. A nationwide outbreak of invasive pneumococcal disease in Israel caused by Streptococcus pneumoniae serotype 2. Clin Infect Dis 2021;73:e3768-77. Crossref

13. Bridy-Pappas AE, Margolis MB, Center KJ, Isaacman DJ. Streptococcus pneumoniae: description of the pathogen, disease epidemiology, treatment, and prevention. Pharmacotherapy 2005;25:1193-212. Crossref

14. Centers for Disease Control and Prevention. About pneumococcal vaccines. Available from: https://www.cdc.gov/vaccines/vpd/pneumo/hcp/about-vaccine.html. Accessed 12 Nov 2022.

15. Berger A. Science commentary: why conjugate vaccines protect longer. BMJ 1998;316:1571. Crossref

16. Theilacker C, Fletcher MA, Jodar L, Gessner BD. PCV13 vaccination of adults against pneumococcal disease: what we have learned from the Community-Acquired Pneumonia Immunization Trial in Adults (CAPiTA). Microorganisms 2022;10:127. Crossref

17. Centre for Health Protection Scientific Committee on Vaccine Preventable Diseases. Updated recommendations on the use of pneumococcal vaccines for high-risk individuals. Available from: https://www.chp.gov.hk/files/pdf/updated_recommendations_on_the_use_of_pneumococcal_vaccines_for_high-risk_individuals.pdf. Accessed 6 Oct 2022.

18. Morga A, Kimura T, Feng Q, Rozario N, Schwartz J. Compliance to Advisory Committee on Immunization Practices recommendations for pneumococcal vaccination. Vaccine 2022;40:2274-81. Crossref

19. Huang J, Mak FY, Wong YY, et al. Enabling factors, barriers, and perceptions of pneumococcal vaccination strategy implementation: a qualitative study. Vaccines (Basel) 2022;10:1164. Crossref

20. Su Z, Cheshmehzangi A, McDonnell D, da Veiga CP, Xiang YT. Mind the “Vaccine Fatigue”. Front Immunol 2022;13:839433. Crossref

21. Ho PL, Law PY, Chiu SS. Increase in incidence of invasive pneumococcal disease caused by serotype 3 in children eight years after the introduction of the pneumococcal conjugate vaccine in Hong Kong. Hum Vaccin Immunother 2019;15:455-8. Crossref

22. Subramanian R, Liyanapathirana V, Barua N, et al. Persistence of pneumococcal serotype 3 in adult pneumococcal disease in Hong Kong. Vaccines (Basel) 2021;9:756. Crossref

23. Hon KL, Chan KH, Ko PL, et al. Change in pneumococcus serotypes but not mortality or morbidity in pre- and post-13-valent polysaccharide conjugate vaccine era: epidemiology in a pediatric intensive care unit over 10 years. J Trop Pediatr 2018;64:403-8. Crossref

24. Luck JN, Tettelin H, Orihuela CJ. Sugar-coated killer: serotype 3 pneumococcal disease. Front Cell Infect Microbiol 2020;10:613287. Crossref

25. Lo SW, Gladstone RA, van Tonder AJ, et al. Pneumococcal lineages associated with serotype replacement and antibiotic resistance in childhood invasive pneumococcal disease in the post-PCV13 era: an international wholegenome sequencing study. Lancet Infect Dis 2019;19:759-69. Crossref

26. Kobayashi M, Farrar JL, Gierke R, et al. Use of 15-valent pneumococcal conjugate vaccine and 20-valent pneumococcal conjugate vaccine among U.S. adults: updated recommendations of the Advisory Committee on Immunization Practices—United States, 2022. MMWR Morb Mortal Wkly Rep 2022;71:109-17. Crossref

27. Essink B, Sabharwal C, Cannon K, et al. Pivotal phase 3 randomized clinical trial of the safety, tolerability, and immunogenicity of 20-valent pneumococcal conjugate vaccine in adults aged ≥18 years. Clin Infect Dis 2022;75:390-8. Crossref

28. Cannon K, Elder C, Young M, et al. A trial to evaluate the safety and immunogenicity of a 20-valent pneumococcal conjugate vaccine in populations of adults ≥65 years of age with different prior pneumococcal vaccination. Vaccine 2021;39:7494-502. Crossref

29. Mendes D, Averin A, Atwood M, et al. Cost-effectiveness of using a 20-valent pneumococcal conjugate vaccine to directly protect adults in England at elevated risk of pneumococcal disease. Expert Rev Pharmacoecon Outcomes Res 2022;22:1285-95. Crossref

30. Mui LW, Chan AY, Lee A, Lee J. Cross-sectional study on attitudes among general practitioners towards pneumococcal vaccination for middle-aged and elderly population in Hong Kong. PLoS One 2013;8:e78210. Crossref

Healthcare professionals are not above the law. In the event of substandard medical care that resulted in patient death, it is only right that society and families be provided opportunities to seek explanation, redress, justice, and closure. Civil proceedings and professional regulatory mechanisms are commonly pursued avenues recognised by healthcare professionals as proportionate; criminal law intervention is justified in some circumstances, but it is a more unsettling approach.1

Criminal law intervention is unsettling not so much because of the actual imposition of criminal penalty where deserved but because of the very thought that one could be a single mistake away from being charged for a crime, as well as the adverse effects that such fear may have on professional culture, clinical practice, and patient welfare. It is also unsettling because of uncertainties regarding the threshold for prosecution.

Despite criticisms concerning its circularity, vagueness, and the arguable lack of requirement for a clearly culpable mens rea, the offence of gross negligence manslaughter (GNM) has survived repeated calls for legal reform, and it continues to be applied in ‘medical manslaughter’ cases.1 As for other crimes, the decision to prosecute must consider two factors: first, whether there is a reasonable chance of securing a conviction, and second, whether the public interest requires a prosecution to be pursued.2

The first factor is related to the determination of whether there is sufficient evidence to prove all ingredients of the offence. As established in the British case of R v Rose, a conviction of GNM requires the court to be satisfied that (in addition to the basic elements of civil negligence) it was reasonably foreseeable to the suspect that the breach of duty would give rise to a ‘serious and obvious risk of death’, and that the circumstances of the breach were ‘truly exceptionally bad and so reprehensible… that [the breach] amounted to gross negligence and required criminal sanction’. An ‘obvious’ risk must be clear and unambiguous based on knowledge available at the time of the breach, rather than one which might become apparent on further investigation. Importantly, a recognisable risk of something serious is not the same as a recognisable risk of death.3 Whether and how these principles might have been followed in other common law jurisdictions remain to be discovered. A hypothetical question to ask could be whether the circumstances of an inadvertent omission of drug prescription are truly exceptionally bad and so reprehensible as to warrant prosecution.

The second factor is related to the fundamental principle that not all offences for which there is sufficient evidence should automatically be prosecuted; the public interest must require such an approach. When evaluating the public interest balance, an inexhaustive list of factors are considered, subject to the circumstances of the case. The exercise of this discretionary power is complex and demanding; even experienced prosecutors may have difficulty agreeing on a consistent approach to GNM cases.4 It is of note that whilst the public interest is unlikely to allow of a disposal less than prosecution when the victim has suffered significant harm, the suspect’s level of culpability should also be considered. The problem is that an ‘honest’ mistake—made without intent to cause harm or recklessness as to the risk of harm—is exactly what might be caught (or not) under the arguably elastic and arbitrary scope of GNM.

Because GNM is not an offence specific to medical cases, there is no reason to expect routine consideration regarding the impact of criminalising medical error on the broader public interest. However, poor morale, staff attrition, loss of trust, the rise of defensive medicine, and the suppression of a learning culture are highly plausible consequences of over-criminalisation with serious implications for quality of care and patient safety.1 In the United Kingdom, a series of high-profile cases caused sufficient public outcry that the Secretary of State for Health and Social Care instigated a rapid policy review into the application of GNM in healthcare5; another review was later commissioned by the General Medical Council.6 Neither review was intended to recommend changes in the law; both were undertaken to identify potential improvements within the existing legal framework.

Both reviews found that, although the threshold for prosecution has been set appropriately high following the decision in R v Rose, there remained a perception among healthcare professionals that the legal test has not been applied in a consistent manner, and that individuals were under investigation where the prospect of prosecution or conviction may be low. Both panels saw a need to enhance the transparency and understanding of the law, as well as the threshold for prosecution so as to provide assurance regarding how decisions are made. A series of guidelines was subsequently issued by the Director of Public Prosecutions.

The reviews also highlighted the central role of expert opinion in triggering an investigation and in determining whether a case should be prosecuted. Because problems with expert testimony may not be uncovered until trial or appeal, an unsound or biased opinion could potentially subject a healthcare professional to otherwise avoidable legal proceedings. Indeed, questions were raised regarding the use of expert witness opinion during the pre-trial stage, the competence and conduct of some experts, the experts’ understanding of the law, and their understanding of their duties to the court. In Hong Kong, a training course for expert witnesses is available through the Hong Kong Academy of Medicine. Formal mechanisms to ensure the recruitment of competent expert witnesses, the engagement of a dedicated panel of 'super-experts' at the pre-trial stage, and the scrutiny of opinions regarding quality would be welcome.

Finally, the reviews emphasised the importance of maintaining an open and just culture of candour and learning. Families who feel that they have been denied information are more likely to seek answers through legal processes; thus, the method in which healthcare service providers manage the aftermath of a patient’s death should be carefully considered. Legal protection may be given to statements that arise during internal proceedings, thereby creating a safe space for healthcare professionals to discuss and learn from their mistakes.

There is no doubt the criminal law serves important functions in safeguarding patient welfare, but it is also a blunt instrument that can destroy the fabrics and ideals of a healthcare system if not applied judiciously. Medical manslaughter cases should be handled with exceptional care—not because healthcare professionals are an exception to the law, but because of the exceptional damage that a single case can do. Neither medicine nor the law operates in a vacuum. Both earn society’s trust and deference through not their power but the good they do, and both should reckon with each other’s unique strengths and values, limitations, and challenges. Now that the likelihood of what happened in the United Kingdom being repeated in other places is all but real, it will be up to policymakers to determine how best to calm nerves and learn from lessons learned elsewhere.

The author is solely responsible for drafting of the manuscript, approved the final version for publication, and takes responsibility for its accuracy and integrity.

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

The author has disclosed no conflicts of interest.

1. Leung GK. Medical manslaughter in Hong Kong—how, why, and why not. Hong Kong Med J 2018;24:384-90. Crossref

2. Department of Justice, Hong Kong SAR Government. Prosecution code. 2013. Available from: https://www.doj.gov.hk/en/publications/pdf/pdcode1314e.pdf. Accessed 23 Jan 2023.

3. R v Rose [2017] EWCA Crim 1168.

4. Quick O. Prosecuting ‘gross’ medical negligence: manslaughter, discretion, and the Crown Prosecution Service. J Law Soc 2006;33:421-50. Crossref

5. UK Department of Health and Social Care. Gross negligence manslaughter in healthcare. 2018. Available from: https://www.gov.uk/government/publications/williams-review-into-gross-negligence-manslaughter-in-healthcare. Accessed 20 Jan 2023.

6. General Medical Council. Independent review of gross negligence manslaughter and culpable homicide. 2019. Available from: https://www.gmc-uk.org/-/media/documents/independent-review-of-gross-negligence-manslaughter-and-culpable-homicide---final-report_pd-78716610.pdf. Accessed 20 Jan 2023.