Making the leap from government service into private practice was once a straightforward step for doctors. Prominent physicians set up as consultant specialists and junior doctors opened neighbourhood clinics. Not anymore. Whether working for one of the growing number of health care groups or setting up on their own, doctors find each route presents mounting challenges. Increasingly, many find the solution lies in setting up group practices.
'The heyday is gone,' says Chan Hing-wai, recalling his dilemma when deciding to leave the Hospital Authority. 'Twenty years ago, doctors could easily go into private practice regardless of their seniority; they opened clinics without worrying about business. Nowadays, there are too many newcomers.'
However, worsening terms in public service - the cash-strapped Hospital Authority began hiring physicians on contract in 1997 and cut pay scales for new staff three years later - prompted an exodus of doctors such as Chan. The turn-over of public doctors doubled from about 3 per cent in 2003 to 6.7 per cent last year.
Chan thought going solo was too risky: with five years' experience at a public hospital, he wouldn't have the clout to attract enough patients.
However, getting a job with a health management organisation (HMO) has its drawbacks, too. It does mean a steady income and salaries can be 50 per cent higher than in government, Chan says. 'But with the higher salaries, you're expected to work even longer hours and more irregular shifts [than in the public service].'
At the same time, doctors' complaints of HMO managers interfering with treatment at clinics to cap costs have made many wary of working for big health care groups. The Medical Association has long called for government control of HMO operations to protect patients and doctors. If treatment goes wrong, it's the doctor who faces punishment, says association vice-president Louis Shih Tai-cho.
Chan's solution to his predicament was to join forces with colleagues to form a family clinic group, the Hang Seng Medical Practice. Although each partner runs a clinic like a sole practitioner, they support each other as a chain operation.
'Like most chain businesses, profitable outlets must sometimes subsidise loss-making ones, especially new clinics which need time to attract enough patients to cover set-up costs,' says Chan.
The partners find that a group practice offers advantages such as spreading business risks, better leverage with suppliers and tapping a bigger pool of patients.
'[Setting up a clinic] is a big investment,' Chan says. 'A sole practitioner has to shoulder the entire business risk, and a clinic would soon have to close if it doesn't have enough patients.
'By having more partners, we find it easier to negotiate with drug suppliers because we can order in bulk rather than individually.
'If I were in sole practice, I could only reach out to patients from one area. But now, patients know us by Hang Seng and may also spread our name to friends who live near our other clinics.'
Besides, as hospitals' expanded outpatient services start to erode the earnings of private practitioners, many realise they can compete more effectively if they unite.
Chan and his partners seem to be off to a good start. Last year they opened another clinic in Jordan in addition to those in Hung Hom, To Kwa Wan and Shau Kei Wan, and have had to hire locums to share the work. However, other young doctors are following suit and Chan faces growing competition as similar group clinics open in Shau Kei Wan.
Setting up group practices has been a growing trend among veteran physicians and junior doctors during the past six years, says urologist Richard Lo. The specialist, who has a keen eye for developments in the medical profession, was among the earliest to take the route when he joined five senior surgeons to set up the Pedder Clinic 12 years ago. Since then, the clinic has signed up another eight surgeons with decades of experience, including Samuel Kwok Po-yin, who joined two months ago.
Practices such as Pedder say they differentiate themselves by offering a higher level of specialisation. 'Thirty years ago, a surgeon would carry out all kinds of operations from brain to toe,' Kwok says. 'As medicine advances, surgeons are expected to develop specialities, whether it's the heart, liver, stomach or other organs. There are many sub-specialities nowadays and each requires mastering different skills and equipment.'
'The positioning of Pedder Clinic is very clear: specialist surgical services,' Lo says. 'Patients who come to our clinic know what they are looking for.'
For senior physicians such as Lo and Kwok, group practices provide a way to raise capital for the latest diagnostic tools and cutting-edge equipment required in more complex day surgeries. Having their own equipment means surgeons are less reliant on hospital facilities, although they still have to admit patients for major operations.
'A piece of equipment like an ultra-sound machine or an endoscopic instrument would cost more than HK$1 million. How many machines can one surgeon afford if he or she operates as a sole practitioner?' Kwok says.
It's also more efficient to share the costs of support staff.
Located across the road from Pedder Clinic, 818 Health Professionals, which opened four months ago, positions itself instead as a one-stop service for families. Similarly staffed by experienced consultants, it offers the expertise of five paediatricians in different sub-specialities, respiratory and family medicine specialists as well as a Chinese medicine practitioner.
Besides convenience, such a clinic appeals to patients who are uncomfortable with hospital settings, says paediatrician Alfred Tam Yat-cheung.
'It's not only kids; some adults don't like going to the hospital,' he says. 'Many prefer to be treated in a clinic, probably after work. They might have to take a day off if they sought treatment at a hospital. It would be hard for sole practitioners to provide a full medical service.'
The preference for group practice is likely to strengthen as Hong Kong's medical profession becomes increasingly dominated by female physicians. 'We are seeing more women doctors and medical students,' says the Medical Association's Shih. 'They prefer to work normal hours and spend more time with family, which can be achieved more easily in a group rather than solo practice.'
But as in all collaborations, the doctors acknowledge that choice of suitable partners is vital. 'We need to share the same mission, for instance, providing quality care and serving the patients' best interest,' Tam says.