The Dilemma of Chinese Medicine Practitioners face in defining ‘Integrative Medicine’ to implement the Chinese Western Integrative Medical System in Hong Kong

Author: Wong Margaret Wai Yan

Introduction

With the 100 years of British colonial rule in Hong Kong before 1997, Western Medicine had been upholding the top position in monopolizing the medical and healthcare system. After 1997, the position of Chinese medicine changed to become highly important in public health. The monopoly of Western Medicine had faded to become resistance towards the “unconventional” and “unorthodox” Chinese Medicine, and Chinese Medicine Practitioners (CMPs) are being marginalized in the health care system. Although the Hong Kong Government had stated the “parallel fashion” between the two medicines, the integration put Chinese medicine practitioners in a dilemma because their roles and responsibilities are unclear, and they are insecure in contact with Western medicine doctors (WMDs).

 

          Objective

This article aims to review Chinese Medicine practitioners’ difficulties and hardships in the face of the convergence of bio-medicine and traditional Chinese Medicine. The literature review illustrated that the introduction of evidence-based biomedicine patterns in clinical practice generated a significant divergence in the validity and reliability of Chinese medicine research findings. This included various arbitrary definitions of integrative medicine, different clinical interpretations regarding biomedicine theories for diagnosis, and Chinese Medicine for syndrome differentiation. The background knowledge and the educational curriculum between Chinese and Western Medicine elicited a lot of mistrust and misunderstanding. To strengthen integration, a communication platform should be built to enhance networking and coordination so that evidence-based Chinese and Western Medicine education can be more inclusive. Frameworks and models should be tailored for CMPs and WMDs to go beyond their limits to accomplish practical integration for the benefit of public health.

 

Problems and Hypothesis

The chief question describes the barriers the CMPs face in their competency in using evidence-based medicine applied to Chinese Medicine to achieve the collaboration of Chinese and Western Medicine in Hong Kong.

The first hypothesis is a poor knowledge base of CMPs on evidence-based medicine. The second hypothesis is that CMPs can identify their roles and responsibilities during the clinical implementation of integrative medicine.

 

              Knowledge of the Issue

After 1997, the Hong Kong Government initiated a policy of incorporating Chinese and Western Medicine in a “parallel profession” (Hesketh & Zhu, 1997). However, this medical pluralism was monopolized by Western Medicine for deep-rooted historical reasons. The incorporation was presented in a cross-hybrid principle to encourage Chinese Medicine Practitioners to know more about evidence-based medicine (EBM). Still, the clinical practice of using EBM should be circumscribed to outpatient service only (Chinese Medicine Division, Hong Kong Hospital Authority 2008).

It is known that this pluralist model can provide a series of choices for patients for alternative and complementary medicine. CMPs are concerned with the ways of incorporation in which the modes of cooperation, communication, and application of Western Medicine EBM are not well established. The CMP's commitment to using EBM in research studies was not strong enough to be built up. The respects from either side of the dual medicine were rendered from ignorance, objection, and resistance to integrating biomedicine and Chinese Medicine integration. There were no objective standards for integrating biomedicine and Chinese Medicine (Kaptchuk, 2005).

Therefore, dual medicine was not effectively integrated into a plausible pluralistic model for the public sector. Integration is an excellent, challenging task, but it is not impossible. Although Traditional Chinese Medicine (TCM) service was provided in the public sector, the formal institutional integration was poorly designed and formalized. For example, the inter-professional referral system was not well structured for professional development and the enhancement of patients’ wellness (Chung et al., 2011; CMCHK, 2023).

In March 2020, Hong Kong's government expanded TCM service by subsidizing the daily operation of 18 public CM district clinics. The annual provision was allocated for operation from HK$94.5 million in 2015-2016 to HK230 million in 2021-2011(Research Office HK, 2022). This supportive policy could help CMPs work more on chronic clinical cases. Still, the roles and responsibilities of Western Medicine were not clearly defined, especially in evidence-based medicine. They conditioned specific referral protocols in the integrative services inside and outside of the 18 district clinics (Chung et al., 2021). The functional and structural links between WM and TCM professionals are minimal and ambiguous.

The whole medical and healthcare system in Hong Kong was still dominated by Western Medicine, which was a “solo or major player” in the integrative public healthcare sector (HA, 2019). Figure 1 provides an overview of the roles of the CMPs in the Western Health Care System in Hong Kong.

Figure 1

The Overview of Chinese Medicine Practitioners in the Western Health Care System in Hong Kong.

 

Note: Most CM practitioners work in solo practices in the private sector.

Source: reference from “Overview of the Health Care System in Hong Kong (2023), https://www.gov.hk/en/residents/health/hosp/overview.htm”

Not only did primary healthcare limit the development of Chinese Medicine but the secondary and tertiary public healthcare systems could not be touched by Chinese Medicine. The whole ‘territories’ were the entire domains of Western Medicine. WM monopolized the public health system of Hong Kong. Until now, in 2023, the healthcare system in Hong Kong did not allow and legalize referrals from CMPs (CMCHK, 2023) even though dual medicine “encourages cooperation, research, and open communication and respect between practitioners” (Anderson et al., 2019), the “honest disagreement” (Anderson et al., 2019) among CMPs and WMDs was not healthy for the collaboration of the dual medicine.

The underlying objective of medicine is to save patients. CMPs are trained with the influence of China’s long-established Confucian and traditional culture (Kwan, 2020). In the Chinese Medical Doctor Declaration, professionalism was defined for CMPs in such as “equality and benevolence, the primacy of patients, honesty and fidelity to promises, commitment to excellence and prudence, incorruptibility and impartiality, and lifelong learning.” At the same time, WMDs’ Physician Charter illustrated the groundwork of the Hippocratic Oath, which stated the Western definition of professionalism (Yasin et al., 2019) for deontological principles: autonomy, justice, non-maleficence, and beneficence. Even if the principles for these dual medicines in professionalism were similar, the differences were found in the background training of Western and Chinese Medicine. The “low congruence in the validity of bio-scientific research methods about the Chinese medicine paradigm.” (Ijaz, 2019) contributed to WM being “professional monopolizers” in integrative medicine. Therefore, the WMDs had their“countervailing power of facilitating or rejecting the use of TCM services” in Hong Kong (Chung et al., 2011, CMCHK, 2023).

 

Methodology

This article reviews the integrative healthcare system in Hong Kong to reflect the dilemma of CMPs in the monopolized world of Western Medicine. The literature was reviewed by searching the international databases of PubMed, EBSCOhost, Medline, Cochrane, and ScienceDirect of Elsevier. The citations for each literature article examined biomedicine and evidence-based medicine involving CMPs’ professionalism in Hong Kong and other places. The eligibility screening through backward and forward citation chasing was also used using Google Scholar.

A qualitative method was utilized. Important themes were identified and categorized for discussion retrieved from the contents of the literature. The historical background that led to the dominance of Western medicine and the burgeoning effect in the medical system of Hong Kong was reviewed. Methods included reviewing interviews on CMPs and WMDs and their participation in the questionnaires for their view on integration were investigated. The barriers that continued working in the present system for integration with shared opinions from practitioners in the qualitative research study were also explored.

The foremost barrier that led to the dilemma was the definition of integrative medicine.

 

Defining the Definition of Integrative Medicine (IM)

Integrative medicine has an array of hundreds of different standard definitions, which are described as “unorthodox,” “unconventional,” and “non-mainstream” (Ng et al., 2022). These hundred different versions of definitions in IM were always used interchangeably in many different medical articles (Table 1). This resulted from limitations on the integrative medicine development in categorization therapy. For example, many WMDs were skeptical about Chinese natural therapy like herbal therapy and acupuncture as there was no scientific evidence to support their underlying physiology and mechanism. This led to the conclusion that herbal medicine and acupuncture were arguably excluded from the standard list of therapy categorization because of their undefined and unidentified scientific-based definitions. In addition, concepts like Yin & Yang and the Five Elements were considered unorthodox in theory and could not be verified by randomized control trials (RCT) (Xu & Xia, 2019).

To overcome the shortcomings of CM in the lack of safety and efficacy in research studies, the operational definition was defined and standardized with a list of therapies (Ng et al., 2022). But, the therapeutic categorization of integrative medicine (IM) was arbitrarily selected. The categorization was justified to be highly comprehensible (Ng et al., 2022). Table 2 shows the operational definition of complementary & alternative, and integrative medicine alphabetically.

 

Table 1 shows the chronology of defining coordination and integration.

Table 1

Chronology of defining coordination and integration.

Source: reference from Burns et al., 2022

Table 2

The operational definition of complementary & alternative, and integrative medicine is illustrated in the list.

 

 

Note that the contexts shown in alphabetical order of procedures or therapeutic names offered patient-centered care in comprehensive services in proximity of search terms.

Source: reference from Ng et al., 2022

 

Tradition vs. Modern Chinese Medicine

          Introducing integrative medicine with biomedical evidence-based methods was a big challenge to traditional CMPs. The challenge was not limited to the internal problem of the definition of integrative medicine but also the challenge between conventional and modern CMs to incorporate evidence-based medicine. Modern CM practitioners described integration as a “new medicine.” It emphasized adopting modern scientific methods to identify and interpret traditional diagnostic methods of syndrome differentiation in Chinese Medicine by clinical assessment to ensure safety and effectiveness (Burns et al., 2022). For example, the Chinese Medicinal formula treatment for COVID-19 was standardized and produced into pharmaceutical medicine to treat acute and chronic episodes of COVID-19 when the clinical quantitative and qualitative data were collected in the evidence-based studies with the approved results from statistical and official reports against the pandemic.

 

Operational definition of Integrative Medicine (IM)

Without universal consensus, the arbitrary definition reckoned another definition. Theoretical arbitrary definition of IM could not be applied officially and clinically; therefore, the operational definition was born to be proposed and modified to combine another approach to get a new definition (Ng et al., 2022). Accordingly, there were numerous of website search terms of definition such as “ operational definition of alternative medicine”, “operational definition of complementary medicine”, “operational definition of integrated medicine”, and “operational definition of integrative medicine” etc..

 

Definition of Herbal Therapies in Integrative Medicine

Herbal therapies were defined in different languages, mixing multiple common and scientific names with chaos. One example can be illustrated in chelation therapy. This therapy was adopted in Western Medicine to treat heavy metal poisoning. However, when this therapy was categorized as complementary medicine, the definition of this therapy was given to treat atherosclerosis (Ng et al., 2022). To this extent, the misalignment of definition generated a mismatch in therapies upon categorization. The non-standardization and inconclusiveness for consistency in definitions posed arbitrary ongoing and endless definitions of new definitions among countries.

 

CM Syndrome Differentiation vs. WM Evidence-Based Model

Syndrome differentiation is the Chinese medicine diagnostic method used according to the patient’s signs and symptoms during consultation. This diagnostic method formulated the ‘disease-pattern ‘ model (Nilsen & Bernhardsson, 2019). In the dual medicine environment, the definition should be categorized and standardized by empirical studies through evidence-based medicine research. Nevertheless, the categorization and standardization should be determined in contexts including but not limited to patients, practitioners, multiple disciplinary professionals, organizations, socio-politics, and culture so that the interweaving determinants could be formed in a framework to develop a core context for systematic convergence. As an example of traditional Chinese medicine pattern differentiation for diagnosis, the tongue and pulse examination can be computerized scientifically in a program of data input to compare with the WM pathological and biochemical tests. The data input can be entered into other categorized factors for evidence-based research studies, such as physical, psychological, spiritual, and cultural changes in therapeutic interventions, to formulate a holistic database on the core contexts for unifying definitions.

 

Capable Leaders for Defining Definition

World consensus on CM definitions requires capable leaders to align differences. Facing the internal resistance to Westernization from the Traditional CMPs and external opposition from the Western Medicinal regulatory bodies, the leaders should not only recognize the importance of defining IM definitions, responding to the patient’s demand for better choices with Chinese Western Medicine collaboration with consistency can fill up the ineffectiveness from either side of Chinese and Western Medicine to enhance the development of evidence-based Chinese Medicine to reinforce validity and reliability on Integrative Medicine treatments.

 

Conclusion

Inconsistent and non-unified arbitrary definitions of Integrative Medicine can produce disastrous effects on the correctness of treatment therapies. Not to mention the adherence to scientific evidence-based medicine, the internal disagreement on using traditional versus modern Chinese Medicine posed an unhealthy resistance to Integrative Medicine development. Defining IM definition involves a dynamic process in a country’s policy, which relies on other countries’ recognition. The clinical health care practice and changing contexts in the fields should be added to incorporate different factors for the identification and definition process. The definition of IM should not be arbitrarily defined without evidence-based scientific support. Systematic inputs from multidisciplinary practitioners and medical professionals from different sectors elicit more constructive and systematic frameworks for integrating Chinese and Western Medicine.

 

Reference

Burns, L. R., Nembhard, I. M., & Shortell, S. M. (2022). Integrating network theory into the study of integrated healthcare. Social Science & Medicine, 296, 114664.

Chinese Medicine Division, Hong Kong Hospital Authority 2008 https://www.ha.org.hk/ho/corpcomm/Annual%20Plan/2008-09.pdf, https://www.cmro.gov.hk/html/eng/whats_new/COVID-19_anti-epidemic/chinese_medicine_services_under_the_hospital_authority.html

 

Chung, V. C., Hillier, S., Lau, C. H., Wong, S. Y., Yeoh, E. K., & Griffiths, S. M. (2011). Referral to and attitude towards traditional Chinese medicine amongst western medical doctors in postcolonial Hong Kong. Social Science & Medicine, 72(2), 247-255.

 

Chinese Medicine Council of Hong Kong (CMCHK), 2023 https://www.cmchk.org.hk/pcm/eng/#../../eng/main_index.htm

 

Hesketh, T., & Zhu, W. X. (1997). Health in China: traditional Chinese medicine: one country, two systems. Bmj, 315(7100), 115-117.

 

Kaptchuk, T. J., & Miller, F. G. (2005). Viewpoint: what is the best and most ethical model for the relationship between mainstream and alternative medicine: opposition, integration, or pluralism? Academic medicine: journal of the Association of American Medical Colleges, 80(3), 286–290. https://doi.org/10.1097/00001888-200503000-00015

 

Ng, J. Y., Dhawan, T., Dogadova, E., Taghi-Zada, Z., Vacca, A., Wieland, L. S., & Moher, D. (2022). Operational definition of complementary, alternative, and integrative medicine derived from a systematic search. BMC complementary medicine and therapies, 22(1), 104. https://doi.org/10.1186/s12906-022-03556-7

 

Nilsen, P., & Bernhardsson, S. (2019). Context matters in implementation science: a scoping review of determinant frameworks that describe contextual determinants for implementation outcomes. BMC health services research, 19(1), 1-21.

 

Overview of the Health Care System in Hong Kong (2023), https://www.gov.hk/en/residents/health/hosp/overview.htm

 

Xu, J., & Xia, Z. (2019). Traditional Chinese medicine (TCM)–Does its contemporary business booming, and globalization really reconfirm its medical efficacy & safety? Medicine in Drug Discovery, 1, 100003.