5.6 The Nature of TCM Practice

Practitioners were requested to identify the principal modality used in their TCM practice:

  • 54% practise predominantly acupuncture;
  • 3% practise predominantly Chinese herbal medicine; and
  • 28% combine both acupuncture and Chinese herbal medicine.

Substantial differences exist between primary and non-primary TCM practitioners (see Table 5.5 and Figure 5.4). Primary TCM practitioners more frequently combined acupuncture and Chinese herbal medicine (59% of primary practitioners identified this option), whilst non-primary TCM practitioners are more likely to use acupuncture alone (72% of non-primary practitioners identified this option). Responses in the `other' category included a wide variety of non-TCM therapeutic practices.

 

Table 5.5: Type of TCM practice by nature of main practice. (More than one option could be selected).

Practice Type Primary TCM Non-primary Total Percent of
TCM responders
Predominantly acupuncture 161 412 585 54
Predominantly Chinese
herbal medicine		 28 3 32 3
Combination of
acupuncture & CHM		 254 39 302 28
TCM massage 119 17 142 13
Other 74 95 174 16

 

 

Figure 5.4: Nature of TCM practice indicated as percentage of total TCM activity for primary and non-primary TCM practitioners

Other Other

Predominantly
Acupunture

 Massage Massage
Combination

Predominantly
CHM

 Predominantly
CHM
Combination Predominantly
Acupuncture

 

TCM consultations

Practitioners on average undertake 25 TCM consultations per week (SD +31). There are no significant differences between States. Average TCM consultations performed, hours per week practised, and length of treatment sessions are summarised for both primary and non-primary TCM practitioners in Table 5.6 and Figure 5.5. Overall, primary TCM practitioners perform substantially more TCM consultations per week, spend more hours in TCM practice, and treatment involves longer contact time with the patient. In order to calculate average (mean) patient treatment time and face-to-face contact time, mid-points were used for the time interval categories in questions 11 and 12 from the workforce survey.

 

 

Table 5.6: Average number of TCM consultations and hours in practice per week, with duration of treatment for practitioner and for patient (Standard deviations in brackets)

Primary TCM Non-primary TCM
practitioners practitioners
TCM consultations/week 32.3 (SD 34.3) 18.3 (SD 25.7)
TCM practice/week (hours) 27.3 (SD 15.4) 7.8 (SD 8.9)
Face-to-face contact time (mins) (Q11)* 25.0 (SD 10.9) 15.8 (SD 10.3)
Patient treatment time (mins) (Q12)* 42.0 (SD 15.0) 30.0 (SD 13.6)
* Items on the workforce survey (see Appendix 15)

 

 

Figure 5.5: Average number of TCM consultations per week, hours in practice per week, duration of treatment for practitioner, and duration of treatment for patient

Patient treatment time(mins)
Face-to-Face contact time (mins)
Hours of TCM practice/week
TCM consultations/week

 

 

Table 5.7: Total TCM consultations performed per year by nature of practice (percentage of total consultations in brackets). #This figure was based on HIC data.

Practitioner group Total TCM consultations per year per practitioner (responders only) Estimate of total TCM consultations per year for workforce (extrapolated to whole workforce)
Non-medical TCM practitioners 1413 (62%) 1,899,429 (67%)
Medical TCM practitioners 854 (38%) 922, 714 (33%) #
Total consultations 2267 2,822,143

 

The mean number of TCM consultations per year for medical and non-medical practitioners of TCM has been calculated by multiplying TCM consultations per week for these groups by 48 weeks. This figure has been used to estimate the total TCM consultations per year provided by non-medical practitioners. The total acupuncture consultations per year provided by medical practitioners was obtained directly from the Health Insurance Commission (1995 figures) rather than extrapolating from figures based on less certain response rates for medical practitioners. These figures are presented in Table 5.7. The 1995 HIC figure of 902,714 consultations is increased to 922,714 for 1996 based on a similar growth rate over the previous three years. This increase should also allow for a small number of Chinese herb consultations undertaken by medical practitioners. The TCM workforce as a whole will undertake approximately 2,822,143 consultations in 1996.

The figures in the first column of Table 5.7 are based on the sample of survey respondents only. It is calculated that approximately twice as many TCM consultations are performed each year by non-medical TCM practitioners compared to medical TCM practitioners (column two).

Specific TCM modalities used

A range of modalities are used in TCM practice, including laser acupuncture, electroacupuncture, cupping and moxibustion. Table 5.8 identifies those techniques and their frequency of usage by State and occupational group. Figure 5.6 illustrates the comparative percentage of the workforce that utilise these techniques frequently. In some instances there are substantial differences between primary and non-primary TCM practitioners and these are highlighted in Table 5.9 and Figure 5.7.

Usage of Chinese medical theory

Practitioners were asked to respond to two questions (numbers 45 and 46) regarding the theoretical frameworks they use to guide their TCM practice. TCM philosophy is adopted more readily as the basis for practice by primary TCM practitioners than by allied health practitioners using TCM as part of their practice. In answer to the question `Do you rely more predominantly on a TCM philosophy and theoretical framework for making your diagnosis and guiding your acupuncture or Chinese herbal medicine treatments?' 90% of primary TCM practitioners answered yes, in contrast to 24% of non-primary practitioners.

Table 5.8: Numbers of practitioners using various TCM modalities in their practices. Rows total 1074 cases excepting missing cases 

TCM
modalities		 Never,
or almost
never used		 Occasionally
used		 Used in
about half
of the cases		 Frequently
used		 Always,
or almost
always used
Manual
acupuncture		 52
5.7%		 140
15.3%		 84
9.2%		 216
23.6%		 422
46.2%
Laser
acupuncture		 518
59.3%		 200
22.9%		 51
5.8%		 67
7.7%		 38
4.3%
Electro-
acupuncture		 314
35.2%		 332
37.2%		 105
11.8%		 90
10.1%		 51
5.7%
Raw Chinese
herbs		 614
69.1%		 104
11.7%		 51
5.7%		 50
5.6%		 70
7.9%
Prepared
Chinese herbs		 455
50.7%		 201
22.4%		 96
10.7%		 101
11.2%		 45
5.0%
TCM massage 498
55.8%		 162
18.2%		 87
9.8%		 87
9.8%		 58
6.5%
TCM dietary
advice		 352
39.3%		 225
25.1%		 149
16.6%		 107
12.0%		 62
6.9%
Lifestyle advice 91
10.1%		 153
16.9%		 180
19.9%		 294
32.5%		 187
20.7%
Moxibustion 375
41.7%		 242
26.9%		 127
14.1%		 136
15.1%		 20
2.2%
Cupping 437
48.9%		 257
28.7%		 101
11.3%		 87
9.7%		 12
1.3%
Exercise advice 325
36.1%		 292
32.4%		 125
13.9%		 102
11.3%		 56
6.2%
Point injection
therapy		 742
84.2%		 114
12.9%		 17
1.9%		 7
0.8%		 1
0.1%
Scarring
moxibustion		 848
96.3%		 27
3.1%		 5
0.6%		 0 1
0.1%
Scrapping or
plum blossom		 632
71.9%		 189
21.5%		 34
3.9%		 22
2.5%		 2
0.2%
Imbedding
needles		 604
690.3%		 216
24.8%		 37
4.2%		 13
1.5%		 2
0.2%
Bleeding 655
74.5%		 202
23% 		16
1.8%		 6
0.7% 		0

Figure 5.6: Percentages of the workforce that utilise specific TCM modalities frequently or more often. (This represents a summation of last two columns of Table 5.8)

Manual Acupuncture
Laser Acupuncture
Electro-acupuncture
Raw Chinese herbs
Prepared Chinese medicine
TCM massage
TCM dietry advice
Moxibustion
Cupping
Exercise advise
Point injection therapy
Scarring moxibustion
Scraping or plum blossom
Imbedding needles
Bleeding
Percentage

Diagnostic tests and record keeping

Western diagnostic investigations (either self-initiated or provided by patients or colleagues) were used by 37% of primary TCM practitioners 50% or more of the time. A further 46% of primary TCM practitioners claimed to use them occasionally.

Responses to all questions on record-keeping of patient contacts were positive (questions 48 to 50): 97% of practitioners make notes on every consultation with patients.

Table 5.9: Number of respondents using various TCM modalities in their practices for which there were substantial differences between primary and non-primary TCM practitioners

TCM modalities Nature
of TCM
practice		 Never,
or almost
never used		 Occasion-
ally used		 Used in
about half
of the cases		 Frequently
used		 Always, or
almost
always used
Raw
Chinese
herbs		 Primary

Non-primary		 186
16.8%
413
91.5%		 767
69.4%
25
5.5%		 44
3.9%
5
1.1%		 42
3.8%
6
1.3%		 66
5.9%
2
0.4%
Prepared
Chinese
herbs		 Primary
21.1%
Non-primary		 89
31.1%
356
78.7%		 131
18.3%
61
13.4%		 77
20%
16
3.5%		 84
9.2%
13
2.8%		 39

6
1.3%
TCM
massage		 Primary

Non-primary		 109
26.1%
382
85%		 123
29.4%
30
6.6%		 71
17%
10
2.2%		 69
16.5%
16
3.5%		 45
10.7%
11
2.4%
TCM
dietary
advice		 Primary

Non-primary		 38
9%
309
68.6%		 138
32.9%
80
17.7%		 118
28.1%
24
5.3%		 74
17.6%
29
6.4%		 51
12.1%
8
1.7%
Moxibus-
tion		 Primary

Non-primary		 54
12.8%
315
69.3%		 148
35.3%
85
18.7%		 96
22.9%
26
5.7%		 104
24.8%
27
5.9%		 17
4%
1
0.2%
Cupping Primary

Non-primary		 78
18.6%
353
78.6%		 195
47.2%
53
11.8%		 75
17.8%
20
4.4%		 65
15.5%
17
3.7%		 6
1.4%
6
1.3%
Scraping
or plum
blossom		 Primary

Non-primary		 217
53.9%
403
89.1%		 143
35.5%
37
8.1%		 28
6.9%
4
0.8%		 12
2.9%
8
1.7%		 2
0.4%
0
Bleeding Primary

Non-primary		 236
57.5%
405
91.2%		 157
38.2%
36
8.1%		 14
3.4%
1
0.2%		 3
0.7%
2
0.4%		 0

0

Figure 5.7: Number of respondents using various TCM modalities in their practices for which there were substantial differences between primary and non-primary TCM practitioners

Bleeding
Scraping or plum blossom
Cupping
Moxibustion
TCM dietary advice
TCM massage
Prepared Chinese Medicines
Raw Chinese herbs
Primary Non-Primary
Number of respondents

 

5.7 Referrals between TCM and Non-TCM Practices

Practitioners were asked to identify the sources of patient referral and how frequently their patients were referred to them from each source. These referral patterns to TCM practices are summarised in Table 5.10. There are no major differences between primary and non-primary TCM practitioners in referral patterns. The majority of patients are referred by word of mouth, which includes referral from other patients and through advertising.

Of those who identified themselves as primary TCM practitioners, 60% stated they received occasional referrals from medical practitioners, and a further 13% stated that at least half their patients were referred by medical practitioners.

Forward referral to another health practitioner is relatively infrequent: 72% of primary TCM practitioners stated that they occasionally refer their patients on to a general practitioner, and a further 15% did so at least half the time. Instances of referring on are summarised in Table 5.11.

Among primary TCM practitioners who responded to the survey, 8% shared rooms with a general practitioner or medical specialist.

The degree of communication between TCM and non-TCM practitioners is also described in Chapter 6 which profiles patients and their treatment.

Table 5.10: Referral sources and frequency of referral from each

Source of referral Always, or
almost always
referred		 Frequent
referral		 Referral in
about half
of cases		 Occasional
referral		 Never, or
almost never
referred
Self-referred 359
39.9%		 328
36.4%		 127
14.1%		 68
7.5%		 17
1.8%
Another TCM
practitioner		 3
0.3%		 20
2.3%		 19
2.2%		 406
48.4%		 390
46.5%
Chiropractor 4
0.4%		 13
1.5%		 25
3%		 308
37.8%		 463
56.9%
Osteopath 1
0.1%		 14
1.7%		 20
2.5%		 201
25.3%		 558
70.2%
General
practitioner		 20
2.3%		 61
7%		 92
10.5%		 498
57.3%		 198
22.7%
Medical specialist 6
0.7%		 12
1.4%		 28
3.3%		 268
32.2%		 517
62.2%
Physiotherapist 5
0.6%		 11
1.3%		 28
3.4%		 324
39.3%		 455
55.2%
Naturopath 4
0.4%		 13
1.5%		 37
4.4%		 317
38.4%		 453
54.9%
Western herbalist 0 5
0.6%		 15
1.9%		 162
20.6%		 603
76.8%
Homeopath 0 5
0.6%		 21
2.5%		 178
21.8%		 612
75%
Massage therapist 1
0.1%		 25
2.9%		 65
7.7%		 356
42.6%		 387
46.4%
Pharmacist 3
0.3%		 3
0.3%		 18
2.2%		 204
25%		 585
71.9%
Counsellor or
psychologist		 1
0.1%		 3
0.3%		 31
3.8%		 262
32.1%		 517
63.5%
Health food store 1
0.1%		 15
1.8%		 22
2.6%		 242
29.6%		 537
63.5%
Nurse 2
0.2%		 9
1%		 39
4.7%		 305
37%		 468
56.8%

 

 

Table 5.11: Onward referral destinations and frequency of these referrals

Onward
referral to...		 Always, or
almost always
referred		 Frequent
referral		 Referral in
about half
of cases		 Occasional
referral		 Never, or
almost never
referred
Another TCM
practitioner		 4
0.4%		 10
1.1%		 28
3.3%		 473
56.5%		 322
38.4%
Chiropractor 1
0.1%		 14
1.7%		 33
4%		 364
44.7%		 401
49.3%
Osteopath 1
0.1%		 16
1.9%		 30
3.7%		 291
36.2%		 464
57.8%
General
practitioner		 5
0.5%		 27
3.2%		 74
8.8%		 508
60.6%		 223
26.6%
Medical specialist 7
0.8%		 58
6.9%		 90
10.8%		 406
48.7%		 271
32.5%
Physiother-apist 3
0.3%		 36
4.4%		 83
10.1%		 340
41.6%		 355
43.4%
Naturopath 0 7
0.8%		 26
3.2%		 250
31.3%		 515
64.5%
Western
herbalist		 1
0.1%		 3
0.3%		 14
1.7%		 137
17.3%		 635
80.3%
Homeopath 0 6
0.7%		 20
2.5%		 214
27%		 551
69.6%
Massage
therapist		 1
0.1%		 16
2%		 49
6.2%		 391
49.5%		 332
42%
Counsellor or
psychologist		 1
0.1%		 21
2.5%		 57
7%		 457
56.2%		 277
34%
Nurse 1
0.1%		 5
0.6%		 11
1.4%		 120
15.3%		 645
82.4%

 

5.8 TCM Clinical Experience

Clinical experience in TCM varies significantly, ranging from recent graduates with little experience to 55 years experience. The average (mean) amount of TCM clinical experience of respondents is summarised in Table 5.12. Substantial differences exist between primary and non-primary TCM practitioners.

Table 5.12: Average (mean) TCM clinical experience by nature of practice (standard deviation in brackets)

Mean years of TCM clinical experience
Primary TCM practitioners Non-primary TCM practitioners
Either full or part-time (Q99)* 11.8 (SD 8.7) 6.7 (SD 6.7)
Condensed full-time equivalent (Q100)* 9.1 (SD 8.6) 3.0 (SD 4.9)

* Refers to items on Workforce Survey

 Table 5.13: Location of overseas clinical experience of TCM practitioners by nature of workforce.

Location of overseas TCM clinical experience Primary TCM practitioners Non-primary practitioners
No. Mean % of No. Mean % of
duration primary duration non- primary
(months) TCM workforce (months) TCM workforce
China 215 6.3 50% 85 1.5 15%
Elsewhere in Asia/ SE Asia 51 5.0 12% 78 1.3 14%
Western Europe 22 0.8 5% 46 1.0 8%
USA/Canada 22 1.8 5% 34 1.0 6%
Central/ South America 6 1.3 1% 23 0.5 4%
Africa/Middle East 7 0.9 2% 26 0.5 5%
Eastern Europe/ former USSR 6 0.9 1% 23 0.6 4%
Other 48 7.0 11% 52 0 9%

Figure 5.8: Percentage of TCM workforce with some overseas training by nature of workforce

Other
Eastern Europe
Africa/Middle East
Central/South America
USA/Canada
Western Europe
Elsewhere in Asia
China

 

The number of practitioners and average (mean) amount of TCM clinical experience obtained overseas is summarised in Table 5.13 and Figure 5.8. Among primary TCM practitioners, 50% have an average of 6 months clinical experience in China. In contrast, 15% of non-primary TCM practitioners have an average of only 1.5 months clinical experience in China. This clinical experience in China would be, almost without exception, within public hospitals and demonstrates a sharp contrast in the nature of clinical training for these two groups.

5.9 Cost of Treatment and Practitioner Income

The average fee charged for a follow-up TCM consultation is $30 (S.D. + $20). First consultation fees are variable and were not requested. Weekly costs of TCM treatment are reported in Chapter 6 in the context of the patient profile. Using the average fee of $30 per consultation, the TCM workforce will turnover approximately $84,664,290 in 1996 (based on previous estimate of 2,822,143 consultations).

The average income derived from TCM practice is $17,132 (n=842). When asked what percentage of gross total income is derived from TCM practice, 37% stated their TCM income represented 50% or more of their gross earnings. Large variations were recorded between primary and non-primary TCM practitioners. These are summarised in Table 5.14.

Table 5.14: Incomes by nature of TCM practice

Primary TCM
practice		 Non-primary
TCM practice		 Total TCM
workforce
a. Average (mean) follow-up
consultation fee ($)		 32
(SD 26.5)		 27
(SD 13.8)		 30
(SD 20)
b. Mean gross income from all
sources (Q107) ($)		 34,561
(SD 26,264)		 78,962
(SD 38,952)		 56,688
(SD 39,807)
c. Percentage of gross income
derived from TCM practice		 65.7
(SD 32.5)		 15.9
(SD 18.6)
d. Mean TCM income
(calculated as b*c) ($)		 24,001
(24,944)		 11,057
(SD 13,903)		 17,484
(SD 21,128)

 

5.10 Follow-up Interviews

In order to verify responses to key questions on the workforce survey and eliminate the possibility of overstatement of patient numbers or working hours to inflate the importance of TCM practice, follow-up interviews were held with 30 TCM practitioners, made up of:

  • 22 primary TCM practitioners randomly selected from amongst Melbourne postcodes on the mailing list; and
  • 8 medical practitioners involved in TCM were randomly selected through a professional association mailing list and the Yellow Pages.

(For ethical reasons the HIC and the Australian Medical Acupuncture Society were not able to make their mailing lists available for the surveys). Before being interviewed, practitioners were asked if they had completed the workforce survey. Only practitioners who had completed the survey were interviewed.

Table 5.15 summarises comparative findings between the interview cohort and workforce cohort of TCM practitioners. The findings appear to be consistent with those reported in the workforce survey regarding all key questions. These included percentages of practice devoted to TCM, clinical hours worked and numbers of patients seen on whom TCM treatment is used. Wherever possible the interviewer counted the number of TCM patients seen for each of the last three weeks in the appointment diary of the practitioner. The mean figure for the number of TCM patients seen during these three weeks is provided in Table 5.15.

Table 5.15: Comparison of interview and workforce survey cohorts on key clinical characteristics

Mean (standard deviation) Range
Percentage of practice
which is TCM		 Interviews
Survey		 66 (41.9)
48 (40.0)		 0-100
0-100
Clinical hours worked per week Interviews
Survey		 28 (19.9)
17 (14.4)		 1-70
Less than 4
to more than 40
Number of patients seen
per week		 Interviews
Survey		 45 (37.9)
25 (30.9)		 1-181
1-400

Average figures were slightly higher for the interview cohort than the average responses to the workforce survey. This may be due to three factors:

  • One-third of the interview cohort had to be selected by a mechanism other than from the HIC mailing list.
  • Medical practitioners interviewed were those with a sufficient public profile in TCM to be specifically listed in the Yellow Pages.
  • There were differences in the balance between primary and non-primary TCM practitioners in the two cohorts. The interview cohort consisted of 66% primary TCM practitioners in contrast to 40% representation in the workforce survey cohort. Primary TCM practitioners have been identified as contributing higher figures to all categories in Table 5.15.

Chapter 5: The Workforce Survey

Summary of Findings

  • Response rate: 1,074 practitioners responded to the survey by the due date. This represented a 43% response rate to the UWSM mailing list (non-medical and largely primary TCM practitioners), and an 18% (26% adjusted) response rate to the HIC mailing list (medical and largely non-primary TCM practitioners). The overall response rate was adequate and was estimated to account for 39% of TCM consultations perfomed by medical practitioners. The database which has been developed is accepted by the authors as an accurate profile of the TCM workforce and its practice, and it is considered that TCM practitioners who are not members of any association form a very small percentage of the total TCM workforce.
  • Reliability: Follow-up interviews of a limited number of TCM practitioners did not indicate any bias towards exaggerating of responses in the written workforce survey.
  • Primary practice: 433 practitioners (40%) surveyed identified TCM as their primary health care practice. A further 571 (53%) stated their main health care practice was in another discipline. TCM modalities, especially acupuncture, are utilised widely by a number of health occupations. TCM is generally used as an adjunct to their primary practices. Allied health occupations who use any TCM modality do so predominantly in a part-time fashion.
  • Consultations: The practice of TCM makes a substantial contribution to the Australian health care sector with approximately 2.8 million consultations annually and a turnover of $84 million. Approximately twice as many TCM consultations are performed each year by non-medical TCM practitioners. Substantial differences exist between primary and non-primary TCM practitioners with regard to numbers of TCM consultations per week (primary 32, non-primary 18) and hours of TCM practice (primary 27, non-primary 8).
  • Referral: There are no major differences between primary and non-primary TCM practitioners in referral patterns of patients for TCM treatment. A large percentage of patients are referred by word of mouth which includes referral from other patients and through advertising.
  • Demographics: The mean age of the TCM workforce is 44 years, and 68% are male. More than twice the number of primary TCM practitioners practise in metropolitan as opposed to country regions in the three States surveyed, while about 60% of non-primary TCM practitioners practise in metropolitan regions.
  • Modality: 54% of practitioners practise predominantly acupuncture, 3% practise predominantly Chinese herbal medicine. 28% of practitioners combine both acupuncture and Chinese herbal medicine. Substantial differences exist between primary and non-primary TCM practitioners. Primary TCM practitioners more frequently combined acupuncture and Chinese herbal medicine, whilst non-primary TCM practitioners are more likely to use acupuncture alone. Primary practitioners also use a variety of TCM modalities that are less commonly used by allied health occupations and that carry distinct risks (for example, scarring moxibustion and point injection therapy).
  • Theoretical basis: 90% of primary TCM practitioners claim to use TCM theory in their approach to treatment. In contrast, 76% of non-primary practitioners do not.
  • Experience: 50% of primary TCM practitioners have an average of 6 months clinical experience in China (predominantly if not solely within public hospitals). In contrast, 15% of non-primary TCM practitioners have an average of only 1.5 months clinical experience in China.