Saying goodbye to my doctor: a qualitative study on the experiences of chronically ill patients when facing the termination of a long-term treatment relationship in Hong Kong

Abstract

Background

Having a family doctor is beneficial for patient care. However, it is not uncommon for a treatment relationship to be terminated. Doctors are suggested to implement proper transition procedures should this occur. Nevertheless, the literature shows that patients suffer harm even when a doctor has organized a care transition. Few studies have suggested appropriate procedures for how doctors should transition care upon the ending of the doctor–patient relationship, and the impact on patients following treatment relationship termination has been rarely documented. This study fills the literature gap by investigating a group of chronically ill patients in Hong Kong on how they experienced the termination of a long-term treatment relationship by their family doctors.

Methods

This study adopts an explanatory model and critical medical anthropology as the theoretical framework and employs a qualitative descriptive approach with individual semi-structured interviews. The interviews were conducted from June to September 2025 to investigate the experiences of 35 chronically ill patients following the termination of the treatment relationship initiated by their familiar doctors. The coding and analysis of the data were based on a thematic analysis.

Results

The experiences of the participants were negative and unpleasant when their treatment relationship was terminated by their doctors. Five themes were derived from the data as follows: feeling uncertain about future care, feeling guilty for the new doctor, feeling abandoned, having no motivation to find a new long-term doctor, and feeling incomplete without a formal goodbye. The international guidelines suggest that doctors mostly emphasize legal and ethical procedures to reduce their legal liability when they terminate a treatment relationship, but the participants expected a humanistic and emotional approach when the treatment relationship was terminated.

Conclusion

Micro experiences of the participants could be due to the macro social structure of Hong Kong society. Merely organizing a care transition, which is the current medical guideline and practice when a treatment relationship has to be terminated, may not be enough for patients in this Chinese context. Care transition plans are suggested to emphasize emotional adaptation preparation, as some participants’ accounts suggest the importance of symbolic closure resembling ritual transition.

Introduction

A family doctor is a main primary health care provider who provides comprehensive, whole-person, continuing, preventive, and coordinated care to a patient and the patient’s family members [1, 2]. Having a family doctor is beneficial to patient care, particularly for chronically ill patients, as having a stable family doctor follow up on their chronic conditions can improve patient satisfaction and treatment outcomes and provide a more stable control of chronic conditions [3]. Patients also benefit from the longitudinal care provided by family doctors. When a patient has a longer relationship with a family doctor, the decrease in after-hours care, hospital admissions, and mortality is greater [3]. A nationwide Norwegian study identified relatively linear relationships between the length of the patient‒physician relationship and emergency care visits, hospital admissions, and overall mortality; the study concluded that patients who had a regular doctor relationship for more than 15 years could reduce after-hours care or hospital admissions by approximately 30% and overall mortality by approximately 25% compared with those who had a regular general practitioner for only 1 year [4]. Because family doctors often provide longitudinal care, a strong relationship based on trust is expected between patients and their family doctors. Such a strong relationship with family doctors can be extended to patients’ family members [5].

Termination of the treatment relationship by family doctors and its impact on patients

However, the termination of a treatment relationship between patients and their family doctors is not uncommon. Termination is the end of a particular doctor–patient relationship—usually permanently—which can be initiated by either the patient or the doctor or it may be the result of “overriding conditions,” such as when the patient moves out of the area served by the practitioner [6]. Other reasons noted for the termination of the doctor–patient relationship include the lack of agreement on a treatment plan, the patient no longer requires treatment, the doctor retires or closes his or her practice, and the doctor or the patient moves away [7, 8]. When a doctor is unable to continue the treatment relationship with a patient, it is suggested that a proper transition procedure should be implemented by the doctor, such as providing a reasonable notice period for the termination, making clear to patients about the doctor’s recommendations for their ongoing treatment, assisting patients in finding another source of treatment, organizing the transfer of care to another doctor and transferring patients’ records to the new doctor with patient consent [7].

Still, patients may still suffer harm from the termination of a treatment relationship even when a family doctor has organized a care transition according to medical guidelines for their patients. Hayes-Bautista [9] used the metaphor of “divorce” to depict the termination of a long-term treatment relationship between a doctor and a patient, moreover, the researcher noted that a termination initiated by doctors is often more damaging to patients, as patients may believe that such termination is the result of their noncompliance with their doctors’ advice, which leads to their sense of guilt. Stokes et al. [6] also indicated that the ending of a doctor–patient relationship can be negative and disruptive for patients and that treatment termination initiated by doctors can impose more serious consequences for them. Emotional burden and distress are particularly more remarkable in patients whose treatment is terminated by their doctors if they have a long-term treatment relationship with them. Patients are widely reported to have a feeling of being abandoned in these cases [7, 8, 10]. A study conducted in the United States revealed that the termination of a long-term treatment relationship can negatively affect the confidence of patients in establishing a new treatment relationship, as 38% of patients fail to re-establish a new treatment relationship with a new family doctor, and 25% of patients end the new treatment relationship after six months, even when they can locate a new family doctor [11]. Another study conducted in the United Kingdom also indicated that the termination of a treatment relationship can lead to patients’ negative emotions, such as anger, victimization, and powerlessness [10]. The doctor-initiated termination of a treatment relationship is thus shown to have negative effects on patients and can be physically and psychologically detrimental to them.

Study significance

Most of the current literature focuses on the benefits of having a family doctor [3, 12, 13]. Barriers to having a family doctor in Hong Kong have also been investigated [14]. However, there is scant literature concerning the impact on patients when family doctors terminate the care of their patients. Although few studies have focused on the ending of doctor‒patient relationships, these few studies examine mostly the appropriate procedures for how doctors should transition care for patients in the Western context [7, 8]. Studies on the impact of the termination of long-term treatment relationships on patients are scarce and limited to experiences in the United States and the United Kingdom [6, 10, 11], and they remain understudied in the Chinese context. This study therefore fills the literature gap by investigating a group of Hong Kong Chinese chronically ill patients on their experience when a long-term treatment relationship is terminated by their family doctors. Understanding these patients’ experience and behavior will enable primary health care providers and health authorities to prepare patient-sensitive care transition recommendations that reduce the negative impact on patients and that suit the Chinese context.

Primary health care context of Hong Kong

Hong Kong is a unique society for this study. The health care system follows a dual pillar system. On one pillar it is the public health care sector, focusing on the provision of secondary and tertiary care. Although the public health care sector also provides primary health care service in the form of general outpatient clinics (before 11 October 2025) and family medicine clinics (after 11 October 2025) [15], relationship between doctors and patients is weak as patients would see different doctors at each time of consultation. Public health care is considered as a safety net for the citizens in terms of health care, and it is fully funded by the government. On the other pillar it is the private health care sector, which is the chief provider of primary health care. Private health care is mostly funded by private funds and operated as private business, offering personalized and more convenient health care services to those who are willing to pay and can afford higher fees for their health care [16]. Approximately 70% of primary care is offered in the private health care sector, but there is no formal family doctor arrangement in the private health care sector at the time of this study [17]. Patients using primary health care service in private sector can usually enjoy strong continuity of care as they can consult the same doctor at their discretion. However, patients can choose to see different doctors in each consultation if they wish. Under this context, it is expected that once a patient has determined to follow a doctor, relationship between this patient and the doctor will be strong. Following the family doctor models that are widely practiced in western countries, it is expected that family doctors would only be seen in the private sector in Hong Kong’s health care context.

The history of family doctor development in Hong Kong can be traced back to 1977, when the Hong Kong College of General Practitioners was established [18]. However, rarely these general practitioners would be regarded as family doctors. The training of family doctors has become more systematic with the establishment of Family Medicine Units in the two university medical schools, following the establishment of Hong Kong Academy of Medicine in 1993, in which family medicine has become one of the medical specialties in Hong Kong [18]. Those who have completed the family medicine training in the Hong Kong Academy of Medicine are regarded as “family physicians,” which is a specialist in Hong Kong. In theory, both general practitioners and family medicine specialists can be viewed as family doctors, though “family doctor” is not a common terminology used in Hong Kong’s primary health care context.

Although family medicine has been made as a medical specialty in 1993, this does not help much for the people of Hong Kong to aware about “family doctor”. The family doctor system is underdeveloped in Hong Kong [17]. According to the Primary Healthcare Blueprint by the Health Bureau issued in 2023, only 23% of the Hong Kong population has a family doctor, and 40% of the population visit different doctors (doctor shopping) for the same sickness [19]. Doctor shopping is common if patients are dissatisfied with the medical care offered by their doctors [14, 20]. Whether a patient follows the same doctor in the private health care system is at the discretion of the patient, and the patient is free to choose the preferred doctors according to own preference. As patients can choose their preferred doctors freely, this same doctor can be general practitioners practicing in the patients’ neighborhood, or be family medicine specialists, or even be the specialists in other disciplines, depending on the preference of individual patient. However, this preferred doctor is rarely named as “family doctor.” Mercer et al. [14] further confirmed that family doctor is an underrecognized concept among their chronically ill informants in Hong Kong, and “familiar doctor” or “neighborhood doctor” were used more often by their informants to refer to those doctors whom they had a more stable relationship. Their informants’ understandings of family doctor showed no relationship with primary health care and family medicine, and it was not uncommon for their informants to refer those specialists who had taken care of their chronic conditions—usually the doctors whom their informants would see more often and more regularly—as “family doctors.” The concept of a family doctor, thus, is a loose one and underdeveloped at both institutional and community levels.

Following Mercer et al. [14] and the primary health care context of Hong Kong, the definition of family doctor in this article is based on the definition by the research participants. The participants were asked about if they had a family doctor in the interviews. If the participants found difficulty in understanding “family doctor,” a more widely used terminology “familiar doctor” will be used in the interviews. Although the participants’ understandings on “family doctor” were based on their own perceptions and included general practitioners and specialists, their understandings showed some common features as they considered high trust on and having a long treatment relationship with the doctor as important in defining a family doctor. Although there is no formal family doctor arrangement in Hong Kong, it is expected that the relationship and bonding between a doctor and patient would be close and affective once the patient determines on their own to have the doctor as a long-term treatment provider. “Familiar doctor,” thus, is equivalent to “family doctor” in this study, in line with the situation in Hong Kong.

Theoretical framework

The “explanatory models” approach and the “critical medical anthropology” method are the two major perspectives in the literature concerning doctor–patient relationships. The explanatory models approach focuses on what sickness and health mean to individuals and following what they perceive, how people behave regarding treatment [21]. Explanatory models refer to the beliefs, expectations, norms, behavior, meanings of health and illness, therapeutic activities and the evaluation of outcomes embedded in a person’s cognitive system and general cultural pattern [22]. These models are “partly conscious and partly outside of awareness” ([22]: 109). Explanatory models between doctors and patients are always different and conflicting in terms of their therapeutic values, expectations and goals, leading to the idea of a conflicting explanatory model [23]. Following Kleinman’s notion of a conflicting explanatory model (1988) [23], the explanatory models of doctors and patients on treatment relationship termination are expected to differ. Doctors are asked to focus more on the proper procedures for terminating a treatment relationship to avoid legal trouble [7, 8], while patients tend to concentrate on the psychological and emotional aspects and tend to suffer more from emotional disturbance during the termination of a treatment relationship [6, 9, 10]. However, Lazarus [21] also noted one key insufficiency of the explanatory model, which is that it emphasizes almost exclusively the cultural determinants. Lazarus [21] further argued that future studies need to investigate what is occurring in the interaction and how this can influence the perceptions and experiences of both doctors and patients. An almost exclusive concentration on eliciting and interpreting patients’ explanatory models has made difficult a critical understanding of how the macro social context has influenced the doctor’s role and, therefore, the doctor’s responsibility in the interaction [21]. To overcome this insufficiency, the framework of critical medical anthropology, which incorporates power and social structure, is also used in this study.

Critical medical anthropology addresses the limitations of anthropological studies that fail to examine individual beliefs and actions in light of the larger political economy. In this framework, social relationships are in conflict, and the analysis of doctor–patient relationships should not be seen as an isolated dyad but as part of the medical system integrated into a specific historically constructed social framework [21]. Power and social conflict, which mirror the social relations of class in capitalist societies, are at the center of this approach. According to this framework, the interaction between doctor and patient should be analyzed as an extension of power relationships, because in such interactions, the power between doctors and patients is asymmetrical, and doctors are often in a more powerful position that can dominate patients’ experiences [21]. This framework provides a systematic analysis of how the political economy of a society can affect participants’ experiences and perceptions through investigating factors at the individual, micro-social, intermediate-social, and macro-social levels [24]. At the individual level, personal factors and social support networks influence a person’s health-related experiences [24]. At the micro-social level, the interaction between a person and their health care providers would play the influence [24]. A person’s health-related experiences are also affected by institutional and government policies at the intermediate-social level and by ethnocultural-medical beliefs and capitalistic ideology at the macro-social level [24]. Thus, critical medical anthropology can expand the explanatory model’s understanding of treatment relationship termination, particularly terminations initiated by doctors, from a more macro perspective. This methodology can be used to investigate patients’ experiences by incorporating the power asymmetry between doctors and patients and how this power asymmetry may affect patients’ responses, such as locating a new family doctor and how long this will take. Thus, the explanatory model is good at investigating the micro experience, whereas the critical medical anthropology approach is suitable for investigating the macro social structure of patients’ experience. This study therefore incorporates both the explanatory model and the critical medical anthropology framework to contribute to a new investigation direction of both the micro and macro domains.

Methods

This study adopts a qualitative descriptive approach that collects data through individual semi-structured interviews. Qualitative research is widely used to understand patterns of health behavior and people’s lived experiences and health care needs to design and inform appropriate health interventions [25, 26]. This inquiry examines the “how” and “why” of people’s health care decision-making [27] and explains the phenomena by making sense of the complex social reality [28]. A qualitative descriptive approach provides straightforward descriptions of participants’ perceptions and experiences [29]. This method recognizes the subjective nature of the problem, and the findings are presented to reflect or closely resemble the terminology used in a research question [30]. It provides factual responses to how people feel and experience [31], and researchers can stay closer to the data and the words used by the research participants, as this technique allows a lower level of interpretation and inference from researchers [32]. The qualitative descriptive approach matches the explanatory model and critical medical anthropology framework used in this study, as these anthropological models mostly involve a descriptive analysis, which contextualizes the relationship of causality in a social setting [33]. The qualitative approach is an excellent fit with this study’s core investigation of the lived experiences of the participants when they encounter the termination of a treatment relationship.

Research ethics

This study received ethical approval from the Institutional Review Board of The Hong Kong Polytechnic University prior to data collection (approval number HSEARS20250512008). All of the participants were provided with an information sheet written in the local Chinese language that outlined the nature of the study, why they were recruited to participate, the data and their confidentiality, and their rights as research participants. All of the participants provided written consent to participate in this study.

Data collection

To investigate the participants’ experiences following their doctor’s termination of their long-term treatment relationship, purposive sampling from May to June 2025 was applied. Purposive sampling is a core qualitative sampling method that focuses on selecting information-rich cases that can provide in-depth and detailed insights into the core phenomenon under investigation [34]. The method sampled research participants who were chronically ill patients who reported having (1) ever had a family doctor or familiar doctor (regardless of whether this doctor is a general practitioner/specialist in family medicine/specialist in other specialties) caring for their chronic condition(s), (2) a treatment relationship that was terminated by this doctor, (3) at least five years of a treatment relationship with this doctor before termination, (4) an age of 18 years or above, (5) Chinese ethnicity, and (6) been born and educated in Hong Kong. Sampling only Chinese individuals who were born and educated in Hong Kong ensures that the participants have a long exposure to Hong Kong’s health care system and culture that could facilitate the investigation of their experience in this specific social context. The sampling targeted participants who had at least a five-year treatment relationship with their doctor before termination, as a cross-sectional study conducted in the United States reported that patients are more open with their doctors when this relationship is longer than five years [35]. The sampling criterion of having ever had a family doctor or familiar doctor (regardless of whether this doctor is a general practitioner/specialist in family medicine/specialist in other specialties) caring for the participants’ chronic condition(s) was used because Mercer et al. [14] observed that some of their informants in Hong Kong regarded the specialists who take care of their conditions as family doctors. This criterion suits the Hong Kong health care context where the family doctor system is not well developed. In this study, “familiar doctor” was the most frequently used term among the research participants.

Each of the thirty-five participants were interviewed once from June to September 2025. Semi-structured interviews ranged from 68 to 110 min. Data saturation was achieved, as no new codes and themes emerged at the 29th interview, and six more interviews were conducted to confirm that the data were saturated with no new codes and themes [36]. The participants in this study were recruited from different sites. In the first stage of recruitment, recruitment posters that listed the sampling criteria were posted in the public areas of a local university. However, sampling all of the participants from one university may create bias in the study, especially a demographic bias that results from the university environment. Hence, more than half of the participants were recruited in the second stage of recruitment, in which they were purposively sampled from chronically ill patient self-help groups and from Facebook. Some participants were recruited from chronically ill patient self-help groups because they were receiving long-term care and thus had a greater likelihood of experiencing the termination of a treatment relationships by their doctor. Two patient self-help groups, which are for chronic heart disease patients and renal disease patients respectively, were selected as the sampling sites, because these two self-help groups had organized a talk for their members about ways to maintaining a good partnering treatment relationship with doctors on their chronic conditions. On the other hand, the use of social media platforms in participant recruitment is supported in the literature [37]. Based on the existing network of the principal investigator, a local medical doctor’s Facebook fan page, which is written in the local language of Hong Kong and has more than 33,000 followers, was the other sample pool for the second stage of participant recruitment. With the consent of the owner of this Facebook fan page, an e-post with the sampling criteria was displayed on this page for participant recruitment. This Facebook fan page was selected because its owner has written quite a number of posts which are about the importance of putting trust on doctors in a treatment relationship. Basing on the talks organized in the two patient self-help groups and the posts in the doctor’s Facebook fan page, the participants sampled were expected to have a higher awareness and be more emotionally affected on this topic.

An interview question guide (Appendix 1) with an inductive and open-ended design was employed to allow the participants to easily share their experiences. The interview question guide was developed with reference to the literature on patients’ experiences when a long-term treatment relationship is terminated by their family doctors [6, 7, 9–11]. As this study followed the explanatory model and critical medical anthropology as theoretical frameworks, some interview questions and probing questions were designed according to their areas of concern, especially on how the participants and their doctors communicated about and how the participants felt and experienced about the relationship termination. To ensure that the interviews were conducted consistently, facilitate the data analysis procedure, and allow in-depth conversation, the researcher interviewed all of the participants individually in a private room at the researcher’s institution face-to-face in Cantonese, which is the native language of both the researcher and the participants. Each interview was audio-recorded with the participant’s consent.

Data analysis

After each interview, the key points and the researcher’s impressions and observations were documented in an interview diary. Data analysis was conducted synchronously with data collection, in line with the principles of qualitative research. This procedure involved a quick and initial data analysis that informed the later data collection process. The interviews were transcribed verbatim. The interview data were analyzed through Braun and Clarke’s [38] six-phase thematic analysis by the researcher with an inductive process. The researcher read all of the transcripts to be familiar with the interview content, which provided the researcher with a comprehensive understanding of the entire experiences of the participants. The transcripts were then re-read line-by-line to identify codes [39]. All interview transcripts were analyzed with an inductive approach by the researcher basically. All statements or phrases were identified, extracted, described, and translated into codes, which were then labeled and categorized. Codes and themes were assigned semantically basing on the explicit and surface-level meaning of words in the interviews at the first level following a descriptive approach. In addition, following the two theoretical frameworks of explanatory model and critical medical anthropology adopted in this study, the coding process also followed a deductive approach, paying particular focus on searching the micro experiences of the participants as well as the macro social structures that could influence their experiences. Some codes and themes were assigned with the consideration of the two theoretical frameworks. Overlapping codes were collated and consolidated to form broader themes. Recurrent themes were highlighted and consolidated to form categories after repeated examination and comparison. The data analysis process involved documenting codes, themes, and categories and supporting interview quotes in a coding table [40]. Specific concepts and categories were identified in the coding table to transform the interviews into meaningful symbols to enable a deeper understanding of the participants’ thoughts. Latent themes and researcher’s reflections in doing the coding were then noted and analyzed further in a codebook at the second level, basing on the semantic themes identified to uncover the participants’ meanings in which they did not articulate explicitly. The selected interview quotes used in the reports were translated from Cantonese to English, and back translation was employed to ensure their accuracy.

Data trustworthiness and researcher’s reflexivity

The positionality of a researcher can profoundly influence the research process, research outcome, and research credibility [41]. As a researcher with anthropology as a major discipline during the undergraduate and Masters studies and with public health in research doctoral study, I have been engaging with the study of illness experience of chronically ill patients. My particular interest in chronically ill patients’ experience research can be due to my other social role as a patient with several chronic conditions. I have been under the care of four specialists, from seven years to more than three decades. My long experience as a chronically ill patient not only has made me to have a particular interest in pursuing medical anthropology as my research career since research postgraduate training, but has also enabled me to achieve an emic understanding on my research participants who are also sick.

Personal reflexivity is a continuous process throughout the duration of the study [42]. This study is initiated based on my personal experience, when one of my attending specialists terminated his practice because of retirement. This was shocking to me as this specialist is the youngest doctor when compared with the other three specialists, who have been taking even longer care on my other chronic conditions. Being born, raised up, educated, and working in Hong Kong—a context where there is no formal family doctor arrangement—my health perceptions and behavior have been shaped by the primary care context of Hong Kong. Similar to the research participants in this study, I also consider these four specialists as my “family doctors” because I have a long treatment relationship with them and I trust them, though I aware they should not be referred as “family doctors” academically. The first scenario that I was able to have a more academic understanding on family doctor is when I was working for the research of Mercer et al. [14] as a research assistant. Although I understand that the four specialists cannot match with the academic understanding of “family doctors,” and some of them would know in more details about my other co-existing chronic conditions than the other specialists, I cannot escape from the impact of the primary health care context of Hong Kong and still perceive the four specialists as my “family doctors” since I have the longest and the most stable treatment relationship with them.

I had been feeling sad for months after I knew this specialist was retiring, because I know I would not be able to see him again after his retirement. I had been struggling on how I should proceed with the long-term treatment on the other. Although this specialist has organized a one-year transition for me before passing me to another specialist, I felt even more devastated when the last day of his practice arrived. I started to wonder how other chronically ill patients would experience when their doctors who have been following their conditions terminate their practice. This experience, as a result, has contributed to this study. My position as a chronically ill patient who has grown up in Hong Kong offers a distinct advantage in terms of accessing the participants and discussing the issue in-depth with them. As engaging in a personal reflexive exercise in a research is noted to be a powerful learning experience for a researcher [42], I also want to better prepare myself for the retirement of the other three specialists, whom I believe they will retire sooner or later.

Throughout the research process, I maintained a reflective stance, acknowledging the potential challenges related to my internal and external perspectives, while allowing participants to guide the conversations. Reflexive writing was conducted throughout the data analysis process in the codebook [42]. An interview diary was prepared after each interview to allow the recording of key points, observations, my experiences and feelings, and brief analysis in each interview, which was cross-referenced with the coded interview data. Collaborative reflexive practice was conducted through member checking, in which each participant was asked to read the transcripts of their interviews to ensure that their meanings were not distorted during the transcribing process, and each of them was invited to provide additional thought on the codes and themes in the member checking process [42]. All coding and analyses were performed based on the interview transcripts following the requirements of qualitative descriptive research. To overcome the limitation of single coder in this study, the second round of coding was conducted by the researcher two months after the first round of coding to enhance data credibility by achieving intra-coder reliability. This re-coding procedure could enhance consistency in the coding process as well as promoting researcher’s reflexivity [43].

Results

Participants

The demographics of all 35 participants are shown in Table 1. All of the participants had at least one chronic condition and reported having at least a six-year treatment relationship with their familiar doctor before their doctor terminated this relationship, and the majority had more than ten years of treatment relationship. All their familiar doctors were working in the private health care sector and owned their clinics, and they were practicing as general practitioners (n = 28), family medicine specialists (n = 1), and other specialists such as cardiologists and nephrologists (n = 6) before they left the practice. In Hong Kong, general practitioners are non-specialists, and all doctors with a MBBS or MBChB degree but without other recognized specialty credentials are defined as general practitioners. Specialists such as family medicine specialists, cardiologists, and nephrologists are required to complete the postgraduate medical training to that required of a Fellow of the Hong Kong Academy of Medicine in the relevant specialty, and register on the Specialist Register [44].

Table 1.

Demographics of the participants

Informant code	Sex	Age	Education level	Occupation	Types of familiar doctor reported	Years of treatment relationship with the familiar doctor	Chronic condition(s)
P1	M	41	Master	Customer service	General practitioner	6	Hypertension, gout
P2	M	39	Master	Customer service	General practitioner	10	Hypertension, asthma
P3	M	55	Bachelor	Banking and finance	General practitioner	28	Hypertension, diabetes
P4	M	41	Bachelor	Sales and marketing	General practitioner	22	Heart disease
P5	M	40	Post-secondary	Fashion design	General practitioner	15	Hypertension, asthma
P6	M	36	Bachelor	Logistics	Nephrology specialist	22	Chronic kidney disease
P7	M	58	Bachelor	Human resources	General practitioner	31	Hepatitis B
P8	M	44	Post-secondary	Clerical	Cardiology specialist	18	Heart disease
P9	M	36	Bachelor	Public relations	General practitioner	32	Diabetes
P10	M	50	Bachelor	Teacher	General practitioner	24	Hypertension, gout
P11	M	76	Secondary	Retired	General practitioner	44	Hypertension, diabetes
P12	M	60	Secondary	Sales and retailing	General practitioner	35	Hypertension, diabetes
P13	M	62	Secondary	Sales and retailing	General practitioner	30	Hypertension, diabetes
P14	M	64	Secondary	Sourcing and merchandising	General practitioner	30	Hypertension, fatty liver
P15	M	56	Secondary	Clerical	General practitioner	29	Hypertension, diabetes
P16	F	51	Bachelor	Teacher	Cardiology specialist	26	Heart disease
P17	F	44	Bachelor	Financial consultant	General practitioner	20	Heart disease
P18	F	46	Post-secondary	Clerical	General practitioner	24	Systemic lupus erythematosus
P19	F	50	Bachelor	Customer service	General practitioner	33	Hypertension, gout
P20	F	39	Bachelor	Executive	General practitioner	7	Diabetes
P21	F	42	Master	Accountant	Cardiology specialist	28	Heart disease
P22	F	43	Bachelor	Insurance	Nephrology specialist	16	Chronic kidney disease
P23	F	56	Post-secondary	Insurance	General practitioner	36	Heart disease
P24	F	35	Master	Clerical	General practitioner	20	Gout
P25	F	60	Secondary	Catering	General practitioner	33	Diabetes
P26	F	70	Secondary	Casual catering worker	General practitioner	42	Heart disease, diabetes, hypertension
P27	F	71	Secondary	Casual catering worker	General practitioner	35	Heart disease, hypertension
P28	F	62	Post-secondary	Executive	General practitioner	38	Hypertension, heart disease
P29	F	49	Master	Teacher	General practitioner	26	Gout
P30	F	48	Master	Information technology	Family medicine specialist	43	Breast cancer, arthritis, hypertension
P31	F	60	Post-secondary	Civil servant	General practitioner	40	Hypertension, diabetes
P32	F	51	Bachelor	Civil servant	General practitioner	34	Diabetes
P33	F	42	Bachelor	Personal secretary	General practitioner	21	Diabetes
P34	F	76	Secondary	Retired	Cardiology specialist	33	Hypertension, heart disease, diabetes
P35	F	62	Secondary	Shipping and logistics	General practitioner	34	Gout

The chronic conditions of all of the participants were under the care of their familiar doctors in the past. Besides their chronic conditions, the participants reported that they would also go to their familiar doctors for acute conditions. The majority of the participants were informed about the termination of the treatment relationship by their familiar doctors (17 through written or verbal notice in the doctors’ offices during follow-up, 9 through postal mail, and 1 through email), but eight participants did not receive a termination notice from their doctors. Among the 27 participants who were informed, the retirement of their doctors was the most common reason for the termination of the treatment relationship (n = 18), whereas moving (n = 5) and personal or family issues (n = 4) were the other reasons that their doctors terminated the treatment relationship.

Experiences of the termination of a long-term treatment relationship

The experiences of the participants were negative and unpleasant when their treatment relationship was terminated by their doctor. Five themes were derived from the semantic analysis of the interview data, including feeling uncertain about future care, feeling guilty for the new doctor, feeling abandoned, having no motivation to find a new long-term doctor, and feeling incomplete without a formal goodbye.

Feeling uncertain about future care

All of the participants (n = 35) expressed uncertainty about their future medical care after they discovered that their familiar doctors were discontinuing their practice. This is particularly apparent among those participants who did not discuss with their doctors about the care transition.

“I don’t know where I can go now. This is really shocking. I have never thought my doctor would stop his practice. I feel very uncertain. I know I have to find another new doctor; otherwise, I will not have any medicine to take soon. However, which doctor can I go to? Some doctors in my neighborhood are not good, and some doctors no longer accept new patients. Where can I find good doctors?” [P8]

This uncertainty was not eliminated even if their familiar doctors had arranged a care transition for their patients. This is particularly the case when the transition arrangement by their familiar doctors could not accord with the consideration of the participants. If such an inconsistency between the participants’ expectation and their doctors’ transition plans occurred, then the discussion about the care transition between the participants and their familiar doctors was usually brief, and the participants exhibited more hesitation in the discussion. This led to more uncertainty among the participants in their future care.

“My doctor did not discuss with me much about the arrangement after his clinic closed down. He just said I can follow him to his new clinic, or I can find another new doctor in the neighborhood. I do not think I would follow him to his new clinic because his new clinic is in another district and is far away from my home. If I find another new doctor that is close to my home, I do not know who I should go to. I dare not ask him who I should go to if I want to find another new doctor in this neighborhood because he would not feel happy.” [P3]

Feeling guilty for the new doctor

In most cases, a care transition to a new doctor was arranged for the participants by their familiar doctor. However, more than half of the participants (n = 28) failed to follow the new doctor wholeheartedly because the bonding and relationship with their familiar doctors was so strong that they found it difficult to start a new treatment relationship with another doctor. Constant comparisons between their familiar doctor and the new doctor were common among the participants, which often led to them feeling a sense of guilt toward the new doctor.

“Although my old doctor had arranged another doctor for me before his retirement, I do not want to go to the new doctor. I do not mean that this new doctor is not good; this new doctor is indeed good, and he is very caring and enthusiastic about my sugar urine [diabetes]. However, I just want to go back to my old doctor. I know this is unrealistic because he has retired already. I am feeling guilty for the new doctor because I am still thinking about my old doctor even though he has been retired for years. I know this is unfair to the new doctor because I should have put my whole heart into the new doctor and stop thinking about the old doctor. However, I cannot stop thinking about the old doctor. It is really difficult for me to put my whole heart into the new doctor because I still miss my old doctor.” [P13]

Feeling guilty, in another sense, could also be related to the participants’ feeling that they had betrayed their familiar doctors if they could not put wholehearted trust on the new doctor that was arranged by their familiar doctor. This participant continued:

“I am also feeling guilty because I always feel that I fail to obey my doctor’s instruction to follow the new doctor. The new doctor is arranged by my doctor, and this arrangement is just like the final words by my doctor. The feeling is complicated; I still want my doctor back, but at the same time I know I have to follow the new doctor, because the new doctor is the final thing that my doctor has done for me. I should accept this with gratefulness, but I cannot. I feel that I have betrayed both the old and new doctors.” [P13]

Feeling abandoned

Another remarkable theme demonstrated by the participants was that almost all of them (n = 32) felt abandoned, even if their familiar doctors had organized a care transition. The participants often engaged in a mental struggle; although they understood that their relationship with their familiar doctors would not last forever, they blamed their doctors for leaving.

“The feeling is complicated and bad. I understand my doctor should have his own life and being a doctor is just a job, and he would retire from his job one day. However, when I knew my doctor would stop his practice, I felt very sad and complicated. I know I should not blame him, and I know I cannot expect my doctor to devote his whole life to his patients. However, I cannot stop myself from blaming him. How could he give up his patients so easily? We have been seeing him for such a long time. I felt that I was dumped.” [P26]

In addition to feeling abandoned, some participants also developed anger when their familiar doctors left their practice—even if a care transition was arranged. A care transition for patients—especially for the patients who have a stronger emotional attachment to their doctors and a longer treatment relationship with their doctors—may require further concern and emphasis on patients’ emotional needs when doctors are leaving their practice. As demonstrated by this participant who had decades of treatment relationship with her familiar doctor, organizing a physical and logistic transition of care may be far from sufficient in terms of some patients’ expectations. If their emotional needs during the care transition are not addressed, then some participants can develop more extreme emotional responses.

“I have several familiar doctors for my different body parts. I have been seeing each of my doctors for a long time; the shortest is ten years, and the longest will be thirty-three years this year. All of my doctors are aged over 60, and one or two of them even have health issues, so I am psychologically prepared for my doctors to leave one-by-one, and I am not sure if I can still see them at my next appointment. Yet leaving a doctor whom I have followed for ten or even thirty years is still difficult to accept no matter how much psychological preparation I have done. Indeed, one of my doctors is retiring, and the new doctor has gradually taken up his clinic. I feel that my doctor wanted me to go to the new doctor as soon as possible, but I did not want to go to the new doctor so soon at that time, so he was so kind that he offered a one-year transition for me, and I could still see him in that year. However, it was still very hard for me to come to the last day of his consultation. The feeling was very complicated; I know I could not be too greedy as he had this special arrangement for me, but I felt angry and had a feeling of being abandoned—is finding another new doctor to take up the clinic enough for patients? Maybe the answer is ‘yes’ for my doctor; but to me, it is talking about decades of relationship—is it really that easy to put down?” [P34]

No motivation to find a new long-term doctor

Following the development of negative emotions during the care transition, almost all of the participants (n = 30) felt demotivated and pessimistic in developing another long-term treatment relationship with a new doctor. The macro social atmosphere of migration that occurred in Hong Kong following the social movement and extradition bill crisis in 2019 [45, 46] further contributed to this pessimism among the participants.

“I feel pessimistic about a real long-term doctor–patient relationship. I had once believed that I had found a good doctor who I could rely on and put my trust in for my health. I had believed that he is still not very old and that he should still have a long way before reaching retirement. However, he closed his clinic because he has to move to another country. Currently, many people are talking about migration. Human relationships have become much more short-term in recent years because of the social environment of Hong Kong. When everyone is thinking about migration, you really cannot expect a long-term and stable relationship. I have already given up on building another long-term relationship, because doctors should be those who are the most capable of migrating, so it will be difficult to develop a long-term relationship with your doctor now. Even if I want to develop a long-term relationship with a new doctor, he or she may migrate to another country soon, so what for? Now, I would not have the intention to see the same doctor, but would see different doctors every time depending on my convenience.” [P28]

The termination of the long-term treatment relationship was emotionally difficult for the participants even when a care transition was organized because the participants perceived the long-term treatment relationship with their familiar doctors as a form of friendship. However, this was not a real friendship, as the participants were well aware that they could never become friends with their doctors. When their doctors terminated their practice, the participants understood that they would never see their doctors again. Such emotional complications not only demotivated the participants from rebuilding a new long-term treatment relationship with another doctor but also affected the participants’ treatment-seeking behavior by keeping them from seeing the same doctor and performing more doctor-shopping.

“It is emotional hurt, and I do not want to suffer from this again. Yes, I understand everyone leaves their job someday, and everyone retires. However, emotionally, it is still very hard for me to know that my doctor would leave the practice. Even if my doctor has arranged another doctor for me and has informed me about his retirement one year in advance, I still feel that it is very difficult to accept. The situation is like you know a very good friend for many years, and now, this very good friend has died or has migrated to another country, and you know you can never see this friend again. Maybe for a good friend, you can still visit him or her for good reasons. However, for a doctor, even if you have known him or her for many years, I do not have any opportunity to see him or her again. We would never come out for meals because we are not friends after all. The relationship is really coming to a total end, and I know I can never see this doctor again. This really hurts, because my emotional investment on this doctor is huge. It has taken me months to recover from such sadness, though I still think of this doctor sometimes. I do not want to suffer anymore, so I do not go to the new doctor after my doctor retired. Now, I only go to public clinics, or go to different doctors in private practice. In public clinics, you see different doctors each time; there is no bonding, no relationship, no emotion invested, no expectation, so there is no hurt.” [P31]

The strong emotional needs in the care transition are demonstrated further by the following participant. Specifically, strong emotional disturbance can still result even though a long care transition and additional buffer were organized by a familiar doctor.

“My doctor decided to retire a year ago. Actually, the new doctor had already taken over the clinic at that time. However, perhaps because of the handover process, my doctor still continued seeing patients for a few hours every week in his final year of service. I was fortunate enough to be able to see him for my long-term condition until the very end of this transition year. However, I still felt bad when the last day came. I still remember that Saturday, I was my doctor’s last patient. When my doctor said, ‘next time, Dr. X will follow up on your condition. Thank you so much for letting me see you for so many years. Do you remember? You hated taking liquid medicine when you were a kid,’ my eyes were full of tears. I am very grateful to my doctor for allowing me to see him in this final year because I know many other patients had to see the new doctor immediately. To me, this transition year was a farewell year, allowing me to have a buffer period to gradually process the end of our relationship, though I know I would never be well prepared even if I were granted another five years of a buffer period… I still need time to digest it as I still feel hurt. If I am unsure whether I can maintain a doctor–patient relationship with the new doctor, it might be better not to start [a new treatment relationship]. Leaving a doctor that you like is really heart breaking, and I do not want to experience this again.” [P30]

The macroeconomic environment of capitalism has influenced private practice doctors to operate in corporate practice and made it more unfavorable for the cultivation of a long-term treatment relationship between doctors and patients. An increasing number of doctors in private practice are working as employees of medical corporations, which implies that they are less stable in a clinical practice. Such operational change contributed by the profit-oriented economic environment of Hong Kong has made the termination of treatment relationships more common and has demotivated some participants from searching for another long-term treatment relationship with a doctor.

“Now it is getting more and more difficult to build a long-term relationship with a doctor in the private system. More and more clinics are operated in business chains in the private system now, so the doctors are just employees, and they may switch jobs or they may be transferred to another clinic by their bosses. It is unlike thirty or forty years ago when I was a kid, where doctors in the private system were running their own clinics as bosses, and so they would be more stable in their clinics. Just like my doctor, he has moved to another clinic, and I am picked up by another doctor in the same clinic without notice. I can expect this new doctor to transfer to another clinic after some time. If the doctor–patient relationship is getting more and more short-term because of the new business model, then why should I expect a long-term relationship with the new doctor? I also want to have a long-term relationship with my doctor, but now many clinics in the private system are following the new business model, and they are operated as business chains, which doesn’t allow me to build a long-term relationship with a doctor.” [P1]

Feeling incomplete without a formal goodbye

Less than half of the participants (n = 16) did not have an opportunity to discuss the care transition with their familiar doctors, either because their doctors did not discuss it with them or for a few participants, their doctors terminated their practice without notifying them. Eight participants were not informed about their doctors’ termination of practice. All of these participants commonly expressed regret, as they perceived that their relationship with their doctor was not completely over. The ability to say a formal goodbye to their doctors was perceived as ideal for these participants.

“I knew my doctor would retire when I went to his clinic before, as he had put up a notice in the clinic’s waiting area. However, when I saw the doctor in the consultation room, he did not mention a word about the closing of the clinic. I did not ask the doctor about the closing, as I thought it may be private. After all, if he wanted to talk about the closing, he would. Because he did not mention the closing, we cannot discuss. I could not say a formal goodbye to him and thank him for his care during these twenty years. This is something that I regret and feel incomplete about. You know, you would not be able to see him again. I feel regret because I am not brave enough to say a formal goodbye and thank you to him.” [P24]

Being able to say a formal goodbye to their doctors who had a long treatment relationship with the participants was emotionally important to them. To these participants, being able to say a formal goodbye to their doctors was perceived as ritualistic, and it symbolized the complete end of the relationship. A few participants unfortunately did not have such an opportunity, as their doctors terminated the practice without notification.

“The clinic closed down all of a sudden. I did not receive any information about the closing of the clinic from the doctor. I knew the closing only when I last went to my familiar doctor for a bad flu. When I arrived at the clinic, the clinic was dark, and there was only a notice attached on the door, saying that the clinic was permanently closed because the doctor retired. I understand the decision by the doctor as he is quite old already. However, I just feel if he could say goodbye to us, even very briefly, it will make the whole story have a better ending. After all, this doctor had been in this housing estate for many years already, and most patients are residents here and had seen him since childhood like me. Although I cannot say we are friends, we would greet each other if we met on the street. Having an opportunity to say a formal goodbye to each other would be a better ending for this thirty-year relationship, and a formal goodbye means much to me. Now I feel something important is missing. I don’t know how the doctor would think; but to me, I really want to say goodbye to him. It is just like when someone has died: you need a funeral to make the whole thing complete and to say farewell to the relationship completely.” [P9]

Discussion

Unlike the international literature, which indicates that the termination of treatment relationships is often due to a relationship breakdown between doctors and patients [47, 48], this study investigates the perspectives of patients when the treatment relationship is terminated by their familiar doctors with whom they have a strong emotional attachment and a good treatment relationship. Doctors and patients have conflicting explanatory models for illnesses and health beliefs [49–51]. Further than this, as demonstrated by this study, the participants and their familiar doctors also had conflicting explanatory models on how the treatment relationship should be terminated. The guidelines for terminating a treatment relationship suggested for doctors in the international literature mostly emphasize legal and ethical procedures to reduce doctors’ legal liability [7, 8, 48, 52]. However, the participants expected more humanistic and emotional concerns when the long-term doctor–patient relationship was terminated by their familiar doctors.

The conflicting explanatory models on how a treatment relationship should be terminated between the participants and their familiar doctors were intertwined with how the participants and their familiar doctors perceived the doctor–patient relationship, which is also in conflict. According to the international guidelines, doctors should consider doctor–patient relationships as professional relationships with low levels of personal emotional attachment where they have to maintain professional boundaries from patients [53, 54]. Hong Kong follows similar practices in which family doctors also perceive the avoidance of overcommitment with and the maintenance of emotional detachment from their patients as the most appropriate forms of doctor-patient relationships [55]. However, the participants often had an intense emotional attachment to their familiar doctors, for example, the participants found difficulty in following the new doctor because they could not put down the treatment relationship with their familiar doctors, and would feel guilty if they could not wholeheartedly trust their new doctor if this new doctor was arranged by their familiar doctors. Also, they felt abandoned or even angry when their familiar doctors terminated their practice, which is highly consistent with overseas experience [7, 8, 10]. It was often emotionally difficult for the participants not only to withdraw themselves from their familiar doctors but also to follow a new doctor even when their familiar doctor had arranged a care transition. This emotional attachment between the participants and their familiar doctor may explain the observation of past literature on why it is often difficult for a patient to reestablish a treatment relationship with a new doctor and why there is a greater tendency to end a new treatment relationship prematurely even when a new family doctor is located [11]. As demonstrated by the participants, their emotional attachment with their doctors was strong, which was believed to be far stronger than their doctors’ as their doctors were perceived as not valuing their long-term treatment relationship seriously. Such conflicting explanatory model between the participants and their doctors on doctor–patient relationship had made the relationship termination even more unpleasant, sometimes end up with anger as experienced by some participants.

Following the strong emotional attachment between the participants and their familiar doctor, the loss of motivation to see a new familiar doctor for their care was prevalent among the participants, as they did not want to suffer another emotional turmoil if the new doctor had to leave the treatment relationship. This further explains the overseas experience as observed by Groisser et al. [11]. This also has implications for participants’ treatment-seeking behavior, as some of them were more motivated to see doctors who are expected not to offer long-term treatment relationships, such as doctors in the public health care sector, and other participants would intentionally maintain distance from the new doctor emotionally. Although few studies have pointed to the possible relationship between doctor-shopping and the termination of the treatment relationship by doctors, some participants had self-reported that they had developed doctor-shopping behavior since the treatment relationship was terminated. In contrast to the international findings that show dissatisfaction with a doctor and insufficient communication between doctors and patients are key factors of doctor-shopping [56], this study shows that the termination of the treatment relationship by doctors also served as another reason of doctor-shopping. Presumably, these are not ideal for the participants’ health outcomes, particularly for the participants who have chronic conditions that require long-term treatment.

The longer the treatment relationship with their doctors, the stronger the emotional attachment of the participants with their doctors, and the more unpleasant the experience according to the participants. Those participants who had a longer treatment relationship expressed more traumatic experiences in facing the termination of a long-term treatment relationship. It is expected that this group of participants may encounter more emotional difficulty in establishing a new treatment relationship with a new doctor. Literature shows that new treatment relationship can be fragile as new patients are at most risk of dropping out from care [57]. Strong emotional attachment of the participants with their doctors following their longer treatment relationship may complicate the establishment of a new treatment relationship. Although having a long-term treatment relationship with a doctor is always supported in literature [3, 4], this study also shows that having had a long-term treatment relationship with a doctor can affect patients’ behavior in treatment seeking when they have to move to a new treatment relationship. More attention thus needs to be focused on those patients who have already established longer treatment relationship with their original doctors about their reestablishment of treatment relationship with a new doctor.

The findings demonstrate that merely achieving a medically appropriate care transition plan for the patients to avoid legal trouble for the doctor, as suggested by the medical explanatory model [7], may be too limiting and far from sufficient if a patient-centered care transition is organized. The participants expected that a care transition plan would not be viewed merely as an emotionally free procedure to avoid legal issues but one that also emphasizes the adaptation and preparation of patients, particularly emotionally. I argue that the handover of care should not only be a physical handover but also an emotional handover for patients who have a long-term treatment relationship with their familiar doctor.

As demonstrated by the findings, a formal termination of the treatment relationship was perceived as essential to feel that it was real to the participants. The participants expected an opportunity to say goodbye to their doctors to make the relationship termination complete. As suggested by the participants, silent closure without notification was the worst scenario. Furthermore, merely providing a written notice about the termination may not be enough, as some participants expressed that they would hope their doctors to inform them verbally. They would feel grateful when their doctors shared about the past histories of their treatment in the goodbye, and would treasure the buffer period being offered by their doctors before the total termination so that they could accept their doctors’ departure gradually. Being able to say goodbye to their doctors had a remarkable symbolic meaning for the participants emotionally in processing and accepting the termination of the treatment relationship. Indeed, the anthropological literature has indicated that rituals are important and often performed during a change in a human relationship, such as its termination. van Gennep [58] viewed human life as a series of separations, transitions, and incorporations and indicated that an individual confronts periodic challenges during these life stages, which an individual must manage before they move to the next social station. To help an individual cope with these crises at different life stages, society has developed ceremonial responses called “rites of passage,” which are symbolically important in helping an individual make sense of the stress and disconnection induced by life changes [58]. Additionally, rites of passage can prepare an individual to move on to a new social stage [58]. In an anthropological study of the end of relationships, van Gennep [58] investigated funerals and reported that the ritual of a funeral can assist a community in accepting that a person is no longer alive. Turner [59] even noted that separation is a very important stage of a rite of passage that indicates that a person is moving away from the original relationship before moving to a new relationship. These anthropological understandings can help us comprehend the experience and emotional needs of the participants when their treatment relationship is terminated by their familiar doctors. In accordance with van Gennep [58], having a formal farewell with their familiar doctors can be viewed as ritualistically and symbolically important to the participants, and may have helped the participants make sense of the relationship’s termination, recover from grief and sadness, and prepare them to move on to a new treatment relationship with a new doctor.

The experiences of the participants can be explained by the emphasis of the critical medical anthropology framework on the political economy perspective in terms of the macro social structure. According to this framework, the interaction between the participants and their doctors in a treatment relationship termination should be analyzed as an extension of power relationship, where the power between doctors and patients is asymmetrical. Such an asymmetrical power relationship between doctors and patients has been documented in western literature [60], and is even more compelling in Hong Kong, as literature has shown that doctors usually occupy a dominant position in a treatment whereas patients tend to be passive, which is a common medical culture in Hong Kong [61]. As demonstrated from the participants, they were often in a more passive position throughout the discussion of care transition, and their doctors mostly dominated the discussion and would have planned everything for the transition. Even the care transition plan by their doctors failed to satisfy the needs and concerns of the participants, the participants dare not to raise their concerns to their doctors though they considered their doctors as “family doctors.” Consistent with Lazarus [21], doctors are often in a more powerful position that can dominate the participants’ experiences in the encounter of treatment relationship termination. Without the opportunity for a mutual discussion because of the asymmetrical power relationship between doctors and patients, it is expected that the participants would have even more unpleasant encounter in a treatment relationship termination, such as feeling unhappy with their future medical care and guilty for the new step-doctor, because their doctors had arranged the transition in which the participants dare not to refuse. The explanatory model on how care transition should be organized, thus, was in conflict in view of the power imbalance between the participants and their doctors.

On the other hand, the corporate business operation model of doctors in private practice makes the cultivation of a long-term treatment relationship even more unfavorable. As the participants experienced, there is a lack of continuity in patient care because doctors are more frequently switched in these corporate clinics. This affected the motivation and confidence of the participants in rebuilding a treatment relationship with their new doctors. Concurrently, Andrews [62] reported a similar impact on long-term patient care by a corporate model of medicine and indicated that the corporate model has eroded the family doctor model and the doctor–patient relationship in the United States. Berger et al. [63] further noted that the corporate model of health maintenance organizations in Israel has made explanatory models of doctor–patient relationships even more conflicting. In contrast to the expectations of patients, doctors place greater importance on pragmatic aspects such as fairness, reliability, devotion, and serviceability and less importance on interactions and friendships with patients. The corporate business operation model of doctors in private practice, thus, not only has eroded continuity of care and imposed more instability in the cultivation of long-term treatment relationship between the participants and their doctors, but it has also complicated the asymmetrical power relationship between doctors and the participants. Having a long-term treatment relationship is no longer the micro arrangement between the participants and their doctors, but it is heavily influenced by the macro economic structure of Hong Kong. The participants’ experiences, thus, were contributed by the corporate capitalists to some extent. In addition, the migration of their doctors from Hong Kong to another country in recent years following the social movement and extradition bill crisis in 2019 [45, 46] led the participants to not have a strong motivation to search for a new familiar doctor. Comparing with the participants whose familiar doctors retired, those participants whose familiar doctors were moving or having personal or family issues (including migration) had expressed higher sense of abandonment and grief, and higher tendency of doing doctor-shopping to avoid another emotional hurt. This shows that retirement would be more acceptable emotionally as a reason of treatment relationship termination to the participants, and did less damage to the participants in reestablishing a new treatment relationship with a new doctor. These perspectives from critical medical anthropology framework thus can provide the macro social structure reasons in understanding the conflicting explanatory model between the participants and their doctors in experiencing the long-term treatment relationship termination.

Limitations and further research

This study has several limitations. Because this study was conducted on a group of chronically ill patients in Hong Kong with no formal family doctor arrangement, the participants had their own understandings on family doctors and their understandings on family doctors are expected to be different from western context. It should be noted that specialists were also perceived as “family doctors” as with general practitioners and family medicine specialists according to the participants’ perceptions. The term “familiar doctor” was used instead of “family doctor” while interviewing the participants, as “familiar doctor” is a more common terminology in this primary health care context. The perceptions and experiences of the participants are thus not transferable to other societies where a family doctor system is well established. Moreover, all of the participants had chronic conditions, and they had at least secondary school education with quite a number of them with tertiary education, hence their experiences are not transferable to those who do not have chronic conditions and those with lower education. The relatively high education of the participants may also affect their expectation of treatment relationship with their doctors, and this may affect their experiences when they encountered treatment relationship termination. Some participants were sampled from Facebook fan page; their digital use and their long exposure of the doctor’s Facebook articles may affect how they interpret their experiences.

Lacking the perspectives of doctors and an absence of doctors’ voices about their experiences who had terminated or are terminating their practice is another limitation of this study. This limitation has made the in-depth investigation of the theoretical argument of conflicting explanatory model as suggested by Kleinman [23] difficult. Doctors’ perspectives could only be based on the past literature that focuses on care transition according to medical guidelines without first-hand data. Hence, future research should investigate in-depth about the voices and perspectives of doctors.

Conclusion

This study revealed that for the participants, the termination of a treatment relationship initiated by their familiar doctor is often emotionally burdensome. Their unpleasant experiences occurred because of the conflicting explanatory models not only on how a treatment relationship should be terminated between the participants and their familiar doctors but also on doctor–patient relationships between the participants and their familiar doctor. The experiences of the participants demonstrate that merely achieving the medical explanatory model of care transition is far from sufficient in catering to patients’ emotional needs. The participants expect care transition plans that also emphasize emotional adaptation and preparation, as some participants’ accounts suggest the importance of symbolic closure resembling ritual transition. These findings can help doctors who are providing long-term care to plan ahead for a more patient-sensitive care transition when they need to conclude their practice.

Judy Yuen-man Siu

is an Associate Professor at the Department of Applied Social Sciences of The Hong Kong Polytechnic University. This author has a bachelor’s and master’s degree in anthropology and has a Doctor of Philosophy in population health/medical anthropology.

Appendix 1

Interview question guide

The questions below are only a guide. Probing questions were asked according to the responses of the informants and are not listed below.

1. How many years was the relationship you had with your family/familiar doctor? Why did you see this doctor for a long time?

2. Why do you consider them your family/familiar doctor?

3. Will you go to your family/familiar doctor for ALL kinds of health problems? Are there any situations that you will/will not go to this family/familiar doctor, and if so, why?

4. Will you go to this family/familiar doctor when you are not sick at all? If yes, can you share what these situations are?

5. Did your doctor discuss with you about them leaving? How did they discuss leaving with you?

6. What were the topics of discussion (e.g., the transition of care to whom? Practical and emotional concerns, etc.) when your doctor told you about this leaving?

7. How did you feel when your family/familiar doctor told you about their leaving? What were your responses?

8. When your family/familiar doctor discussed the transition of your care to another doctor with you, how did you feel? What was your response to your doctor?

9. Did you manage to see this new doctor who took over your care? Why/Why not?

10. How do you feel about this new doctor? Can you adapt to their style? Why/Why not?

11. Do you think you will continue to see this new doctor? Why/Why not?

12. How did this experience of your ex-doctor’s leaving affect you? (Probe: Confidence and willingness to establish a new treatment relationship with a new doctor?) Why do you think so?

13. As your family/familiar doctor is leaving your care, what can the new doctor do for you to make you feel better? What can the government health authorities do for you?

14. Do you have any final words to say to your family/familiar doctor?

Author’s contributions

JYS designed the study, collected, analyzed and interpreted the data, and wrote the manuscript. The author read and approved the final manuscript.

Funding

This study did not receive any funding.

Data availability

The datasets generated and/or analyzed during the current study are not publicly available because of the privacy and confidentiality of the research participants but are available from the corresponding author upon reasonable request.

Declarations

Ethics approval and consent to participate

This study received ethical approval from the Institutional Review Board of The Hong Kong Polytechnic University prior to data collection (approval number HSEARS20250512008). All data collection and analysis were performed in accordance with relevant guidelines and regulations as stated in the Declaration of Helsinki. All of the participants were provided with an information sheet about why they were recruited in this study and their rights as research participants, and they provided written consent to participate in this study.

Consent for publication

All of the research participants provided written consent for the data to be published. The data provided by the research participants were presented anonymously, with all personal identification data removed.

Competing interests

The authors declare no competing interests.