Desired Chinese medicine practitioner capabilities and professional development needs: a survey of registered practitioners in Victoria, Australia

Chinese medicine (CM) is a unique medical system that has been taught and practised in China for more than 2000 years. Over the last several decades, CM has been increasingly used in the Western world, including Australia [1]. In parallel, CM education has been introduced in public and private institutions in a number of Western countries. In Australia, currently more than 20 institutions provide degree or diploma level education in CM [2]. Of these, four publicly funded Australian universities offer degree programs in acupuncture and/or Chinese herbal medicine. While the expansion of education programs in CM in the West has been welcomed, the consistency of educational quality has been an ongoing concern.

As a worldwide trend in medical education, there has been a growing emphasis on the learning process and learning outcomes, shifting from the traditional focus on course content and hours of tuition [3]. The required capabilities of practitioners have been used to guide curriculum design in most health practitioner education programs [4]. It is expected that by the time students graduate, they will have developed defined capabilities which meet the expectations of the public for safe and effective clinical practice.

Some medical schools in Australia have also introduced such capabilities into their curriculum. For example, the University of New South Wales has developed a new curriculum in which the capabilities of medical graduates are central to its design [5]. At RMIT University, all undergraduate and postgraduate programs are required to apply a capability-based curriculum approach. This approach was adopted in the design of the recently introduced postgraduate Chinese herbal medicine program in the School of Health Sciences [6].

Victoria is the only state in Australia, and also the first jurisdiction outside China, to have established and enforced standards of education and practice in CM. The Chinese Medicine Registration Board of Victoria (CMRBVic) has also published course approval guidelines for CM educational programs [7]. These guidelines use a traditional approach by describing the general outcomes of knowledge, skills and attributes of graduates of the approved courses, but they fail to define clearly demonstrable CM practitioner capabilities. Therefore, program approval is still largely based on general principles, rather than on more objective and measurable criteria. In addition, over nine hundreds of Chinese medicine practitioners were registered under much more flexible requirements between 1 January 2002 and 31 December 2004, known as the grand-parenting or transitional arrangement.

In developing the postgraduate Chinese herbal medicine program mentioned above, RMIT classified the Registration Board's guidelines [7] into four broad categories of desired capabilities: technical; communication; sustainability; and, research. A total of 28 capabilities were included under the four categories in a desired capability chart which was used to guide the development of the new masters program. Details of the process have been described elsewhere [6]. This capability chart was used as the basis for a bilingual (English/Chinese) questionnaire developed to seek practitioner views of the capabilities desired for Chinese medicine practice.

Variable qualifications and backgrounds are anecdotally presented among the current registered practitioners, while the CMRBVic education standards are based on what the profession has defined. This survey was to gather existing practitioners' views on desired capabilities of Chinese medicine practice against the CMRBVic requirements for new graduates to determine the knowledge and skills gaps between the two categories of practitioners. Consequently, professional development needs and strategies could be developed by the CMRBVic and/or the profession to narrowing down these gaps to ensure consistency of standards of practice.

Human Research Ethics approval was obtained from the RMIT University's Human Research Ethics Committee prior to the commencement of the survey.

There is no existing literature on practitioners' view of the importance of desired CM professional capabilities. The current study surveyed all registered CM practitioners in the State of Victoria, Australia to obtain existing practitioner views regarding desired capabilities and to identify their continuing educational needs. The findings of this study may inform the development of CM educational programs, and are of relevance to regulators who are increasingly concerned about continuing mandating professional development (such as the Victorian Health Professions Registration Act 2005) [9] and ensuring that health professional education reflects contemporary requirements of a changing health industry [10]. These findings may also be relevant to a broad range of health professionals as well, beyond CM practitioners.

The response rate of this study was 32.5%. The mailing list used in the current survey was provided by the Chinese Medicine Registration Board of Victoria and hence. Hence, the sampling frame was the totality of eligible population. Perhaps, the most noteworthy shortcoming of the current survey is that two-thirds of the targeted population did not respond. This may have introduced a non-response bias towards the rating of capability items. Despite the fact that the study sample was comparable to the target population on important characteristics (see Methods), interpretation of the findings from this study needs caution and a follow-up study is required with an effort to increase the response rate. The other issue is to clarify the meaning of postgraduate studies as it appeared to be understood differently by participants

It is understood that effective clinical practice is dependent on graduates' ability to integrate and consistently apply a number of capabilities beyond profession-specific skills and knowledge [11]. Thus, it is not surprising that technical capabilities (specifically, the ability to perform acupuncture treatment and/or dispense an herbal prescription) were considered to be the most important aspects of clinical practice, followed by responsible and sustainable practice capabilities. As a clinically oriented workforce, practitioners seek to learn their trade. In contrast, most participants considered the ability to develop a research protocol, an element of the research and information management capabilities, to be only moderately important. Such views reflect the theoretic underpinning of Chinese medicine held by members of the profession, something that needs to be addressed through continuing professional education and incorporation of the importance of this activity into CM practitioner education. Nevertheless, in recent years, there has been an increasing body of scientific evidence of CM treatment from rigorously designed clinical research which may serve as the base of integrative health care.

The country where practitioners' obtained their CM education appears to be an important factor influencing their rating of the importance of a number of capabilities, in particular, communication capabilities. A much lower proportion of those without Australian qualifications considered communication capabilities to be important. This may be related to socialisation during the course of education, which in turn reflect differences in the value orientation in health professional education generally or in specific curriculum design [12]. At the same time, it might also reflect self-selection, that is, Australian trained CM practitioners choose to enter the profession because they consider it to offer a holistic approach to health-care in contrast to conventional health-care professions. These findings are consistent with a previous study comparing CM tertiary education in Australia and China. They suggest that, CM education in Australia shares a number of common features with that in China, but the location of education has an impact on its curriculum design as well [12]. This is a matter that warrants additional exploration.

In relation to the "less important" capabilities, over one-third of male participants considered patient referral capability to be less important. This is a finding that will be of concern to health policy-makers, in the context of ensuring continuity of care and the most appropriate care. New graduates rated higher identifying key business issues than did elderly practitioners. This may reflect their educational background and the early stage of their practice development. However, it is clear that participants without overseas experience would like to gain further qualifications, but were less willing to engage in research studies. In addition, participants with Australian qualifications would like to pursue postgraduate study, but not research. The motivation underlying selection of a particular course for professional development warrants further study.

Much educational research has been done for the western medicine profession, however, in the USA, the concept of embedding desired essential capabilities into curriculum design is a recent development [13]. These essential capabilities are broadly similar to the capabilities included in the current study. For example, clinical (technical) skills, communication skills, information management and critical thinking and research have all been addressed. It has been stated that such core capabilities [14] would help to determine what teachers are supposed to teach, what students are expected to learn, and what educational experiences all physicians must have.

It is challenging to identify a range of capabilities that truly cover the roles of CM practitioners in the Australian health-care setting. Unlike the situation in Asian countries and a limited number of Western countries, CM practitioners in Australia are mainly self-employed. Compared with the traditional approach to curriculum design, the capability-based approach of professional education potentially leads to individualised flexible learning, transparent standards, and increased public accountability [15]. Other studies have demonstrated that medical residents who had attended courses based on competencies perform better and are safer practitioners [16]. In Australia, criterion-referenced approaches to set standards have been used to define and measure competencies for graduate entry medical programs [17]. A sophisticated model of professional education is required that recognises both basic standards and continuing professional development [18] and thus, to enable Australian CM practitioners to provide a safe and effective health service.

This study provides an in-depth perspective of the professional capabilities of CM practitioners – a profession with increasing numbers of practitioners in Western countries, including Australia. The views on capabilities reported by current practitioners can inform educational curriculum design. However, the lack of recognition of the importance of research capability will continue to hinder the development of CM as an evidence-based healthcare profession.