Continuing medical education in China: evidence from primary health workers’ preferences for continuing traditional Chinese medicine education

Due to the complex and changing nature of medical knowledge, health workers undergo long periods of training, including university education and post-work practice. Previous studies have shown that four or more years of medical school education, and then several years of residency training, are both required to become a qualified physician in many countries, such as Germany, the United States, and China [1‐3]. The advancement of medical practices, the updating of medical knowledge, and constant policy changes in the healthcare system, all of which mean health workers face tremendous learning challenges. Continuous learning and lifelong education ensure qualified health workers provide constantly improving medical services for patients [4]. Continuing medical education (CME) is any activity to maintain, develop, or increase their knowledge, skills, and professional performance and relationships that a physician uses to provide services for patients [5]. Besides keeping healthcare professionals’ knowledge and skills current and promoting more efficient use of health resources, physicians who do not participate in CME have lower persuasiveness in making clinical decisions [6‐8]. CME has been shown to enhance the knowledge, skills, attitudes, and clinical outcomes of health workers [9, 10].

In China, CME is a mandatory requirement for continuous registration, requiring health workers to participate in CME activities each year and earn no less than 25 credits [11]. The content of CME includes new developments and advances in medicine, professional theories, treatment and management of common diseases, health policies and laws, new skills and practices and research capabilities. While CME has a long tradition in China, studies have shown that CME faces problems of outdated curriculum, lack of initiative in learning, only concerned with getting credits, short-term training resulting in unsystematic learning, and insufficient funding for grassroots CME [12‐14].

In China, Traditional Chinese Medicine Technology (TCMT), which includes simple, convenient, cheap, and effective herbal prescriptions, acupuncture, massage, cupping and moxibustion [15], has broad-based patient support and is given equal emphasis with Western medicine in the Chinese government’s Healthy China 2030 Program and health policies [16]. Forming part of China’s CME, the promotion and use of TCMTs promotes the rational use of medical resources, improves the service capacity of TCM, and reduces the medical cost burden of residents [17, 18].

TCMT is an essential component of CME. It plays an important role in enhancing the capacity of TCM health services. The government has been very supportive of the TCMT and has been steadily increasing its support in recent years. The 2022 TCM Development Plan calls for clinical, dental and public health to complete the required TCMT CME, and for 100% of community health units and more than 80% of village health units to be able to provide TCM services [19]. However, we noticed that the CMT CME effect is not ideal in primary health institutions in some areas. For instance, Health workers lack knowledge about TCMT. A study conducted by Wang et al. found that only 41.8% of health workers in Shanghai’s community health units know TCMT [20]. Meanwhile, primary health workers have little interest in learning TCMT and are willing to spend time learning TCMT. A study by Shi et al. showed that 37.1% of health workers in the village were unwilling to learn TCMT [21]. Moreover, Li et al. also conducted a study which indicated that there was a low number of health workers who used TCMT in clinical practice within township hospitals [22]. So, we believe that the TCMT CME should fully consider the learning preferences of health workers.

Previous studies have mostly examined TCMT’s current status, requirements and influencing factors, with few studies examining the motivation to learn TCMTs from the perspective of health workers. This paper addresses how to improve primary health workers’ motivation to learn TCMTs through CME. Specifically, we use a discrete choice experiment (DCE) to investigate Chinese primary health workers’ preferences for learning TCMTs and to explore the incentive mechanisms for promoting TCMT learning.

Developed by health economics, discrete choice experiments (DCEs) are one stated preference method used in applied economics to address key policy issues [23]. DCEs use a survey to quantitatively measure explicit preferences to determine a person’s or group’s trade-offs and choices for products and services under different hypothetical scenarios [23, 24]. Respondents choose between different scenarios that contain hypothetical alternatives, which are composed of different attributes and different levels of each attribute [25‐27]. The different learning scenarios are designed, from which health workers then choose, to measure their preferences for learning TCMTs.

We conducted a face-to-face anonymous survey in Shandong, Henan and Guizhou provinces. A total of 1,063 questionnaires were collected from TCM physicians, CM physicians, and nurses, of which 1,001 (94.2%) were valid, which comprised the study sample.

The mean age of the respondents was 36.6 years (SD = 9.4), and the median of years in the profession was 10 years (IQR: 4 years—20 years); 34.9% of the respondents were male; 32.4% of respondents were CM physicians, 31.5% were TCM physicians and 36.2% were nurses. Half of the respondents had a junior job title (50.9%) and more than half had a bachelor’s degree or higher (58.9%).

Research on how to motivate health workers to maximize CME performance is rare. To assess the motivation for CME, we used learning TCMTs as an example. The Chinese government promotes TCM as an equal treatment to western medicine with official health policy fostering TCMTs in rural and urban areas as a safe, effective, convenient, and affordable primary healthcare services [34]. TCMT CME is fundamental to advancing the Chinese government’s commitment to TCM, but TCMTs learning in China has been unsatisfactory [15, 21]. Conducting an anonymous face-to-face survey of health workers in primary care institutions in three provinces, we found that taking all health workers together, health workers were motivated to learn TCMT when TCMT learning was less costly, less time-consuming, less difficult to learn, and could be learned on the job and used in their daily work. But, taking different classes of health workers, the motivations for TCMT differ across different types of learners.

Turning first to all health workers. the attribute of the highest relative importance was learning expenses (32.0%). In general, primary care workers consider their salaries to be relatively low [35, 36], which makes them hesitant to pay to learn a new technology with which they are not familiar. Learning expenses were followed by the expected efficacy of TCMTs (22.3%), learning difficulty (14.2%), mode of learning (11.8%), type of TCMTs (8.9%), time required to learn (6.2%) and expected frequency of use (4.7%). Consistent with the evidence that innovative learning technology is more likely to be adopted by university teachers when it is perceived as superior to existing tools, easy to use, and readily available [37], our results show that primary health workers were more to undertake CME when the expected efficacy and expected frequency of use of TCMTs was higher than already learned technologies with the same effects. Most Chinese primary care physicians have a low level of education relative to Chinese physicians generally [38], which meant that easy-to-learn technology was more acceptable for these primary health workers. For health workers who are very busy in their daily practice, then on-the-job training or a less time-consuming technology is more popular among these primary care workers. The possible explanation for health workers’ preferences for TCM external treatment technology over TCM internal treatment is that they were more proficient in conventional medicine and had less knowledge of TCM, since TCM internal treatment requires greater theoretical knowledge than TCM external treatments.

Our key finding comes from our latent class analysis model that revealed significant differences in learning motivations according to three main TCMT learner classes: infrequent users (50.1%), workaholics (20.1%) and pragmatists (29.8%). The three groups differed in their socio-demographic characteristics, and required different motivational learning strategies. We recommend CME trainers target different CME approaches to address each of these types of TCMT learners. Infrequent users had significantly lower learning motivation scores and the lowest percentage of TCM physicians. The attributes they valued most were learning expenses and the difficulty of the TCMTs to learn.

The infrequent users group had significantly lower learning motivation scores and the lowest percentage of TCM physicians. The attributes they valued most were learning expenses and the difficulty of the TCMTs learning. This class mostly consisted of CM physicians and nurses who used mainly conventional medical technologies in their daily work; had a weak basic theory of TCM [39]; sought TCMTs that were easy to learn; and preferred TCMT that had low learning expenses. There exists pressure on CM physicians to respond to the national policy to learn TCM technologies [40], however, improving CM physicians’ knowledge of TCM has a positive effect on their ability to provide integrative medical services [41]. For the infrequent user group, we can reduce the learning expenses of TCM learning, select simple TCMTs, and at the same time enrich the teaching mode to increase their interest in learning. By applying targeted learning approaches to the infrequent user group, the motivation of learning TCMTs and the willingness to apply TCMTs in clinical practice in this group can both be increased [42].

The workaholics, who accounted for 20.1% of all respondents, had the longest work years and the attribute they valued most was the mode of learning. Workaholics’ long stay of work implies that they have mastered the necessary medical skills to perform their daily procedures well, so they prefer learning CME on the job, which is consistent with research that found many health workers preferred on-the-job learning due to the conflict between work and learning [43]. This group values small group educational meetings, multidisciplinary discussions (both formal and informal) and interactive workshops, in particular, all of which have been shown to be effective measures of CME [44], and allow for on-the-job learning.

The third class was the pragmatists that contained the highest proportion of TCM physicians, who attached importance on the efficacy and expected frequency of TCMT use, and health workers of this class were more likely to be the actual users of TCMTs. They were extremely passionate about TCM, had a good theoretical foundation in TCM, and could better apply TCMTs learned through CME in practice, so pragmatists attach importance to TMCT frequency of use and efficacy, and expect that TCMTs should achieve more effective results for their patients [45]. For this group, it is necessary to screen learning programs to focus on the most effective TCMTs and to match TCMT learning to the urgent needs of the public [46, 47].

This study has several limitations. Our DCE study focused on seven attributes, but future studies should consider other attributes, such as TCMT equipment conditions and personal development opportunities, which also affect health workers’ TCMT learning preferences. DCEs measure stated preferences, which may differ from their actual behaviors. Further research is needed to expand the measures of primary health care workers’ revealed preferences. This study focused on the learning preferences of primary health workers for TCMTs, which can increase learners’ motivation and improve the quality of learning from a personal subjective perspective, but the data in this study did not analyze the actual objective learning effects, and further research on this topic is needed. Our recommendations apply to primary health workers, and future studies should explore CME for hospital health workers.

TCMT CME is a key driver of the Chinese government’s commitment to promote TCM as an equal treatment with western medicine. Our study reveals the preferred CME approaches and recommends tailored TMCT CME programs. The key finding is that health workers can be divided into three distinct classes of TCMT learners. Infrequent users (class 1) (50.1%) preferred to learn simple and external treatment TCMTs; the workaholics (class 2) 20.1% preferred to learn TCMT on-the-job; and the pragmatists (class 3) 29.8% showed a strong preference for learning TCMTs with higher efficacy and more frequent use. We recommend that different measures can be taken to incentivize the three classes identified: for infrequent users (class 1), healthcare units can offer more free and short-learning in-hospital TCMT CME to increase their knowledge and interest in TCMT; for workaholics (class 2), it is crucial that TCMT CME does not disrupt their regular work; for pragmatists (class 3), healthcare units can offer more free, short-learning and frequently used TCMTs and teach them without disrupting normal work. While we used the example of learning TCMTs for our study, our research conclusions have implications for other CME programs.