Speech delivered at The 3rd International Congress of Traditional Medicine, September 2006 Canada, 50th Anniversary Conference of Beijing University of Chinese Medicine, October 2006. Beijing.
Current international medical education, broadly speaking is based on the system developed in the west. Mainstream medicine is evidence based, evolved in the past two or three hundred years with the advancement of science. A comparative studies of medical education in different countries mirrors similarities in undergraduate study, internship and specialty training requirements. The content of most syllabuses includes western medicine theoretical studies in Evidence Based Medicine, anatomy, pathology, pharmacology, moral & ethical education etc. However, criteria of measurement and enforcement standards differ from country to country. For example, the critical standards of the UK Royal Colleges may be similar to the peer knowledge of specialties in the US, Australia or Japan, the system of educational evaluation and educational standards requirement are different. This prompt the World Medical Association to propose an agreed minimum standards for international medical education without which it will be difficult to achieve international mutual recognition and accreditation. This is a fundamental step in our 21st century world of medicine without frontiers.
We can debate the pros and cons of the globalisation of medicine and global co-operation in healthcare to cope with diseases without frontiers, the like of Bird Flu, AIDS and SARS. However there is no doubt that a rational review of our medical education system is overdue not only because of the CPD requirement for doctors with the rapid changes in clinical sciences and disease management, but also the very validity of Evidence Based Medicine is called into question with the increasing challenge from Dialectical Based Medicine, holistic medicine and revived traditional medicine to western orthodoxy. In 2004, the medical associations of different countries including US, Canada, China and India meet at the Shanghai roundtable summit to discuss international medical leadership and international collaboration concluded with a declaration that “globalisation of medicine is necessary and inevitable” after much deliberation and debates. How does this prediction in the future direction of medicine affect clinical practice and medical education? Is the Chinese model of integrative medicine in a somewhat separate, but collaborative clinical practiced a way forward? Will a real synthesis between western and Chinese medicine be possible? How do these factors affect the training of our future doctors? The search for answers to these questions awaits the arrival of a new bio-economic era.
Chinese Medicine Education, Globalisation, Evidence Based Medicine (EBM), Dialectical Based Medicine (DBM), Mainstream Medicine, Complementary & Alternative Medicine (CAM), Integrative Medicine
Current Perspective and Historical Background
Currently, Chinese medicine education outside China can be described at best “rudimentary” and “non-recognised” globally with the exception perhaps of Korea. Main stream medical education does not accept Chinese medicine as a system of medicine or a specialty in medicine. The obstacles of change in both academic and economic establishment combine with the lack of legal status and so called acceptable clinical evidence presents impossible impasses to progress made so far. Internationally, some universities are offering courses in Chinese medicine and acupuncture but only as health studies and not as part of mainstream medical education for the training of recognized doctors. Chinese medicine together with acupuncture is categorised within complementary and alternative medicine (CAM), i.e. not part of mainstream medicine. In the UK, the stronghold of institutional western medicine; we saw a breakthrough with the medical schools of Guy’s, King’s and St. Thomas sending the students to study Chinese medicine and acupuncture at the Chinese Medical Institute & Register (CMIR, 伦敦中医学院) SSM module with five groups now completed their studies. This may reflect the changing of views in the orthodox camp for an integrative approach in medical education.
Historically, since the publication of the ‘Yellow Emperor’s Classic of Internal Medicine” traditional Chinese medicine education can be summarised into two formats, namely imperial tuition and master-disciple apprenticeship. Four Chinese medicine institutes were established in 1956 and soon after to formalise the training of physicians in Chinese medicine. China’s constitutional policy giving equal importance to Chinese medicine enables it to develop side by side with western medicine. However, in the international context Chinese medicine education is struggling to germinate. A vital part in the process of globalisation of Chinese medicine is therefore missing. This report attempts to highlight the needs, point out the problems and discuss the global direction of Chinese medicine education. With this report, I hope that the issues are placed on an international medical platform promoting the development of a globalised Chinese medicine which retains the best of Chinese tradition within its modernity.
Education is the Foundation for Chinese Medicine Globalisation
Traditionally Chinese society has always given top priority to education and academic achievements. Good education cultivate good physicians without which the internationalisation of Chinese medicine would become a farm without good farmers, a garden without good gardeners. Presently, the negative reactions to Chinese medicine in the West reflect the lack of fundamental education in general and shortage of qualified doctors in particular. Education is of pioneering importance to Chinese medicine. Presently, there are many unqualified “Chinese herbal takeaways” in the U.K. offering inferior Chinese medicine. These short-sighted opportunists have damaged the long-term reputation of Chinese medicine, pushing it into dangerous and difficult situation. This situation can only be rescued by urgent education and regulation.
Chinese medicine has a unique theoretical system, which has proven itself historically to develop in synchronisation with the knowledge of our time. Syndrome differentiation is exactly in line with the new concept of holistic medicine. This unique process of analysing illness in all its manifestation at a certain stage of disease development crosses the boundary of tradition and modernity, east and west, the science and the arts of healing. This process could be the golden key for a new era of global medicine.
Whilst the attitude of the western authority is quite clear about the rapid development of Chinese medicine in the UK, Chinese medicine profession must call upon itself to stop damaging its reputation, its brand name and therefore its long term development.
Chinese Medicine Education — Two Opposing Views
Throughout the history of the Chinese medicine, interactions by opposing school of thoughts are factors driving its development in line with the rationale of our time. Currently, there are two opposing views in Chinese medicine education. The traditional school wishing to conserve the traditional system of Chinese medicine, which has a wealth of well-tested clinical experience argues that integration with Western medicine is fundamentally impossible. The modernist on the other hand holds the opposing views that integration is necessary, and Chinese medicine must re-validate itself using western scientific models such as Evidence Based Medicine. Neither of them is completely correct in their contention.
With the era towards a global medicine upon us, the different schools of thoughts will bring us a modern medical system with the best elements of east and west. The correct process of integration should be evolutionary, emphasising on organic synthesis, rather than forced marriage. The principle should be “identifying our similarities” while “co-exist with our differences “.
The traditionalist and the modernist schools in Chinese medicine education should in my view focus their contention on clinical medicine. Only in clinical practice can we immediately bring in the concrete aspects of integration. Theoretical systems of medicine will take a longer time to integrate. An innovative search for a new system methodology will require enormous international intellectual inputs and clinical evaluation to achieve a consensus on the cognitive logic of medicine. The proposition of a dialectical based medicine (DBM), using dialectical logic to evaluate medical efficacy deserves more academic consideration.
The Problems and Challenges in Globalisation of Chinese Medicine Education
The Question of Candidates
Who are the priority targets for Chinese medicine education in the current global prospective among the conventional doctors, healthcare professionals and the alternative medicine practitioners? While we need to apply different syllabus to teach each group and without neglecting the education of CAM practitioners or the healthcare professionals, I would like to emphasis that the primary target for education in Chinese Medicine should be firstly addressed to qualified doctors in medicine in each country in order to speed up the use of Chinese clinical medicine within mainstream healthcare system. Their authoritative position in medical development and opinions will enhance the process of Chinese Medicine entering the mainstream medicine. The facts are they are dealing with patients all the time, they will be in the front line of adapting Chinese Medicine into an integrative medical approach. Currently, Chinese Medicine has not been included in recognised medical school education, the universities in the UK only offer Chinese Medicine as part of their health studies which does not qualify the students to practise Chinese medicine. We must change this situation.
The Question of Different Medical Systems
How do we explain the theories and methodologies of Chinese medicine to conventional doctors from a different medical background without losing the essence of Chinese medicine? I think a body of knowledge eventually should be evolved by maximising contacts, encouraging debates and exchange programmes.
The Question of Chinese Medicine Legalisation
Medicine licensing process in the west is a hazardous task for Chinese medicine due to its use of complex herbal ingredients. The solution will only be achieved by the collaborative efforts of not only the pharmaceutical, research and governmental organisations but also the financial world when Chinese medicine becomes a viable commercial proposition. The need for a group of all rounded talent is urgently necessary to set the next stage for Chinese medicine research and development.
Continuing Education and Registration
Organisations should be set up to register properly qualified Chinese medicine physicians and to provide a system of re-accreditation fostering continued education required now in mainstream medicine in most countries in the west.
Some Educational Experiences from the Chinese Medical Institute and Register (CMIR)
The Chinese Medical Institute and Register (CMIR), collaborating with Beijing University of Chinese Medicine since 1994, is dedicated to the modernisation of Chinese medicine, and its proper integration into conventional mainstream medical practice. Focusing on educational programmes of a high standard to western medical practitioners, the Institute enjoys the backing of the top educational institutions whilst also co-coordinating research projects internationally. CMIR knows the foremost way for Chinese medicine to be integrated into western medical education system is to achieve the globalization in setting up a special and formal educational system of training for qualified western medical doctors.
CMIR intake the General Medical Council registered medical doctors as the main trainees, and there have been six graduations since October 1995, doctors from over 300 hospitals and surgeries have been trained, Tsingtao Daily praised the CMIR, “Integration of East and West, the Milestone of British Medicine”; “Western doctors are seeking alternatives oriental ways to treat patients”. At present, many of our graduates are running their own Chinese Medicine forums and seminars in their hospitals and practicing Chinese medicine to treat their patients. They published articles and commented, “CMIR courses had made huge difference in my clinical work in what I can offer my patients” (Dr F Nieuwoudt, medical doctor); “I found all the lectures most encouraging and helpful. I found they found the way to help a western trained doctor understand the Chinese medicine approach very well. I have found understanding Chinese medicine and applying it to general practice has improved my clinical skills” (Dr P Herbert, GP Principal. Some published compliments such as CMIR & AcuMedic are exploring the new direction of modern medicine, bringing GPs new hope of complementary treatment, etc. Our graduates and current students are pleading with the British authority to carry out more research on Chinese medicine for proper Chinese medicine and acupuncture legislation.
All the lecturers and students of CMIR will continue its hard work on the globalization of Chinese medicine education and its integration with western medical educational system. The CMIR ten years teaching experience can be summarized as follows:
Linguistically, Chinese medicine is difficult to interpret. Since 1994 the Chinese Medical Institute and Register has gained some experience in structuring a syllabus and teaching methodology that cross the barriers of medical culture.
2.By encouraging the comparison of syndrome differentiation with Western diagnosis methods, we can arrive at a complementary treatment that is clinically more effective than conventional medicine only. Let clinical evidence prove the efficacy of this approach.
3.Within the teaching process, cultivating open debate on both systems of medicine without prejudice, such as comparing Zangfu Qi and blood relationship in Chinese medicine with Western concepts of evidence based physiology.
4.One of the themes of the Chinese Medical Institute & Register is to raise the question of the formation of a global medicine based on an integrative clinical approach that produce better benefits for patients. Since all doctors agree that the ultimate purpose of medicine is to cure their patients.
Requirements in western settings – relationship between doctors and patients and patients safety
In Britain and other western countries the relationship between doctor and patient and the patient safety protocol are very much part of medical education. The emphasis on this protocol has led to the formulation of standards, working procedures to ensure communications between patients and doctor, and to ensure the best possible safety in medical procedures. In the UK, all medical and healthcare techniques are subject to National Occupational Standard (NOS) requirements. At present, herbal medicine and acupuncture has already agreed on NOS standards. I personally participated in the acupuncture section of the standards, pointing out that acupuncture is part of the Chinese medicine, and therefore it should not be isolated as a technique only. Patients should know the reasons, background behind the selection of the acupuncture points and treatments. In this way we can engender understanding of the patients and to ensure the safety in the process.
In the west there are different methods of acupuncture and therefore the formation of a standard syllabus for education is proving to be difficult. For instance, medical acupuncture does not accept or apply syndrome differentiation in Chinese medicine. Their selection of acupuncture points is based on symptomatic reasons. There is also difference within Chinese medicine which includes modern aspects based on recent research as well as traditional Chinese medicine. The term TCM (traditional Chinese medicine) should now be changed to CM (Chinese medicine) to reflect the modern and traditional content.
The conclusive rationale is to set up standards based on not only traditional aspects, but also modern aspects of Chinese medicine. We also have to take into account the different factors in terms of regional variation in mainstream medicine and healthcare system. In western countries we must adapt to the local healthcare and educational system such as the UK NHS and Royal colleges.
Globalisation of Chinese Medicine Education – Future Orientation?
There are tremendous tasks ahead and complicated obstacles to overcome if Chinese medicine is to become part of a new integrated global medical education. Many factors will determine the outcome. I can foresee only a few at this point of time. For instance, international legal environment, regulations, pharma-economics and indeed the shaping of a future medical system and clinical methodologies are amongst the factors that determine the future of Chinese medicine education. This will include the shaping of Chinese medicine itself as a future medical system immediately. However, there are a few concrete steps we can take to positively accelerate this process.
1) To propose an international syllabus for Chinese medicine education, integrate both the traditional and modern concepts of Chinese medicine with a minimum standard for medical education globally.
2) To propose an international standard of practice, CPD programmes and clinical governance for Chinese medicine.
3) To consider a legal status for Chinese medicine in different countries to allow the practice of Chinese medicine as an independent medical system within an integrated mainstream medical environment.
4) To set up an approved assured quality system standards for Chinese herbal medicine.
5) To establish peer knowledge in each specialty within Chinese medicine.
6) To decide on clinical research protocols – enriching the contents of both DBM and EBM researches.
7) To foster an effective international leadership for Chinese medicine.
In conclusion, whether the globalization of Chinese medicine will succeed or not, depends on its ability to integrate within our brave new world of medicine. If Chinese medicine is relevant and effective as a medicine system, it will play a major role in the future development of global medicine despite many conflicting, geopolitical and economic interests at play.
Modernization of Chinese medicine is therefore a priority in ensuring clinical excellence. If we are able to achieve these, then I am confident that Chinese medicine will be an integral part of global mainstream medicine. Chinese medicine education will eventually play its rightful role in medical education worldwide.