Podiatric Medicine in Hong Kong
By Michele Chan, CPM Class of 2020
Hong Kong is an important metropolitan and financial center. It is a city where East meets West due to the influence of British colonization pre-1997. According to the Census and Statistics Department, in 2015, Hong Kong had a population of 7.3 million people (male 3.37 million and female 3.95 million)1 with about 1.1 million senior citizens over age 65. Statistics also indicate that car ownership in Hong Kong is low and public transportation is well developed. Combined, this results in a high walk score of 93, and the walking culture plays a huge part in travelling about the area. Most people walk everywhere in town since it is very convenient with stores and necessities of daily life located nearby. The walking culture thus creates a potential need for podiatric medicine because there is a higher chance of foot injuries and over-usage problems. In addition, the hot and humid weather is not conducive to foot health or to healing of wounds. These facts about Hong Kong, including the culture, environment and population present a strong case for the expansion of podiatric medicine.
As it exists in Hong Kong, podiatry is the accepted medical specialty for foot healthcare approved by the Hong Kong Hospital Authority (HA). Podiatric medicine there emphasizes examination, diagnosis, treatment, prevention and rehabilitation of diseases and/or disorders affecting the foot and its related structures. Podiatrists can perform wound care with special dressings; prescribe therapeutic foot appliances and topical medications for lower extremity conditions. They can perform nail and wart removal procedures but cannot perform surgery that involves the joints, bones or muscles, or order and read reports of imaging studies to treat patients. Patients are referred to orthopedics for surgery if needed. Contrasted with the podiatric specialists in America, Britain, Australia and many other European countries, the scope of podiatric practice in Hong Kong, especially in public hospitals, is quite limited.
Podiatrists in Hong Kong are categorized as Health Allied Professionals but not officially licensed or regulated by any agency. They practice in both public hospitals and private clinics. They are also called podiatrists as in the western countries or Foot Healthcare Specialists in China. Despite the tremendous potential for podiatric medicine in Hong Kong, there are only three Doctors of Podiatric Medicine (DPMs) from the United States and Australia (two DPMs work in the HA and one works in a private clinic) and around 48 podiatrists, or Foot Healthcare Specialists, working in the public and private sectors. Many podiatrists are qualified medical professionals with podiatric training in specialized foot treatments to diagnose foot problems and perform wound care treatments to help patients with ambulation and quality of life. However, podiatrists in Hong Kong (including podiatric surgeons) are not classified as medical doctors and cannot prescribe oral medication or perform foot surgery since it is not within their scope of practice . Therefore, there are very few podiatric surgeons working in Hong Kong due to the limitations in practice and recognition.
Since Hong Kong does not currently have any podiatric training college or a board to oversee registration and regulation of the field, podiatrists achieved their qualifications, clinical training and board certification from the countries where they trained. The United States of America, United Kingdom and Australia are the only 3 countries with podiatry degrees that are publically accepted in Hong Kong. Although the local universities have shown interest in a podiatry degree program, the HA discouraged it since they cannot guarantee jobs for all graduates. Hong Kong government has also refused to license podiatrists since the profession is small, and the majority of the podiatrists work in HA where standards are maintained. There may be voluntary registration in the future for private podiatrists to show their proper credentials.
In the recent decade, the Chinese government recognized the increasing demand for better foot healthcare in Hong Kong. Hospital Authority offers scholarship programs (there is no fixed number of scholarships per year) to sponsor students to the United Kingdom for podiatry training under the condition that they must work in a public hospital setting there for a minimum of 5 years after acquiring their qualifications. Therefore, the majority of the podiatrists in Hong Kong are UK graduates. The podiatric program students graduate with a Bachelor of Science degree while podiatric surgeons need to have post-graduate education. Podiatry in the UK only provides three years post high school training on foot healthcare such as basic pharmacology and minor skin and nail surgery under local anesthesia in HA or private hospitals. They can only prescribe topical medications excluding steroids in Hong Kong.
Podiatry services in Hong Kong are different depending on whether they are performed in public hospitals or in private clinics. The reason for that difference may be due to limited government resources, or lack of public acceptance and awareness. The public hospital system (Hospital Authority) in Hong Kong has service management based on clusters. There are 6 clusters with each having a varying number of hospitals. HA employs approximately 40 full time podiatrists. There are currently three private hospitals with podiatry services and employ 4-5 podiatrists in total. There are five podiatrists in private medical centers with two of them are in sole practices. In public hospitals, podiatry normally provides wound care services and then refers patients to other specialists for further treatments. It is harder for a podiatrist in the public sector to collaborate with professionals in other healthcare fields since time and communication may be compromised. It is not an easy task to help and understand patients quickly with limited assistance from other medical fields. To overcome this, many private clinics work as multiple-specialty medical groups with a team of specialists that could include a surgeon, a physical therapist, a chiropractor and others to provide patients with one-stop treatments. Some of the most common foot conditions treated by private practice podiatrists are nail and skin conditions, biomechanical pathologies and sport injuries. There are almost no patients seeking podiatric assistance in public hospitals for cosmetic foot surgery since the socialized medicine expenses are not covered by government.
Although the needs for podiatric medicine are increasing, there is currently no severe “shortage” of podiatrists in the public hospitals that have podiatry or foot care departments. There are approximately 5 podiatrists to rotate through the foot clinic networks at those public hospitals. Because of this limited number of podiatrists to serve nearly 20 public hospital clinics such as those in the Queen Elizabeth Hospital and Queen Mary Hospital, there is still technically a shortage. In the public sector, there is a triage system to sort out which patients should be seen first in terms of severity of their illness. The Foot Healthcare Specialists judge the urgency of patients’ needs based on their diseases, which include vascular problems and diabetes mellitus, that predispose patients to the high risk of ulceration. Patients with complications usually get foot care in the family doctor clinic or orthopedic clinics. This current system creates a problem as treatment is the primary focus in the public hospitals with limited resources. This leaves little time for preventative and palliative care. Other specialists, such as orthopedic surgeons and physical therapists, are helping to take care of patients with lower extremity problems.
Podiatric patients in Hong Kong range in age from children with foot problems, such as sport injuries, to the elderly who suffer from chronic illnesses such as diabetes, gout, rheumatoid arthritis and stroke, conditions that require specialized foot care. Similar to most podiatric patient groups in the world, the elderly population in Hong Kong is the most common sector to have foot problems. As the World Health Organization (WHO, 2014) statistics indicate, diabetes mellitus is becoming more prevalent globally. Hong Kong citizens, especially the elderly, are facing the increasing incidence of diabetes and the associated medical problems and complications involving the feet. Unfortunately, according to Foot Healthcare Specialists, many diabetic patients in Hong Kong are not diagnosed and may be unaware that they have the illness. They do not understand the complications of diabetes that can affect the lower extremities. They are also unaware and uneducated about the role and benefits of podiatric medical treatment for the complications of diabetes. Currently in the age of convenience, chronic diseases are becoming formidable problems in Hong Kong as well. Being more prone to having a sedentary lifestyle and consuming a more Westernized diet such as fast food and unhealthy processed foods could cause an increase in the number of patients. There are many complications that come with these chronic diseases and one of the major concerns is with the lower extremities.
Since podiatry in Hong Kong is not officially registered and accredited by the government, many patients prefer to seek help from Traditional Chinese Medicine Practitioners called Bone Setters, acupuncturists and acupressure therapists to heal their foot problems. Many people with foot injuries refuse to be treated by western physicians. Besides, patients are culturally different in Hong Kong than patients in the USA. Typically, patients in Hong Kong are thought to have a higher tolerance for pain and try to avoid visiting doctors until absolutely necessary. In addition, many patients have the concept of preserving “full body” and prefer to have intact limbs during their burial as opposed to having any amputation. As a result, many of the patients have severe foot conditions that could benefit from the help of podiatrists.
In conclusion, foot problems are common among Hong Kong residents, especially in the elderly population, but the scope of podiatric services is limited and foot care education for the public is inadequate. If podiatry could become more widely accepted, and services expanded, that area of specialty could take care of those foot problems and diseases. With the increasing demand of and need for foot care, there is an opportunity for the government to improve the podiatric medical services to the community through different approaches. There is a need for public education about preventive podiatric medicine in order to increase acceptance of it. Routine foot examinations for at-risk citizens could also promote better foot health.
Podiatry in Hong Kong is not widely recognized among the healthcare professionals and the community. The Hong Kong government should promote and raise medical and public awareness and acceptance of podiatry and foot healthcare through education about preventive podiatric medicine and routine examinations. The Hong Kong government may need to establish an official podiatric training college and/or include podiatric medicine as a specialty in its existing medical school. In addition, the Hong Kong government needs to have a board exam to certify podiatric medicine practitioners with the proper laws and regulations to govern this field. It would help if the Hong Kong Hospital Authority could start by raising the awareness of medical professionals, since most doctors and other professionals do not really understand podiatry. This effort could better inform people about the prominence and impact of podiatry to human health. Through the proposed effort of the government and the podiatrists, podiatric medicine in Hong Kong can become an official medical specialty that can improve the health and quality of life for the public.
Article by Michele Chan, CPM Class of 2020
References
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