Kenneth Kushner, Shuang Yu

Integration of traditional Chinese medicine and Western medicine in a Chinese community health center

Kenneth Kushner1, Shuang Yu2

Objective:Although the literature is abundant on traditional Chinese medicine (TCM) in the West, there is limited information on how TCM is integrated with Western medicine (WM).We describe how one Chinese Community Health Service (CHS) system located in Beijing integrates WM and TCM.

Methods:Our information is based on the authors’ observations, interviews with center TCM practitioners, and discussions with center administrators.

Results:We summarize our observations according to the following themes: selection of type of practitioner; frequent diagnoses of patients seen by TCM clinicians; types of TCM services provided; economic factors; challenges; and future directions. Patient age, nature of the problem, and cost may determine whether or not Chinese patients initially consult TCM or WM practitioners. Because of referral pathways between the WM and TCM practitioners, up to one-third of the patients receive integrated care. TCM physicians see more patients per day than do their WM counterparts; TCM physicians also earn higher salaries. Although there are clearly close collaborative relationships between the TCM and WM practitioners, a few TCM providers report that lack of respect between the two fields may be a barrier towards further integration.

Conclusion:Given governmental policies and the cost differentials between WM and TCM, the future for the integration of the two medical traditions within the CHS system appears to be favorable; however, issues of mutual respect and workforce issues may challenge successful integration. Our impressions are limited by the fact that we observed practices in only one community in one district of Beijing.

Traditional Chinese medicine; integrative medicine; community health centers;China

Introduction

How to combine Western medicine (WM) and traditional Chinese medicine (TCM) has long been an area of interest within the discipline of integrative medicine (IM) as practiced in the West. For that reason, TCM techniques, particularly acupuncture, are frequently used in IM settings. Perhaps less known to a Western audience is the Chinese version of IM. Like the Western counterpart, Chinese TCM is also concerned with how best to integrate WM and TCM. As Lu [1] recounts, interest in integrating WM and TCM arose in the 1950s when TCM-trained scientists werecross-trained in WM. Chinese IM differs from Western IM in that the latter combines a broad range of complementary and alternative medicine (CAM) treatments (including TCM) with WM, although the former combines WM alone with TCM [2].

The English language literature on the application of TCM techniques and principles to a broad variety of medical problems is extensive, and includes at least two English language journals devoted to these topics (Journal of Chinese Integrative Medicine and Chinese Journal of Integrative Medicine [formerly the Chinese Journal of Integrated Traditional and Western Medicine]). A small number of the articles published in these journals discuss how TCM and WM are integrated in clinical settings; this is true of the Western IM literature as well. Information is limited with respect to how WM and TCM might work together in the same setting and how clinical decisions might be made.

The purpose of this article was to describe how WM and TCM are integrated in a multi-site CHS system in one community (the Yuetan neighborhood in Beijing, China). Because many Western readers are likely unfamiliar with the Chinese community health service (CHS) system, we will describe the role of the CHS in the Chinese health care system.

The CHS system arose from health care reforms promulgated by the central government of China over the last decade. The institution of a free market economy in the late 1970s brought an end to a healthcare system which provided universal coverage and which emphasized specialty care in government-owned hospitals. With the transition of the country to a market-based economy in the late 1970s, many hospitals and other health facilities lost some or all government subsidies. Hospitals and other health facilities were forced to increase revenue through the prescription of high-tech procedures and high-cost pharmaceuticals, thus resulting in a costly and inefficient hospital-based system. Simultaneously, the collapse of rural health cooperatives, which funded basic health care for peasants, resulted in the percentage of rural citizens with medical benefits decreasing from 85% to 4.8% by 1980[3]. The CHS system created a network of community-based centers that combine primary health care and public health services in an effort to “reduce costs, improve efficiency,and improve access to care” [4]. In so doing, the government intends to replace many top-tier neighborhood hospitals with CHS facilities [5]. The most recent health reforms in 2007 and 2009 put greater emphasis on the role of CHS system in the overall health care system of China [4].

The CHS centers combine basic primary care and public health services. All centers are expected to provide the following six services: prevention; health education and promotion; birth control; outpatient evaluation and management of common illnesses; case management of chronic disease; and physical rehabilitation [5]. Many centers have smaller, affiliated clinical facilities (usually translated into English as “stations”). In 2006, the Chinese central government mandated that all CHS centers must include TCM services [6]. More recently, the State Council established updated national goals for the CHS centers. One goal was that more than 95% of the CHS centers and 70% of the stations provide TCM services by the end of 2015. In addition, 20% of the staff must be TCM practitioners in 95% of the CHS centers. Further, at least 70%of the stations must have at least 1 TCM practitioner. The document also mandated that all provinces and cities must offer a standardized TCM curriculum for general practitioners [7].

Methods

This article is based on descriptive observations by the first author during numerous trips to Beijing since 2001, and on the knowledge and observations of the second author, a TCM practitioner in the Yuetan CHS Center. In 2012, interviews were conducted with TCM providers working at those sites,as well as administrators of the Yuetan CHS system. This project received an exemption from the University of Wisconsin Institutional Review Board.

The Yuetan CHS system is located in the Xicheng (Western)district of Beijing, and is one of 15 such systems in that district. The Yuetan CHS system serves the Yuetan (Temple of the Moon) neighborhood, which occupies approximately 4.14 km2and has 130,000 residents. The system was started in 2000 with the construction of the Yuetan CHS Center, a 5-story clinical and administrative facility. There are currently 10 smaller stations, which extend the reach of the center into the community. The center and the stations are affiliated with Fuxing Hospital, an 816-bed community hospital owned by the Xicheng District Health Bureau. Fuxing Hospital is a teaching hospital affiliated with Capitol Medical University.

The center and stations are staffed by a total of 199 health providers (99 physicians, 54 nurses, 7 social workers, and 39 other personnel [pharmacists]). Slightly greater than one-half(57%) are based in the center building. The following services are offered at the center and stations: general practice; family planning; women’s health; pharmacy; preventive services;mental health; X-ray; ultrasound and ECG; child health care;dental care; immunization; disease surveillance; audiometry;and TCM.

Nearly an entire floor of the center building is dedicated to TCM. The TCM staff is comprised of 17 physicians, 1 nurse,and 1 pharmacist. Fourteen of the TCM providers work at the center, four at the stations, and two providers rotate through various locations. Two of the TCM practitioners have master degrees; the remaining practitioners are bachelor-level clinicians. The TCM services include acupuncture (including moxibustion and electroacupuncture), massage (including pediatrics), cupping, bloodletting, herbal therapy, ear cutting,and TCM health education. The center also has a rehabilitation program that combines WM and TCM services, as well as a pharmacy that is stocked with a limited number of packaged TCM remedies. Patients are referred to dedicated TCM pharmacies for more complex prescriptions. The center and stations served 414,466 patient visits in 2013, of which 160,587(21%) were conducted by the TCM clinicians.

Results, findings, and observations

We have organized our observations into the following themes:how selections are made between WM and TCM treatments;what conditions the practitioners think are best treated by WM versus TCM methods; how WM and TCM practitioners communicate and cooperate; and perceived barriers to the successful integration of WM and TCM.

Selection of type of provider

Patients are allowed to choose the type of provider (WM or TCM) as they see fit. Overall, patients tend to choose WM practitioners, primarily general practitioners, as a first line of treatment. In general, older patients are more likely to select TCM practitioners than younger patients. The TCM physicians interviewed varied in their estimates of the percentage of patients who seek the help of a WM practitioner first,but agreed that patients often consult a TCM practitioner if WM treatment is not successful. Between 20% and 30% of the patients seen by TCM practitioners are referred directly by WM clinicians. Similarly, the TCM practitioners refer 20%–30% of their patients to WM physicians. The referrals to WM practitioners tend to be for cardiac problems (including hypertension) and diabetes. Approximately 20% of the patients referred to WM practitioners receive WM treatment only; the remaining 80% of patients are referred back to the TCM staff for traditional treatment.

Frequent diagnoses of patients treated by traditional Chinese medicine practitioners

The TCM practitioners reported that pain, particularly knee pain, back pain, and headaches, are the most common reasons for TCM treatment. Other problems commonly treated are menopausal symptoms, infertility, hypertension, gastrointestinal disorders, urinary problems, emotional/mental problems,and functional somatic problems. Treatment of patients after cancer treatment to “balance their body” was also mentioned.

Types of traditional Chinese medicine treatments

offered

Most patients receiving TCM treatment are given a combination of acupuncture and herbal remedies. Only 1%–2% of the TCM patients received herbal treatment alone. As mentioned above, the center pharmacy maintains a limited supply of packaged TCM remedies. The center pharmacist will call a dedicated TCM pharmacy when patients need more complex herbal prescriptions.

Economic factors

Both TCM and WM practitioners cited cost as a major advantage of TCM over WM treatment. The average physician costs for a WM course of treatment is 59.6 RMB (9.75 USD), compared with 36.7 RMB (6.00 USD) for the course of TCM treatment. Medicine costs an average 226.1 RMB (40.00 USD) per WM prescription, although TCM prescriptions average 171.4 RMB (28.00 USD). Approximately 85% of center patients have health insurance, which reduces out of pocket costs to 10%. Unlike many other CHS centers in Beijing where the physicians are on fixed salaries, the Yuetan CHS Center physicians are paid on an incentive basis. In 2014, the WM physicians averaged 110,000 RMB (17,988 USD) per year,although a TCM physician averages 140,000 RMB (22,894 USD). The TCM practitioners see an average of 40 patients per day, although the WM practitioners average 30 patients per day.

Challenges

The TCM practitioners cited a lack of respect for their specialty by the WM practitioners as a major challenge. TCM practitioners believe that although they have respect for WM,this is not reciprocated by their WM colleagues. Some TCM interviewees thought that the lack of respect stemmed from inadequate education about TCM in WM training; one TCM practitioner cited a lack of awareness on the part of WM practitioners that TCM has applicability to acute and emergency conditions in addition to chronic illnesses. Workload was another issue for the TCM practitioners. Because of the high demand for TCM services relative to the number of staff, and the lack of nursing and other ancillary support, TCM practitioners view themselves as working harder and longer hours than their WM counterparts. One administrator cited a shortage of properly-trained TCM physicians as being a potential barrier to increased integration of WM and TCM in the CHS system.

Because we did not interview WM physicians, we are not able to comment on their perspectives on the challenges to the integration of WM and TCM.

Future directions

Both TCM practitioners and center administrators were quite sanguine about the future of TCM in the Yuetan CHS system.Both cited the cost differentials between TCM and WM, government support of TCM services, and patient demand. Both TCM practitioners and the system administrators cited workforce issues as key challenges for the future. How to interest young TCM practitioners to work in the CHS system, as opposed to more traditional TCM hospitals, remains a major concern.

Discussion

The CHS system in China is a relatively new development designed to reduce the emphasis on costly hospital-based specialty care by creating an infrastructure of communitybased clinics emphasizing primary medical care and public health services. The inclusion of TCM services has become an important, government-mandated component of the CHS mission.

In this descriptive article we reviewed the system in one community in which WM and TCM services are co-located and in which patients are given considerable choice whether they would like to see a WM or TCM practitioner for a given problem. It appears that patient age, the nature of the problem, and cost may determine whether the patient initially consults TCM or WM practitioners. There are also referral pathways between the WM and TCM practitioners, which result in integrated care for up to one-third of the patients.TCM physicians see more patients per day than their WM counterparts. TCM physicians also earn higher salaries.Although there are clearly close collaborative relationships between the TCM and WM practitioners, the comments by the former regarding lack of respect may be a barrier towards further integration. Better education of WM practitioners on the advantages of TCM and vice versa might help foster better trust and communication between the two types of clinicians. Given the central government’s increased emphasis on TCM services in the national CHS system, it is possible that increased mutual respect between TCM and WM practitioners, as well as greater integration of TCM and Western services, will increase in the future. The size of a properly-trained TCM workforce may, however, constitute a barrier to the integration of TCM and WM services in the CHS system.

Our observations are limited because we observed practices in only one CHS system in one district of Beijing. For that reason, we cannot generalize to other CHS institutions in that city or other provinces of China. Similarly, we did not interview WM physicians working in the Yuetan CHS system, thus we cannot comment on their perception of TCM and how it is integrated with WM. We hope that this article will stimulate further scholarly interest in the integration of TCM and WM within the Chinese CHS system.

conflict of interest

The authors declare no conflict of interest.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-pro fit sectors.

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6. State administration of Traditional Chinese medicine of the Peoples’ Republic of China. Opinions on promoting traditional Chinese medicine as part of community health practices in urban areas. 2006 [cited March 5, 2015]. Available from: www.gov.cn/zwhd/2006-08/10/content_376481.htm.

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Notes for China Focus

The significant development of family medicine and community health around the Asia-Pacific rim has been con firmed by China’s health care advances. China’s establishment of the combined mode of family medicine and community health has had a great effect on improving residents’ health, reducing costs of medical services and optimizing community health care. China Focus aims to provide a forum for the timely communication of family medicine and community health issues between China and the world. We welcome manuscripts contributions.

Currently, articles focusing on the integration of traditional Chinese medicine and Western medicine are rare outside of China. Professor Kushner pays close attention to this neglected subject. His article introduces the current situation to the world,puts forward useful insights for further development, and stimulates more focused studies on this topic.

For more information on the integration of traditional Chinese medicine and Western medicine, please refer to http://www.chinagp.net/ or contact the editorial of fice via of fice@fmch-journal.org.

1. Department of Family Medicine,University of Wisconsin, Madison,WI, USA

2. Yuetan Community Health Services, Beijing, China

Kenneth Kushner, PhD

Department of Family Medicine,University of Wisconsin, Madison,WI 53715, USA

E-mail: Kenneth.kushner@fammed.wisc.edu

26 March 2015;

20 April 2015