Internationalisation of Chinese Medicine Education: Challenges and Solutions

1. Internationalisation of Chinese Medicine Education: Challenges and Solutions Charlie Changli Xue Division of Chinese Medicine RMIT University, Australia E-Mail: charlie.xue@rmit.edu.au

2. Usage of complementary medicine worldwide (Source: WHO Global Atlas of Traditional, Complementary and Alternative Medicine, Kobe, 2005 Ernst, Prevalence of complementary medicine, a systematic review)

3. MacLennan et al.’s survey in 2004: 52.2% used complementary and alternative medicine (CAM). Bensoussan & Myers’ survey in 1996: At least 2.8 million Chinese medicine consultations per year, representing an annual turnover of AUD$84 million. Commonwealth report in 1997: Complementary medicine provides health care to 57% of Australian. 2005 survey in Australia (Xue et al 2006 unpublished data): 68.9% Australian have used complementary medicine and nearly one in five have used Chinese medicine. Usage of CAM by Australians

4. Regional differences in CM use 25.1% (13.5%) 10.3% (6.0%) 17.2% (6.5%) 17.1% (11.7%) % ≥ 1 CM therapy (%) ≥ Visit 1 CM practitioner * Data not show separately for ACT, NT and TAS, combined, 15.0% used CM, and 9.2% visited a CM practitioner) 22.7% (15.4%)

5. The future of Chinese medicine will depend largely on what answers can be provided on efficacy and safety (harm against-benefit).(Scheid, V. The globalisation of Chinese medicine, The Lancet, 354, Supp 4, 1999, page SIV10)

6. CAMEducation, an unmet demand(Ernst E. FACT. March 2003;8(1):1-2)Effective credentialing should meet the desire to protect public from dangerous practice against the wish to grant patients access to reasonably safe and effective practice.(Eisenberg D et al. Ann Intern Med 2002; 137:965-973) The future graduates of TCM course will have to face the continuing development and modernisation of TCM. … change from experience-based to evidence-based practice(Chan, K & Lee, H. The Way forward for Chinese medicine. Taylor & Francis 2002, page 389).

7. Traditional Medicine Practice • Range of traditional medicine practice (WHO 2002) • Systematic practice: highly developed and well-documented such as Chinese and Indian Traditional Medicines • Simpler forms: in isolated ethnic groups • Traditional medicine as supplementary treatments provided by other health professionals • Practitioner regulation: Chinese medicine practice has been regulated in the State of Victoria (www.cmrb.vic.gov.au)

8. Types of Education Needed • Quality training for primary Chinese medicine practitioners and continuing education • Medical and other healthcare professions need adequate knowledge and skills to understand potential benefits and risks of Chinese medicine • Public education related to benefits and risks of traditional medicines, in particular, concurrent use of Chinese and western medicines

9. CM Tertiary Higher Education in Australia, UK, US and Canada

10. CM Tertiary Higher Education in Australia, UK, US and Canada

11. Rationale of using CHM • Less than two thirds (60.4%) for the purpose of treating medical conditions, approx. 40% for general health and well-being only • The most common conditions being treated were cold and flu (11.6%) and energy (qi) related problems (8.5%). CHM users mentioned at least 30 different conditions that being treated by CHM

12. Rationale of using acupuncture • Vast majority (92.0%) for the purpose of treating medical conditions, 8.0% was for general health and well-being only • The most common conditions being treated were back pain and related problems (20.7%), shoulder pain and problems (15.5%), arthritis (8.5%) and injury (7.0%)

13. Chinese Medicine Education • ½century in the Chinese higher education system • From one uniform system to more flexible • What can we learn from China’s experience • Understanding education needs in a Western country such as Australia • Developing programs that address the local issues: healthcare systems, regulatory matters, etc.

14. WHO Expert Meeting on Traditional Medicine Education QA, Melbourne 2003

15. General medical education principles (WHO 2001) • Combination of knowledge, skills and attitudes • Difficult to define concrete list of factual knowledge, practical skills and attitudes • Encourages Self-Directed Learning (SDL) and some in depth studies • Emphasizes sufficient clinical training • Emphasizes study in disease prevention • Encourages students to be enquiring, analytical, and to develop professional attitudes

16. General objectives for primary healthcare practitioner training (WHO June 2004: Reporting on Working Group Meeting on Quality of Academic Education in Traditional Medicine ) • To produce broadly educated traditional medicine practitioners with an appropriate foundation for general health practice • Knowledge, skills and attitudes in traditional medicines and scientific principles • Ability to practice independently, safely, ethically and effectively, with continuing education • Emphasises sufficient clinical training and adapting an evidence-based approach in clinical practice • Encourages students to be enquiring, analytical, and to be responsive to changing needs

17. Points for Consideration: Chinese Medicine Programs (1) • CM is not in isolation:concurrent use of modalities • Unique characteristics and integrity of CM theoretical framework should be preserved:a common problem • Balance between western and CM: integration is encouraged to meet public expectations • Complementarities between Western and CM in clinical practice:selection of treatment options based on evidence, affordability and accessibility

18. Chinese Medicine Programs (2) • Clinical training should be adequate:availability of facilities • Critical thinking and research skills should be embedded:EBM and EBCM • Adoption of recent advances of teaching technologies and innovative curriculum design to enhance learning outcomes and learning efficiency:outcome measures • Learning from the past forms the basis of future success:literature and future research planning

19. Definition of ‘Curriculum’ Curriculum’ is defined as: “all the arrangements the institution makes for student learning and development and research. This includes the content of the course, student activities, teaching approaches, and the ways in which the teaching and learning is organised. It also includes decisions on the need for and use of facilities.”* *Adapted from the Osteopaths Registration Board of Victoria Accreditation Policy: Procedures and Guidelines for Accreditation of Osteopathic Programs, February 2000.

21. Educational standards endorsed by the registration board/association • Guidelines for the Approval of Courses of Study in Chinese Medicine as a Qualification for Registration (CMRB, VIC) • Australian Guidelines for Traditional Chinese Medicine Education.Australian Acupuncture and Chinese Medicine Association.

22. CMRBVic Standards for Course Approval • Graduate knowledge, Skills and Attributes • Theoretical knowledge • Clinical Skills • Practice Management and Interpersonal Skills • Professional Ethics and Values • Course Structure and Operation • Aim of Course • Philosophy and Objectives • Course Documentation • Unit Documentation • Teaching and Learning Methods • Assessment • Student Selection Criteria

23. CMRBVic Standards for Course Approval (continued) • Course Management • Institutional Support • Organisation Structure • Course Development • Support for Research • Review and Evaluation • Resources and Physical Environment • Funding • Work Environment • Student Support • Staff Qualifications and Skills • Teaching Facilities • Clinical Facilities and Placements

24. CMRBVic Standards for Course Approval (continued) • Curriculum • Program Length • Four academic years (8 semesters full time study) • 500-800 hours supervised practical clinical training • Relative Weighting • Modes of Delivery • A substantial proportion of face-to-face education • Encourage innovation in the delivery of courses • Theory and Clinical Studies • Biomedical and other Sciences • Clinical Training in Chinese Medicine • Practice Management • Professional Values and Behaviour

25. Developing a capability based curriculum:Capability enables one to respond to NEW & CHANGING circumstances (Stephenson J & Yorke M 1998)

26. What is capability? • Is an integration of knowledge, skills, personal qualities and understanding used appropriately and effectively • More than just highly focused specialist contexts • But in response to NEW & CHANGING circumstances • (Stephenson J & Yorke M 1998)

27. Evidence of capability • Act effectively & appropriately • Explain why • Live and work effectively with others • Learn as an individual or with others in unfamiliar situations (Stephenson 1992)

28. Core Graduate Capabilities of Chinese Medicine Education: A Practitioner-Based Survey in Victoria

29. Overall capabilities for CM Practitioners • CM practitioners are primary health care professionals • They are required to practice CM at an accepted level and in a professional manner • Act as an effective member in a multidisciplinary health care system

30. Capabilities required to ensure safe and effective practice of CM • Technical capabilities (12) • Communication capabilities (4) • Responsible and sustainable practice (6) • Research and information management (6)

31. Technical capabilities (an example) • to apply Chinese medicine principles and diagnosis skills • to formulate a herbal prescription or make modifications • to develop a treatment plan including time-lines for treatment and review …

32. Overview • Questionnaires were sent to all registered CM practitioners in Victoria (n=714) • 228 valid questionnaires were received (response rate=31.9%), of these, 55.8% are male and 44.2% are female. • Characteristics of survey participants are considered to be representative: • 98.2% practice acupuncture, • 71.0% practice Chinese herbal medicine, • 60.3% practice Chinese therapeutic massage and, • 45.7% practice Chinese medicine dietary therapy. • Bachelor degree or above (75.0%) • Nearly half (46.1%) practiced Chinese medicine >=10 years. • Nearly two quarters (59%) have never practiced overseas, whereas15.3% have practiced overseas for 10 years or more.

33. Results: mean score of technical capabilities An ability to give nutrition and dietary and preventive medicine advice in terms of CM knowledge for all areas of CM An ability to perform acupuncture treatment procedures and/or prepare and dispense a Chinese herbal prescription

34. Mean score of other capabilities An ability to develop a research protocol An ability to practice within regulatory/ ethical/safety frameworks

35. Further professional development • Short courses in CM to update clinical knowledge and skills: 61.9% • Research studies to specialise in one or more areas to enhance practice: 44.6% • Postgraduate studies to gain further qualifications: 37.4% • Short courses in Western medical sciences to ensure safe practice: 23.4%

36. Research informs education • Are distal points efficacious for TTH?(Xue et al Headache 2004;44:333-341) • Significantly improved headache frequency, duration, pain intensity, pain threshold, sickness impact scores • Conclusion: EA to distal points alone is effective for short-term symptomatic relief of TTH. • Combining Acupuncture and CHM for SAR: No additional effect(Xue et al HKMJ 2003;9:427-434) • Acupuncture or CHM alone was effective (separate publications) • Systematic review on CHM: effective (Xue et al Current Medicinal Chemistry 2004;11:1403-1421) • Combined the two, did not produce any additional benefits

37. Education reflects research • Incorporation of research findings into curriculum and teaching materials • Is Chinese medicine effective for SAR and PAR? • What treatment protocol should be adapted? • Duration of treatment: acupuncture Vs CHM • Promote EBCM development: • Level of evidence: limited evidence available • Searching for historical/traditional evidence • Evaluating low level evidence: instrument development • Disseminating evidence: database development • See www.chinesemdicne.com

38. Chinese Medicine Portal

39. Challenges and solutions (1)

40. Challenges and solutions (2)

41. Acupuncture Practice in a Public Hospital

42. Summary/Comments • The setting of CM practice in Australia and other countries is substantially different from China • CM is not in isolation and expectation of CM practitioners is significantly higher in the areas of biomedical science and clinical skills • Education should reflect research findings • Research should inform education • Standardization, EBM and integration are the major challenges • Capabilities of graduates should be the main focus on program development in CM • International collaboration

43. Comments • Leadership role of international organisations in this development such as WHO and major professional associations • Future directions: mutual recognitions, specialisation, effective application of teaching technology • The role of continuing professional development