A Brief Discussion on the Specialty Development System of Chinese Medicine Practitioners in Hong Kong

: Since the Subsidiary Law on Chinese Medicine Registration has been implemented by the Legislative Council of Hong Kong (HK) in 2000, the status of Chinese medicine (CM) has gradually improved. In addition, the first Chinese medicine hospital in HK will be operated in 2025. More and more HK citizens and Chinese medicine practitioners (CMPs) believe that there is a need to develop CM specialties. However, over the years, no major breakthrough in the HK CM specialty system development due to disagreements among CMPs on how to divide CM into specialties. This article aims to find out a possible CM specialty system by discussing the reasonable study time of specialties, treatment methods and diseases, sustainable development of subspecialties, and characteristics of CM. It is recommended that a three-year basic training on CM treatment skills, which are "Chinese Materia Medica", "Acupuncture and Moxibustion" and "Tuina", plus three-year advanced training on a disease basis by an independent specialist college. This structure provides a comparable structure to the current Western medicine specialty system with the possibility and feasibility for continuing development of the CM specialists that can temporarily satisfy the opinions of all parties. This suggested structure may act as a foundation to facilitate the discussion in the CM industry.


Introduction
In 2000, the Legislative Council of Hong Kong formally legislated the Subsidiary Law on the Registration of Chinese Medicine Practitioners.Chinese medicine practitioners (CMPs) must pass the licensed medical practitioner registration examination recognized by the Hong Kong Chinese Medicine Council before they can practice medicine in the name of "Chinese medicine practitioners" in Hong Kong (HK) [1].CMPs can also legally prescribe valid sick leave certificates and work injury certificates, etc. [2], which gradually improves the status of CMPs in the mind of HK citizens.With the gradual improvement of the professional image of CMPs, not only the elderly who believe in Chinese Medicine (CM), but also more young and highly educated people are willing to accept and use CM [3].Of the female patients who visited CMPs, 71.1% were from the 15-54 age group, and 79.6% owned a college degree or above [4].The Hong Kong Special Administrative Region Government established the Chinese Medicine Development Committee in 2013 to provide advice on the long-term development and CM policy in HK [5].In order to cooperate with this plan, the medical record exchange plan has been extended to the electronic medical record system of Chinese and Western medicine by "EC Connect" in 2022 [6].Currently, the HK government has launched a series of training courses for auxiliary medical professionals such as nurses, pharmacists, etc. to learn and understand the basic concept of CM, so as to promote the exchange and understanding of Chinese and Western medical personnel in line with the operation of the first HK CM hospital in 2025.Since the Central government of China formally set that enhancing the CM service is an important strategy in the latest Five-Year plan [7], the post of the Commissioner for Chinese Medicine Development is going to be established in 2023 to strengthen the development of Chinese medicine under the HK government [8].Obviously, the HK government is paying more and more attention to CM.
Nevertheless, the development of CM in HK is not as smooth as the expectation.For example, the development of CM specialties has been discussed for many years, but no specific implementation plan and timetable is available yet.One of the main reasons may be that the CM industry has not yet come to a clear consensus [9].According to Section 74 of the Chinese Medicine Ordinance (Cap.549), CMPs can only add the titles of "general practice", "acupuncture" or "bonesetting" to their titles.This only represents the CMPs' qualifications of practice but not their professional status.The three universities that offer Bachelor of CM courses and a representative of the CM industry have already established CM specialist development working groups for "Internal Medicine", "Acupuncture" and "Orthopedics" in 2014 [10], but no plans have been announced and implemented yet.Even though the operation of the first CM hospital in HK inevitably has to include the specialties of CM, the HK government has not yet set clear restrictions on this in the tender requirements, and only listed that "Internal medicine", "External medicine", "Gynecology", "Paediatrics", "Orthopedics and Traumatology", and "Acupuncture and Moxibustion" are required [11].
Our previous research in 2017-18 (results have not been published) showed that most of the interviewed HK citizens support the establishment of the CM specialist system (65% aged ≤18; 19-30 years old 84.7%; 31-60 years old 89.1%).Besides, according to the latest research results by The Education University of Hong Kong, 65.6% of CMPs agree that HK should establish professional or specialist colleges to promote further professional training of CM [12].It is clear that the development of a specialist system for CMPs is a mainstream opinion in HK society.
The obstacle to CM specialization may be largely due to the differences among CMPs on how to divide them into specialists.For example, those who focus on the holistic concept of CM may think that CM should be a "general practice"; those who focus on CM treatment methods may consider "Internal medicine", "Acupuncture" and "Tuina"; those who emphasize on CM traditional or licensure exams may support the division of "Internal medicine", "External medicine", "Gynecology", "Paediatrics", "Orthopedics and Traumatology", and "Acupuncture and Moxibustion"; while those who believe in the integration of Chinese and Western medicine may support the classification based on the Western medicine specialties, etc.In fact, each classification method has its advantages and disadvantages.The original intention of classification should be to make it easy for others to understand and play a role in simplifying and controlling complexity.Therefore, to achieve effective classification, at least two points should be considered: 1) It can reflect the characteristics of CM, and 2) It can facilitate users to choose the appropriate specialist.In the following, we are going to discuss a possible CM specialist based on these two points with different basic implementation elements.

Study Period
The time limit can be helpful for designing how to allocate.
One of the purposes of considering the establishment of a CM specialist is to enhance the status and professionalism of CMPs.Since the bachelor's degree program in CM and Western medicine are both in a six-year period, the six-year period for the CM specialist system can also be considered to be in line with the Western medicine specialist training [13].With a time frame, we can design how to reasonably enrich its content and reflect the two main considerations.
As some Western medicine doctors may not be able to complete the entire six-year specialist training [14], the specialist training of CM should also set up a "halfway station", such as a three-year basic plus three-year advanced training model.As indicated by the survey results of The Education University of Hong Kong [12], the specialist system of CM should be run by an independent professional or specialist college.Therefore, if a CMP has only completed three years of basic training, the college may consider granting the title of "Associate Fellow", and granting the title of "Fellow" and "Specialist Chinese Medicine Practitioner" when completing the whole six years of training.

Treatment Methods and Diseases
The treatment methods of CM are mainly summarized as "Chinese Materia Medica", "Acupuncture and Moxibustion" and "Tuina"." Chinese Materia Medica" generally refers to all the methods of using herbs, including internal and external usage; " Acupuncture and Moxibustion" can include the treatment by all CM instruments, including acupuncture, moxibustion, scraping, cupping, pressing of buliuxing (cowherb) seed, etc.; while "Tuina" refers to any method of manual treatment, which including various massage techniques, reset, etc.These CM treatment methods can be applied to various diseases and should not be limited to certain types of diseases.
On the other hand, diseases are unique as they have their own independent pathogenesis: their occurrence, signs and symptoms, complications, and prognosis.Hence, its treatment response can be predicted systematically, such as "influenza", "stroke", "muscle contusion" and so on.Although citizens may easily associate certain diseases directly with what they believe is the best treatment method in CM, in fact, all the above three diseases can be treated by "Chinese Materia Medica", "Acupuncture and Moxibustion" or "Tuina".In contrast, if suffering from "muscle contusion" during exercise, it is generally considered that it is most appropriate to seek "fall and hit" (Orthopedics and Traumatology) treatment.The actual treatment may include "acupuncture and moxibustion" to regulate qi and relieve pain, "tuina" to regulate tendons and rejuvenate, and "herbs" to apply externally to reduce swelling or taken it orally to remove blood stasis.Hence, the treatment method and the disease type are not directly equated.
Just like the specialist classification of Western medicine, it is traditionally divided into major internal medicine and surgery based on internal and external treatment.Therefore, when dividing CM, it should start with the treatment method first, and divide it into "Chinese Materia Medica", Practitioners in Hong Kong "Acupuncture and Moxibustion" and "Tuina".Each category takes three years to study with at least one year of theoretical lecture and two years of clinical practice.This can not only effectively improve the practical operation and clinical application level and skills of CMPs, but also be the basis for further sub-disciplines.

Sustainability of the Specialties System
The development of the Western medicine specialist system is still moving forward today, which suggests that the system of CM specialists should also consider its sustainable development.If the mainframe and direction are wrong at the beginning, it will be extremely difficult to reset it in the future.
Since Western medicine is well recognized by the citizen in HK, it is generally easier for the public to understand its divisions as most of them are distinguished by disease types."Chinese Materia Medica", "Acupuncture and Moxibustion" and "Tuina" have been used as the foundation to build solid treatment skills for CMPs in the first three years of training, so the next step, which is the next three years of training, should consider how to improve CMPs' knowledge of a certain type of diseases and their ability to communicate with other medical professionals such as western medicine doctors.
"Internal medicine", "External medicine", "Gynecology", "Paediatrics", and "Orthopedics and Traumatology" are some extent of the classification method that reflects the types of diseases in CM. "Internal Medicine" refers to all diseases that occur inside the body; "External medicine" refers to diseases that mainly occur on the body's surface; "Gynecology" refers to diseases related to women's special physiological characteristics; " Paediatrics" refers to diseases related to the physiological characteristics of children's growth and development; "Orthopedics and Traumatology" refer to diseases related to bones, joints, and trauma.In addition, referring to the research results of The Education University of Hong Kong, more than 60% of the interviewed CMPs believe that "Oncology" and "Dermatology" should be established independently [12], which shows that this is based on the particularity and predisposition of an actual disease.Based on this principle, the classification of specialists in the next three years should be supplemented according to actual needs and should not be limited.
The model of three-year treatment skills training plus three-year specific disease training not only takes into account the uniqueness of CM, but also considers the actual needs and allows flexibility.For example, "Chinese Materia Medica" can be combined with "Gynecology" while "Acupuncture and Moxibustion" can also be matched with "Gynecology".Hence, the classification of diseases is not limited by the treatment methods, and the treatment methods are also not limited by the types of diseases.The classification of specialists according to disease types can also facilitate CMPs who do not have to repeat some basic operation parts when they study more than one specialty.

Develop Specialties with CM Characteristics
A major feature of CM is the holistic concept, so "general practice" which is similar to the concept of "Family medicine" in Western medicine should be regarded as a "specialty" instead of a "general outpatient" [15] and can be renamed as "Whole" to distinguish.After completing one of the basic subjects of "Chinese Materia Medica", "Acupuncture and Moxibustion" or "Tuina", CMPs should be allowed to choose and spend the remaining three years studying the other two subjects and become a "Whole" treatment "specialist".This can address the community outpatient clinics' actual needs and preserve CM's characteristics to the greatest extent.
In addition, each type of treatment method should be allowed to further develop advanced content and become an independent specialty.For example, "Acupuncture and Moxibustion" will be trained as a basic treatment skill in the first three years, but it can involve a variety of diseases to learn in the next three years.Another example is "Tuina".Although it is aimed at training massage skills in the first three years, knowledge of various diseases can be taught in the next three years and not limited to "fall and hit".
Research of the ancient CM literature is another major feature of CM.Although it seems with no direct correlation with clinical practice, it actually supports the entire CM theory as well as plays an important role in the clinical diagnosis and treatment thinking of CMPs.However, the study of CM theory requires a certain clinical basis, this kind of specialty can be considered in the second half of the training, i.e. the next three years, and become a "Philology" or "Classic" specialty which is similar to the position of the "Pathology" specialty in Western medicine.

Suggested CM Specialties System
Based on the above discussion, a specialties system that addresses different opinions with continuous development feasibility is summarized in Figure 1.This system not only aligns with the existing training period of Western medicine specialties, but also includes the existing working groups for Chinese medicine specialties development of "Internal Medicine", "Acupuncture" and "Orthopedics".This preliminary work allows a flexible but sustainable development framework, which not only covers various mainstream opinions, but also retains the CM characteristics, and avoids the possibility of restricting the CM specialties development in the future.

Conclusion
Although the development of the CM specialty in HK is full of difficulties, it already has one's finger on the trigger.Establishing a system that is suitable for the long-term development of CM in Hong Kong and can accommodate most of the concerns in the CM industry is the most important thing in the establishment of HK CM specialists.The above three-year CM treatment method training combined with the three-year specific disease training system may be a possible basis for further discussion and development of the HK CM specialty system.We hope that the development of CM specialties can be aligned with the operation of the first CM hospital in HK.

Figure 1 .
Figure 1.A sustainable CM specialties system.