Reconceptualizing Professionalism in the Context of Acupuncture: Setting Standards for Future Acupuncturists, a View from Malaysia

Abstract

Introduction Professionalism and ethical practices in the field of acupuncture is scarcely discussed. Professionalism and medical ethics are important topics in conventional medicine and is the supporting structure gathering human trust and belief in the medical system. Medical professionalism is a set of values, behaviors, and relationships that underpin public trust in doctors.1 It lies at the core of the contract between medical professionals and society,2 and is a stabilizing morally protective force in the society.3 Unprofessional conduct in doctors has been associated with an increased risk of adverse medical outcomes in patients. Thus, to ensure better medical outcomes and well-being of the patient, a uniform system of professional practices must be established within acupuncture. Before this, some research has been done regarding this topic, and our study serves to identify open questions regarding professionalism in acupuncture, including whether biomedical and Traditional Chinese Medicine (TCM) knowledge should be a requirement for professionalism, whether ethics should be considered an aspect of professionalism, differences between interpretations of professionalism, who is responsible for establishing these professional standards, and what we the authors suggest to establish a uniform system of professional values in acupuncture. The objective of this study is to review information related to professionalism in acupuncture and to organize the information in a manner that is presentable and clear to the reader. The review highlights professional standards that needs to be adhered to as well as professional practices in acupuncture, including educational requirements, ethics, professional medical practices, as well as ideal implementation of establishing professionalism. The intended purpose of this article is to support uniform adoption of the recommendations for professional and ethical practices in acupuncture practice. Discussion Limitations: Our study has the following limitations. First, due to the lack of relevant resources about professionalism in acupuncture, we selected relevant sources regarding medical professionalism in conventional medicine as well as surveys in a medical college setting to compare with attributes of professionalism based on requirements set by the Ministry of Health in Malaysia, interviews of TCM practitioners, and two relevant case studies of the professionalization in acupuncture in the United States. The requirements and standards for professionalism in conventional medicine cited in this study are only used as means for comparison. In this study, they are merely representative of professional standards set in the field of biomedicine. Second, we used the databases Google Scholar, Web of Science, and PubMed in conducting the search for relevant articles. Literature in Chinese or other languages have not been browsed. Third, the ethical aspects of professional practice as well as professional research and clinical trial methods will only be briefly discussed as they are not part of this main topic. Finally, ethics in the context of TCM based on ancient texts will not be covered. Our article will mainly focus on available literature regarding professionalism in acupuncture, and we aim to redefine and reconceptualize what we think are necessary attributes of professionalism that are effective in enhancing the professionalism in acupuncture and provide directions for future research. Owing to such limitations, further research in the form of surveys, behavioral inspections, and wider search for available literature in different languages is crucial in conceptualizing a uniform international standard for professionalism in acupuncture. ?Profession can refer to the conventions by which people recognize a given expertise, including knowledge and related skills.?4 Comparing the attributes of professionalism stated by relevant sources, we discovered that only one source mentioned the word principles,5 referring to fundamental principles of professionalism (patient welfare, patient autonomy, and social justice). Commitment to competence,5 continuous improvement,6 lifelong/self-directed learning skills,7 excellence5,6 are similar terms mentioned across different sources. Although there are some similarities, it is evident that even within the field of biomedicine, professionalism is not firmly established with a consensus. However, biomedical standards have found its way into influencing the professionalism of acupuncture.4 Biomedicine has claimed a universally untouchable place in the international medical system and is clearly evidenced by its generally being known as medicine. Supreme Court authorities have deemed it as neither a business nor a trade, and had given it immunity from antitrust suits, and had upheld the exclusivity of its license and of its monopoly and control over practice. Owing to this, biomedicine cannot be referred as the gold standard of professional medical identity for all medical modalities, nor is it the perfect authority to set the gold standards for other medical modalities.4 It is evident that two very different paradigms are at work because acupuncture and biomedicine have mutually exclusive conceptualizations of the body. Owing to the differences in knowledge, theoretical composition, and historical constructs of medical modalities, it is almost impossible for one modality to understand the other, much less define what is professional for the other. That is some experts have recommended to establish a separate standard of professionalism for acupuncture. After reviewing available data, we recommend that professionalism be redefined for acupuncture with unique standards in knowledge, practice, and implementation. The ultimate goal is to bring acupuncture to a professional standard that is acceptable by the biomedical model in knowledge, clinical practice, and efficacy, whereas keeping the TCM theories and philosophies that serve as the guidance for practice. In the following sections, we will discuss several important topics within the profession of acupuncture that are still in debate. Does professionalism include ethics and physician conduct? A survey of 109 students and 83 faculty members of Oman Medical College attained surprising and unexpected results about medical professionalism and identified an unaddressed issue: the current generation may have a different perception of professionalism as their personal values and opinions.8 Although medical students expressed a positive attitude toward professionalism, many in the interview felt that ethical thinking and behavior should not be a part of medical professionalism. However, according to Table 1, most sources regarding medical professionalism (government documents included) place a strong emphasis on the ethical thinking and behavior as a professional attribute. Table 1. List Source of the Attributes of Medical Professionalism Source Attributes of medical professionalism General Medical Council's publication of Good Medical Practice5 Providing good clinical care, maintaining good medical practice, teaching and training, relationships with the patients, working with colleagues, probity, and health ABIM Project Professionalism5 Altruism, accountability, excellence, duty, honor/integrity, and respect The Physician's Charter5 Three fundamental principles: patient welfare, patient autonomy, and social justiceTen professional responsibilities: commitment to competence, honesty, confidentiality, relationships, quality of care, access to care, distribution of finite resources, scientific knowledge, and managing conflicts Qualitative Study of TCM Practitioners9 Doctor?patient relationship skills, reflective skills, time management, and interprofessional relationship skillsTwo new subdomains: ?communicated effectively with patient? and ?demonstrated understanding and integrated with conventional medicine? Royal College of Physicians (2005)6 Integrity, compassion, altruism, continuous improvement, excellence, and working in partnership Elements of Professionalism in a Questionnaire conducted in Oman Medical College7 Up-to-date knowledge, teamwork, good communication skills, patient safety, self-management, self-restraint/risk management, humanity, integrity/honesty, logical/critical/creative thinking, physical and mental health, ethical thinking and behavior, lifelong/self-directed learning skills, service oriented, respect for others, self-confidence/self-efficacy, appearance/behavior, etiquette, and foreign language skills ABIM, American Board of Internal Medicine; TCM, Traditional Chinese Medicine. Behavioral and ethical aspects are denoted by doctor?patient relationship5,9 and characteristics such as honor, integrity, honesty, compassion, ethical thinking and behavior, respect, and etiquette.5?7 This brings to concern a dire need for medical institutions and teachers to identify and make explicit the expectations of medical students during the interaction in a clinical setting. Formal teaching of medical professionalism must be deployed. In the Program Standards for Traditional and Complementary Medicine published by the Malaysian Qualifications Agency in 2021,10 Ethics and Professionalism are placed under the same category for student learning outcomes. Thus, it is evident that ethics and moral behavior play a critical role in defining professionalism. Is there a need for TCM knowledge? Biomedical knowledge? In recent decades, acupuncture is introduced into various Western communities.1 Since then, many health professionals reinterpreted and reinforced the theoretical background of the practice with anatomical, physiological, and pathological knowledge. A clear separation appeared in the field of acupuncture, dividing practitioners into two main categories: Traditional and Modern. The attributes of medical professionalism include lifelong learning, scientific knowledge,5 and demonstrating understanding and integration with conventional medicine.9 It is of no doubt that TCM theory is important in explaining the ancient theoretical background guiding acupuncture treatment. However, since the emersion of modern acupuncture, some practitioners firmly believe that biomedicine alone is sufficient for explaining the efficacy of acupuncture. Knowledge of modern anatomy, physiology, and pathology can provide clearer guidelines for the identification of acupuncture points, explain the efficacy of acupuncture from a scientific perspective, and professionalize acupuncture to meet the modern expectations of the scientific and conventional medical community. However, the importance of TCM theory should not be rejected or ignored. Biomedicine and acupuncture are two very different medical modalities. One is guided by Western roots, whereas the other has roots tracing back to China. Biomedicine can only assess the efficacy and validity of the treatment, not the theoretical framework of TCM theories and philosophies. It is nearly impossible to explain concepts in acupuncture such as qi, yin, yang, and meridians in biomedical terms. Moreover, TCM is unique due to its specialization and holistic philosophy of treatment. In TCM, two patients with similar illnesses may be treated in two very different ways depending on their constitution and the symptoms they present.11 Neglecting TCM knowledge for the sake of standardization and integration of acupuncture with Western medicine would lead to the indirect suppression of the variety of acupuncture traditions and remove its strong roots in Chinese Medicine. It is absurd for a medical treatment to be used without the guidance under which it was established. Thus, we suggest for acupuncturists be educated in both TCM and biomedical knowledge, and that in utilizing biomedical strengths to increase the acceptance of acupuncture, implementation of good clinical standards equivalent to biomedicine be practiced. As acupuncture is increasingly being called upon to demonstrate its efficacy, safety, and legitimacy, scientific research and validation under proper clinical trials and methods must be deployed.4 Furthermore, since working with colleagues, interprofessional relationship skills, working in partnership are listed as elements of professionalism, knowledge in both TCM and biomedicine can provide the language of science and ease communication with professionals such as other acupuncturists, physicians, as well as other biomedical professionals. Thus, institutions must ensure that both TCM theory and modern anatomy, physiology, and pathology are emphasized to develop medical professionalism in future acupuncturists. Medical professionalism is patient-centered: Should we also consider prioritizing the well-being of the practitioner? During the Covid-19 pandemic, hospitals are understaffed and have to work with sleep deprivation, excessive or conflicting job demands, long hours, and an imbalance between work and home life.6 Suicide rates appear higher among doctors than in other occupations. In the United States, estimates suggest one physician dies by suicide every day. Also, physical and mental health7 and health5 are listed as elements of professionalism in relevant sources. Thus, it is undeniable that the well-being of the practitioner should be valued in health care systems. Values around professionalism should not force medical professionals into a set of rigid rules that only serve to define who they are professionally, but not who they are truly. Medical professionalism should be genuine and not forced through self-regulation for the sake of professional work. Self-care and self-awareness must be placed before the practice of medical professionalism. After all, we can only properly care for others once we are in a good condition. Rights to health, equity, social justice, diversity and inclusion, physician well-being, and workforce planning should be discussed and implemented for the maintenance of the modern health care system. Reconceptualizing Professionalism in Acupuncture Up till now, there has not been a clear definition for professionalism in acupuncture. Modern efforts to professionalize acupuncture, such as the Clean Needle Technique method and other hygienic requirements, are important constituents that have helped establish professionalism. Other efforts are demonstrated in the transformation of the Chinese Medicine course in West Coast University, highlighting its uniqueness as a science-based school of natural medicine.11 Even earlier, the professionalizing of American Acupuncture as seen in Massachusetts in a step-by-step historical process documented by Linda L. Barnes.4 Two dimensions have been considered in the efforts to professionalize acupuncture: the establishment of schools of TCM and acupuncture, and Accommodation to the Biomedical Model. Establishment of schools with a standard in education ensures enhancement of professionalism in the field of acupuncture as a whole. The Biomedical model requires students to be professional in both appearance and attitude, being neat and clean at all times. Implementation of proper hygiene and precautions can help reinforce the fact that acupuncture is a professional medical system. Medical physicians in the west who have incorporated the use of acupuncture with health systems and hospitals should be evaluated with the same standards set for all acupuncturists.2 However, several crucial aspects of professionalism must also be addressed. First, the accreditation of clinics and practitioners must be renewed on a timed basis (annual/every 5 years) to ensure the validity and credibility of the treatment. Licensing requirements and professional accreditation must not be ignored or circumvented. In Malaysia, the accreditation of practitioners must be renewed every year. Second, a standard should be established for educational institutions to prevent major differences in treatment efficacy and patient distrust in acupuncture as a whole. Finally, cultural and ethical values must be respected and practitioners should flexibly adapt and form a system for establishing professionalism in new areas (countries, cities, etc.) to obtain public recognition and political legitimation.8 In countries such as Malaysia where Complementary Medicine, Traditional Medicine, and acupuncture have been practiced for many years, the public already recognizes their efficacy. However, in countries where acupuncture has never been introduced or known to the public, it must undergo stages as presented in the case of Massachusetts, namely, initial reception of the modality by the public and biomedical community, establishment of specialized training requirement, formation of professional associations, and official licensing and credentialing.4 Of course, it is difficult for all in the acupuncture community to come to a consensus, but establishing professionalism is an achievable feat when shared values are identified. What it means to be a professional acupuncturist As a professional, the practitioner is expected to maintain high standards in treatment, conduct themselves morally, prioritize the well-being of the patient, equally provide treatment without bias, communicate effectively to ensure patients understand the treatment options before confirmation of treatment, maintain proper personal conduct, and should not abuse patient trust by using their position and influence as a TCM practitioner.12 In light of relevant literature, we propose the following aspects as necessary elements of professionalism in acupuncture: knowledgeable (well learned and engaged in lifetime learning in both TCM and biomedicine), providing good quality (hygienic) clinical care, equipped with ethical thinking and behavior, possess interprofessional communication skills (with acupuncturists, physicians, and other professionals), and holds a practitioner license and accreditation. From Conceptualization to Implementation: A Discussion of Responsibilities Sure, there is a need to establish medical professionalism in acupuncture, but whose responsibility is it? What has to be done? It has long been assumed that establishing medical professionalism is the physician's (in this case the practitioner's) responsibility, but is this really correct? Government institutions, accreditation organizations, medical institutions (hospitals and health systems), and educational institutions all have a responsibility in establishing medical professionalism. The practitioner places his values in caring and ensuring patient well-being and providing treatment for patients, but who is there to care for the practitioner? Health systems and hospitals should be responsible for caring for the well-being of the practitioner. Government systems in charge of Traditional and Complementary Medicine should uncover illegal practice and ensure that illegal practitioners and uncertified practitioners face legal consequences. acupuncture accreditation organizations have the responsibility of accrediting and validating acupuncture practitioners as well as clinics. Proper standards must be set and maintained for effective implementation. Finally, educational institutions have a responsibility in proper student selection, developing effective teaching and learning methods, use role modeling (excellence in three aspects: clinical competence, teaching skills, and personal qualities), and constantly perform assessments on professionalism to ensure that quality of professionalism is maintained.13 In West Coast University's example, the author demonstrated how the strategy of delineating boundaries is useful in helping acupuncturists understand what acupuncture is and what it is not.11 With an increased internal awareness of the scopes and boundaries of their practice, acupuncturists can help ?increase the acceptance of acupuncture by establishing its identity as a complement and not an alternative to biomedicine, and the identity of acupuncturists as team players, not competitors.? As for the education curriculum, it is highly suggested for institutions to adapt to an increasingly science-oriented curriculum with a blend of diverse, energetically oriented Asian medicine courses and philosophical concepts to prevent a loss of diversity that is unique to Chinese Medicine. This will ensure that acupuncture becomes a professional system inculcated with professional values associated with biomedical education, examination, practice, and reimbursement. Acupuncture plays a prominent role among complementary, alternative, and integrative medicines and is being widely accepted and recognized by professionals in the biomedical community. Thus, there is a need for continued evaluation of the education curriculum of acupuncture schools as well as how they relate to biomedicine. It is best if the perspective of peers and patients are incorporated in assessments for an accurate measure of professionalism to predict clinical outcomes. Conclusion Medical professionalism is important in establishing credibility, building patient confidence, and improving the professional image of the entire acupuncture profession. This review article is an attempt to collate the recommendations documented by researchers in the context of professionalism in acupuncture. As discussed previously, the present review highlights professional standards that needs to be adhered to as well as professional practices in acupuncture, including educational requirements, ethics, professional medical practices, as well as ideal implementation of establishing professionalism. It is also notable that practitioner health (both mentally and physically) is also included as a characteristic of professionalism to care for the well-being of the practitioner in a patient-centered standard of professionalism. Viewpoints documented as a part of active research in this domain strongly suggest that these recommendations need to be adopted by practitioners elsewhere also. In retrospect, the authors also note that in this era of constant technological advancement and AI, the marriage of medical practices (even complementary medicine) with technology is only a step away. During such synergies, the humaneness of the technology must be emphasized to promote patient trust and enhance technological credibility.14 Other sectors, such as journalism, have demonstrated the important role humaneness14 and algorithmic literacy15 plays in determining information credibility. Future directions in this topic points to the study of the ?coevolution between algorithms and humans, with a focus on the constant interaction, coupling, and mutual tuning of humans and their algorithmic counterparts.?16?18 This review article will serve its intended purpose if it is able to guide acupuncturists toward thinking about the professional aspect of their learning and practice. Uniform adoption of the recommendations highlighted in the review will be a remarkable contribution to the ongoing reforms in professionalizing acupuncture. It may be mentioned in this study that further research on this topic will possibly lead to more insights and better outcome in the future. Implementations by acupuncturists across the globe would go a long way in shaping the future of professionalizing acupuncture. Thus, government health departments, health institutions, accreditation groups, and educational institutions should place a strong value on professionalism and work together in establishing and maintaining professionalism in acupuncture practice.