There has been a worldwide increase in the use of complementary and alternative medicine (CAM) including the use of traditional Chinese medicine (TCM).1–5 TCM encompasses a number of treatment modalities, which include: acupuncture, Chinese herbal medicine, moxibustion, cupping, tuina and tai chi.6 Acupuncture and Chinese herbal medicine are two of the most well-known TCM treatment modalities in many Western countries.7
In China, TCM has been practised for over 2,000 years.8 TCM has been part of the Chinese culture for many centuries.9 In 1950, alongside Western medicine (WM), TCM officially became part of the healthcare system in China.9 In China it is common practice to combine WM and TCM.10 Research indicates that Chinese herbal medicine represents between 30 to 50% of all medicines prescribed in China.11 In 2006, there were 2,665 TCM hospitals and 211 combined TCM-WM hospitals in China.10
While TCM-based acupuncture originated in China over 2,000 years ago,8 more recently Western medical acupuncture (WMA) has also been practised. WMA is an adaptation of TCM-based acupuncture. It differs from TCM-based acupuncture in two distinct ways. Firstly, it is not underpinned by TCM philosophy, but rather by a focus on nerve stimulation. Secondly, WMA is not viewed as an alternative medical system.12 WMA is predominately practised by general practitioners and physiotherapists.12–13
TCM-based acupuncture is one of the most recognised and utilised CAM treatments.1,3,4 In New Zealand, there has been an increase in the use of TCM-based acupuncture, as well as an increase in the number of individuals graduating with formal qualifications in acupuncture and Chinese herbal medicine.2,14 A recent New Zealand-based study found that an almost equal proportion of individuals who identified as being either Chinese or New Zealand European chose to receive acupuncture and other TCM treatment during a four-month period at a TCM clinic in Auckland, the country’s most populated city.15 The Patel et al study15 also reported that during this four-month period, 229 new patients attended the TCM clinic.
To date, limited research exists that has focused on TCM practice in New Zealand. With an increase in the use of TCM-based acupuncture and other TCM treatment modalities in New Zealand, more information is required that focuses on the actual practice of TCM in New Zealand. For example, information pertaining to the conditions for which TCM treatment is sought, including patient demographic information, could provide valuable information that can be used for future healthcare planning. Therefore, the present study was designed to identify differences associated with being a TCM practitioner in New Zealand compared to China.
Eight female and two male TCM practitioners took part in the present study. Participants were aged between 32 and 52 years of age (mean age = 44.7 years, SD = 10.4 years), and had been practising TCM between seven and 30 years (mean = 18.6 years, SD = 11.1 years). Participants had practised TCM in China between two and 19 years (mean = 8.0 years, SD = 5.8 years). Participants had been practicing TCM in New Zealand between one and 27 years (mean = 10.9 years, SD = 10.3 years). Eight participants identified as being Chinese and were born in China. One participant identified as being New Zealand European and was born in New Zealand. This participant also held a Western medical degree and worked as a combined general practitioner and TCM practitioner. One participant identified as being of Middle Eastern descent and was born in Persia. This participant also held a Western medical degree and was a former general practitioner. All 10 participants completed their TCM qualifications in China. Four participants were current full-time teaching and supervisory staff at New Zealand College of Chinese Medicine (NZCCM) in Auckland. Five participants held current part-time teaching and supervisory positions at the College and also had their own private practice. Only one participant did not currently teach or supervise at the College. This participant worked full time as a combined GP and TCM practitioner in her own practice.
An interview schedule was developed for this study by members of the research team. Questions were formulated based on the two main topic areas: (1) differences associated with practicing TCM in New Zealand compared to China, and (2) whether TCM was a first or alternative treatment option for individuals in New Zealand. The interview schedule comprised of three main parts. The two topic areas mentioned above comprised the first two sections, and the final section comprised questions relating to participant demographic information. The interview schedule ensured that all participants were asked the same questions. Questions were designed to be open-ended to allow for discussion and elaboration of responses. The interview schedule is documented in Table 1.
Table 1: Interview schedule.
Topic area one: differences associated with practicing TCM in New Zealand compared to China
Are there any differences between practicing TCM in New Zealand compared to China?
Can you please tell me what these differences are?
Are there any differences in the conditions you treat here in New Zealand compared to China?
Are the patients you treat in New Zealand different from the patients you treated in China in relation to ethnicity, gender and age?
Topic area two: whether TCM is a first or alternative treatment option for individuals in New Zealand
Are there any differences in patient knowledge regarding TCM between patients you have treated in New Zealand compared to China?
Have any of the patients you have treated in New Zealand seen or consulted other healthcare practitioners prior to seeking treatment from you for their specific condition or complaint?
If so, what type of healthcare practitioner(s) did they see or consult?
Have you treated any patients who are concurrently seeking treatment from other healthcare practitioners at the same time they have been seeking treatment from you?
If so, what other type of healthcare practitioner are they seeking treatment from?
Participant recruitment was based on convenience sampling. Potential participants had to be either current or former teaching, or clinical supervisory staff at New Zealand College of Chinese Medicine. There were a number of reasons for this requirement. Firstly, participants needed to have an adequate level of English fluency, as all interviews needed to be conducted in English. Time and expense were also factors that needed to be taken into account. Potential participants were invited to take part via an email invitation, which included a copy of the participant information sheet, consent form and interview schedule. To obtain 10 positive responders, 13 invitations were emailed to potential participants. Nine of the current clinical staff members and the one former clinical staff member took part in the present study. The remaining three potential participants were non-responders. They did not reply to the secondary email invitation that was sent out two weeks after the initial email invitation. Nine participants were individually interviewed at the College by the primary investigator, the College’s Research Project Officer (AP). The former staff member was interviewed at her practice by the primary investigator. The primary investigator holds a doctorate in public health and has extensive experience in carrying out qualitative research. Interviews took between 30 and 50 minutes to complete. Informed written consent was obtained from each participant prior to the commencement of their interview. All interviews were audio-taped and later transcribed verbatim. Ethical approval for this study was obtained from the New Zealand College of Chinese Medicine Ethics Committee.
Data were analysed using an inductive thematic approach based on Auerbach and Silverstein’s16 approach to thematic analysis.16 This process involved four main steps.
- The first step involved reading and re-reading each transcript several times for each individual question within a topic area.
- Identifying text in which participants used the same or similar words or experiences to convey the same idea (eg, repeating ideas).
- Coding the segments of text that were identified in step 2 (the repeating ideas). From this process, themes emerged (eg, an organisation of repeating ideas that is given a name that communicates what participants are trying to convey).
- Verifying the trustworthiness of the findings. This involved members of the research team individually reading the transcripts to verify or disqualify themes. This process was essential in reducing individual researcher bias.
Data were examined under two main topic areas: (1) Differences associated between practising TCM in New Zealand compared to China, and (2) TCM as a first or alternative treatment option for individuals in New Zealand. A number of themes were identified under these topic areas. Themes are discussed below and direct quotes are included that help illustrate participants’ views and experiences of the associated topic area.
Topic: Differences associated between practising TCM in New Zealand compared to China
Theme: Differences in job description
The main difference in practising TCM between the two countries was that in China TCM treatment and Western medicine are integrated to treat certain conditions. In turn, this allowed TCM practitioners to prescribe certain Western medicine drug treatments. TCM practitioners also tend to work in hospitals (in the larger cities) and have the title of doctor, and are viewed as being mainstream healthcare practitioners. The following quotes demonstrate this:
“The job description is different. In China I’m a doctor. We practice both Chinese and Western medicine together. We work in a hospital. It’s combined (TCM and Western medicine).” Practitioner 3.
“In China we are doctors and we can also prescribe certain types of Western medicine drug treatment. But in New Zealand we can only practice TCM, we cannot prescribe Western medicine.” Practitioner 2.
Theme: Pain management versus internal conditions
The main difference in terms of conditions treated between the two countries was related to being able to treat internal conditions in China, whereas in New Zealand, treatment was sought more for pain management purposes. The following quotes convey this:
“In New Zealand, maybe the most common condition treated by TCM is pain. It’s usually related to shoulder, joint or knee pain. In China, besides pain we also treat internal diseases. We treat heart disease, digestive conditions and all kinds of diseases.” Practitioner 1.
“In China we can treat stroke patients and patients with other neurological disorders. Here in New Zealand, most patients are ACC patients. They come for pain related problems. Like neck pain and shoulder pain, lower back pain and ankle pain. It’s more of a focus on the skeletal muscular system.” Practitioner 2.
Theme: Ethnic diversity for TCM treatment in New Zealand
This theme involved practitioners discussing the ethnic diversity of the patients they treated in New Zealand. It highlighted that individuals from a number of different ethnic groups were seeking TCM based treatment. The following quotes convey this:
“In New Zealand, I’m treating Asians, Europeans, Maori and Pacific Islanders.” Practitioner 7.
“I see Asian, Samoan and other Pacific patients. I also have Eastern European patients, Dutch patients, British patients and Australian patients.” Practitioner 8.
Theme: Age differences between the two countries
Two practitioners mentioned that in China it was common practice to treat children compared to New Zealand, where patients were predominately adults. One practitioner did give an account of treating Chinese children in New Zealand, though she mentioned that she did not treat European children in New Zealand. The following quotes demonstrate this:
“In China you have children as patients.” Practitioner 4.
“Here, I have treated Chinese children, but I have not treated European children.” Practitioner 10.
Theme: Gender similarities across both countries
A number of practitioners discussed how the majority of their patients were female regardless of the country they were practising in. The following quotes demonstrate this:
“Gender is similar to China; more females than males coming to the clinic.” Practitioner 2.
“I think it’s very similar; more females.” Practitioner 4.
Topic: TCM as a first or alternative treatment option for individuals in New Zealand
Theme: TCM Knowledge
This theme involved practitioners discussing how TCM knowledge in China is passed down from each generation. Hence, Chinese people have an understanding of the underlying components of TCM philosophy in contrast to non-Chinese individuals, such as New Zealand Europeans, who need to be educated about the philosophical underpinnings of TCM. The following quotes demonstrate this:
“Chinese people have the knowledge and understanding of Chinese medicine because of their cultural background. We don’t need to educate them like we have to with Kiwi patients.” Practitioner 3.
“In China, Chinese medicine is very popular. So you don’t need to give an explanation. But here (in New Zealand) the TCM philosophy is quite unusual for Europeans.” Practitioner 6.
Theme: TCM as an alternative treatment choice in New Zealand
In the following quotes, a number of practitioners discussed how some Chinese individuals were more likely to seek TCM treatment as a first choice of treatment compared to New Zealand Europeans, who appeared to use TCM as an alternative form of treatment after having consulted a Western medicine healthcare practitioner. In most cases this was a general practitioner (GP). The following quotes illustrate this:
“Most Chinese people accept Chinese medicine as their first treatment choice. But here (in New Zealand), Western people would not choose Chinese medicine as their first treatment choice. In New Zealand most people will use TCM as an alternative. Some have already got a diagnosis from their GP and they come to our clinic for alternative treatment.” Practitioner 1.
“For Kiwi people, maybe a second choice, but for Asian people a first choice. I think for Chinese people, because they know Chinese medicine well, if they have any pain related problem, going to the acupuncturist will be their first option. But for Kiwi people many will be referred to an acupuncturist.” Practitioner 2.
“They have either been referred by hospital clinics or they’ve been referred by other general practitioners. Many of the people who come here have already seen an orthopedic surgeon or two or three physicians.” Practitioner 8.
Theme: Acceptance of acupuncture
Compared to Chinese herbal medicine, acupuncture appeared to be an acceptable and more utilised form of treatment for New Zealand European and other non-Chinese patients in New Zealand. Also discussed was the observation that an individual was more likely to seek acupuncture-based treatment in the future if they had a successful experience of their initial acupuncture treatment. The following quotes convey this:
“Kiwis are quite interested in acupuncture, more than herbal medicine.” Practitioner 10.
“In New Zealand, most practitioners and patients will focus on acupuncture unlike in China where we focus on Chinese herbal treatment first.” Practitioner 1.
“In New Zealand, once a patient has been treated with acupuncture, the next time the patient has a similar problem they may think about acupuncture as their first choice of treatment.” Practitioner 2.
This study was designed to identify differences associated with being a TCM practitioner in New Zealand compared to China. The main differences were associated with how TCM treatment (predominately acupuncture) was viewed and utilised by the larger New Zealand population. CAM treatments in general, including TCM treatment are viewed by the general New Zealand population as alternative forms of healthcare treatment. There were also differences in the type of conditions treated between the two countries, as well demographic differences relating to the type of patients treated.
Western medicine and TCM are the two mainstream medical practices used in China.10 In China, TCM treatment is integrated with Western medicine and TCM practitioners can treat a range of conditions, including internal conditions (eg, cardiovascular conditions, stroke recovery, diabetes and cancer). TCM practitioners can also prescribe certain Western medicine drug treatments for a number of conditions. One main reason for this is that biomedicine is part of the TCM degree structure in China.11 A TCM practitioner is part of the mainstream healthcare system. TCM practitioners work in a number of medical settings, including hospitals and clinics.10
In comparison, TCM practitioners in New Zealand are viewed by most individuals as being alternative healthcare practitioners. In New Zealand, TCM practitioners predominantly work in their own private practice or as an employee in a TCM-based clinic which generally offers acupuncture, Chinese herbal medicine and Chinese massage treatment. In some cases, TCM practitioners work exclusively as acupuncturists. TCM practitioners in New Zealand cannot prescribe Western medicine drug treatments.
The TCM practitioners in the present study conveyed that the majority of their non-Chinese patients sought TCM treatment as an alternative form of treatment after they had consulted with another healthcare practitioner, predominantly a general practitioner (GP). A number of practitioners discussed how the majority of patients they had treated in New Zealand sought treatment for pain related complaints and conditions (ie, muscular problems related to both the upper and lower body). A New Zealand study that examined both the demographic profile and the complaints and conditions for which patients sought treatment at a TCM clinic, reported that patients tended to seek treatment for pain management purposes more than any other complaint or condition.15 A number of studies have reported that acupuncture appears to be utilised more for pain relief purposes in regard to the management of chronic conditions or acute injuries (eg, back pain and joint pain).1,3,17–20
Research indicates that individuals tend to seek CAM treatment, such as acupuncture, when conventional Western medicine cannot help treat or manage their condition.2,4,15,19 Data from a New Zealand health survey reported that 53% of respondents had a condition that Western medicine healthcare practitioners could not treat.21 The Patel et al study15 reported that the majority of patients who took part in their study had consulted another healthcare practitioner, namely a GP, prior to seeking acupuncture or other TCM-related treatment.
The practitioners in the present study gave accounts of how a number of their non-Chinese patients seek treatment for pain-related complaints and conditions. This may be associated with the fact that since the 1990s in New Zealand, the Accident Compensation Corporation (ACC) has funded acupuncture treatment for injury-related conditions. ACC fund acupuncture treatment for these conditions based on the efficacy of acupuncture in the management of musculoskeletal pain.22
In 2015, 900 acupuncturists were registered as ACC treatment providers. In 2015, ACC spent almost 27 million dollars funding acupuncture treatment. Almost 20 million of this was spent in the Auckland region. In 2015, ACC received 58,681 claims that resulted in acupuncture treatment. The majority of claims were lodged by a GP (53%) followed by a physiotherapist (24%). The five most common conditions seen by ACC-registered acupuncturists are: lumbar sprain, sprain of shoulder and upper arm, neck sprain, ankle sprain and thoracic sprain.23
A number of practitioners discussed how knowledge of TCM is generationally passed down in China, resulting in TCM being a popular form of treatment for many Chinese people regardless of age. This knowledge of TCM may have appeared to extend to Chinese individuals living in New Zealand, as accounts were given where practitioners treated Chinese children but not New Zealand European children. Age differences in relation to patients treated in New Zealand were one of the main demographic differences that were identified in the present study.
In relation to ethnicity and TCM use, the results of the present study indicate that some TCM practitioners have encountered some of the ethnic diversity that reflects the current New Zealand population.24 While a number of different ethnic groups fall within the Asian category, those who identify as being Chinese make up the largest ethnic group within the Asian category. Auckland also hosts the largest Chinese population in the country.24 Between 2001 and 2013, the Asian population in New Zealand has almost doubled in size.24 In line with these findings, a changing Asian demographic in New Zealand, particularly in the Auckland region may result in a growing demand for TCM. Especially if some Chinese individuals want to combine WM with TCM.
A growing demand for TCM (especially acupuncture) may also be influenced by previous experience of acupuncture. For example, one participant discussed how non-Chinese individuals who have had a successful initial experience of acupuncture treatment are more likely to seek acupuncture in the future for similar conditions. In line with this, one Auckland-based TCM clinic reported that almost one half of all new patients enrolled during a fourth-month period identified as being New Zealand European.15
The one demographic similarity between the two countries was related to gender. Practitioners in the present study gave accounts of treating more female patients compared to male patients across both countries. Both New Zealand and international data indicate that compared to males, females are more likely to seek CAM (and other healthcare) treatment.2,15,19,25
A major strength of this study is that a qualitative methodology using an interview approach was employed. This allowed practitioners to discuss in detail their views and experiences. A potential limitation of the study is that a small number of TCM practitioners were interviewed, all of whom practised in a major city in New Zealand. TCM practitioners practising in other parts of New Zealand may have encountered other differences; likewise, the same could be said about their experience of TCM practice in China. In China, these practitioners had predominately practiced TCM in TCM hospitals in major cities. Hence, generalising findings to the larger TCM practitioner population in both New Zealand and in China should be done with caution. In regard to our sample, it is possible that participants may have felt obligated to participate in the present study as they were all predominately current staff members at NZCCM. However, the Participant Information Sheet did state that participation was voluntary and that participation or non-participation would not influence their employment status.
The present study identified a number of differences associated with being a TCM practitioner in New Zealand compared to China. In New Zealand, TCM practitioners are viewed as alternative healthcare practitioners. Acupuncture is the most utilised form of TCM treatment by non-Chinese individuals in New Zealand, and it appears to be predominately used for pain management purposes. Future research in this area will focus on the professional development of TCM practitioners in New Zealand, including promotion of one’s own practice.