Abstract
Japanese acupuncture and moxibustion (AM) originated in ancient China; however, it gradually became unique to Japan. Regarding the education of acupuncturists/moxibustionists (AMists), ancient Chinese classical theory is reverenced; however, the content being taught largely incorporates modern Western medicine. In this study, we focused on the current school curriculum, national examinations, postgraduate education, and certification systems for physicians and nonphysician AMists. In Japan, only physicians, dentists, or AMists are licensed to practice AM; however, AM has recently been mostly practiced by nonphysician AMists. Medical students are only slightly exposed to AM in their undergraduate curricula; therefore, only a few physicians practice AM. Notably, some universities or public hospitals offer postgraduate education on AM; however, the system has been insufficiently available to both physicians and AMists. Each society has a certification system for physicians and AMists to be recognized as Kampo (Japanese traditional medicine that is primarily a herbal medicine-based treatment) specialists and certified AMists, respectively; however, there is no AM certification system for physicians. Therefore, enhancing undergraduate and postgraduate education for medical AM practitioners is a future challenge.
INTRODUCTION
Currently, only physicians, dentists, and acupuncturists/moxibustionists (AMists) are licensed to practice acupuncture and moxibustion (AM) on patients in Japan. However, there are very few facilities where physicians perform AM treatments, with most AM treatments performed by nonphysician AMists.
“Acupuncture” and “moxibustion” are independent national qualifications. The number of licensed and registered acupuncturists was 191,653 as of 2023, 1 with ∼134,000 engaged in clinical practice. 2 Similarly, the number of licensed and registered moxibustionists was 190,450 as of 2023, 1 with ∼132,000 engaged in clinical practice. 2 The number of registered physicians in Japan was ∼340,000 as of 2022 3 ; however, no data exist on the number of physicians who routinely practice AM. In Japan, most practitioners hold both “acupuncture” and “moxibustion” qualifications; therefore, we will refer to “AMists” in the present study.
There is no AM curriculum for medical students; however, there is a recommended textbook 4 that includes a description of AM. For AM students, the relevant education is conducted systematically under a common curriculum that includes practical education and accompanying practical examinations. Both physicians and AMists are nationally licensed; however, no questions about traditional medical knowledge are asked in the national examination for physicians. 5 Therefore, physicians who wish to practice AM must seek opportunities to learn AM theories and techniques on their own after graduation. To date, no organization or system in Japan certifies physicians as qualified medical AM practitioners. For AMists, approximately half of the questions in the national examinations are related to modern medicine, whereas the other half are related to AM and traditional medicine. Therefore, AMists are primarily taught theories and treatments based on traditional and Western medicine in universities and vocational schools.
The Meiji Restoration of 1868 resulted in radical changes to all aspects of politics, economy, industry, diplomacy, and education in Japan. In 1874, Western medicine was introduced as an orthodox medicine in medical education. Therefore, only those trained in Western medicine were recognized as physicians, and AM became folk medicine, although education for the visually impaired continued. Owing to the “Regulation of Acupuncture and Moxibustion Practice” of 1911, AM school education was resumed for the first time after the Meiji Restoration and is now incorporated in present university and vocational school education. However, in the education of physicians, the policy of prioritizing Western medicine in the Meiji era remains a major influence even today. 6
In the present study, we explored AM education in present Japan, comparing physicians and AMists.
EDUCATION OF JAPANESE TRADITIONAL MEDICINE (KAMPO), INCLUDING AM IN MEDICAL UNIVERSITIES
Kampo is the comprehensive name of Japanese traditional medicine, which includes traditional theory, diagnosis, and treatment with herbal medicines and AM. Currently, Kampo medicine is used in various medical situations, including general medicine, hospital medicine, and acute-to-prolonged infections. A recent survey reported that 86.7% of physicians have prescribed Kampo herbal medicines. 7
The World Health Organization published the International Classification of Diseases, 11th Revision (ICD-11), which includes a supplementary chapter on traditional medicine and came into effect in January 2022. ICD-11 is used for diagnosis and statistical surveys; therefore, a proper understanding of Kampo medicine and education is essential. From the perspective of medical education, the World Federation for Medical Education Global Standards has indicated a connection between complementary and alternative medicine, including Kampo medicine, in Japan. 8
In Japan, the “Model Core Curriculum for Medical Education” has been published by the Ministry of Education, Culture, Sports, Science, and Technology since 2001. In the first publication, Kampo medicine was listed as “Outline the Kampo formulas.” The curriculum was revised in 2011 and 2017, and then in 2023, it was revised to “Understand an overview of the characteristics of Chinese medicine, indications of major Japanese and Chinese herbal medicines (Kampo medicines), and their pharmacological actions.” 9 In addition, the Japan Council for Kampo Medical Education (JCKME) was established by all 82 medical schools in Japan to create a basic curriculum for Kampo medical education in 2015. JCKME made a basic curriculum for Kampo medicine in 2016, 10 followed by model slides and lecture guides. Furthermore, textbooks on Kampo medicine, “Essential Lecture on Kampo Medicine,” including AM for medical students, were published in 2020. 4
EDUCATION OF AM IN SCHOOLS/UNIVERSITIES FOR AMists AND ITS CURRICULUM
To qualify for the national examination, participants must have studied for at least 3 years to acquire the necessary knowledge and skills in traditional medicine, including AM and Western medicine. Universities, vocational schools, and special needs education schools for the visually impaired are available for individuals who intend to become AMists. As of 2024, institutions, including 1 national and 11 private universities, 84 vocational schools, and 56 schools for the visually impaired, offer educational courses for AMists in Japan.11,12
According to the “Regulations for Approval of Schools and Training Facilities for Anma, Massage, Shiatsu, Acupuncture, and Moxibustion” 13 and the “Guidelines for Acupuncturist/Moxibustionist Training Schools,” 14 the curricula to qualify for the national examination are currently required to have 94 credits and 2,655 h of classes. The specific educational content (94 credits) is presented in Table 1.
Courses and Credits in a 3-Year-Course Acupuncture School
In AM universities, the study period is 4 years. The curriculum includes not only specialized knowledge for AMists but also general education, leading to a university degree (bachelor’s degree). Therefore, in addition to the 94 credits stipulated in the aforementioned accreditation rules, ∼30 credits (124 credits in total) are required for graduation. However, the study period at vocational schools is 3 years, and specialized knowledge and skills are acquired in a short period. The study of AM education at universities for 4 years began in Japan with the opening of the Meiji University of Acupuncture and Moxibustion (currently Meiji University of Integrative Medicine) in 1983, and as of 2024, the number of universities offering AM education has increased to 12.
In 2016, the Japan Society of Acupuncture Courses in Universities (JSACU), comprising 12 relevant universities, was established to ensure close communication and cooperation among universities offering AM education, contributing to the promotion of AM education and research. 15 JSACU developed the “Model Core Curriculum for Acupuncture and Moxibustion Education” in 2024 to improve the quality of AMists. Its operation is yet to be implemented; however, the Model Core Curriculum can be adopted as a guideline for 70% of each university’s study hours, and the remaining 30% can be organized voluntarily and autonomously by each university based on its policies. This curriculum provides learning objectives related to practical abilities (knowledge, skills, and attitudes) that students should have acquired by graduation. Table 2 presents the contents of the Model Core Curriculum.
Model Core Curriculum of the Japan Society of Acupuncture Course in Universities
EDUCATION OF AM IN SCHOOLS FOR INDIVIDUALS WITH VISUAL IMPAIRMENT
In Japan, many AM schools were established throughout the country under a policy for individuals who were blind during the Edo period (1615–1868), and anma (Japanese traditional massage and manual therapy) and AM were practiced as professions by individuals who were blind. In the Meiji era (1968–1912), most AM schools were abolished; however, their functions were later taken over by schools for the blind. Even recently, individuals with visual impairment receive AM education to help them become professionally independent.
Currently, institutions training individuals with visual impairment to become AMists comprise 56 schools (1 national and 55 public schools), 1 national university, 1 private school, 4 national employment transition support facilities, and 1 public employment transition support facility. In the Japanese educational system for individuals with visual impairment, the relevant departments do not teach only AM but also teach anma, massage, shiatsu (acupressure), and AM (they are called “department of acupuncture and physical therapy [Riryo-Ka]).” Departments of acupuncture and physical therapy in schools for the visually impaired require 100 credits. 16 Similar to the requirements for students with normal vision, the study period for individuals with visual impairment is 4 years at the university and 3 years at other schools. Departments of acupuncture and physical therapy offer small classes with a maximum of 10 students per class to provide detailed teaching.
According to the Ministry of Health, Labor and Welfare’s Report on Public Health Administration and Services in 2022, 17 14,792 (11.0%) of the 134,218 acupuncturists in Japan had visual impairment. Furthermore, of the 4,176 individuals who undertook examinations to become “acupuncturists” in 2024, 164 (3.9%) had visual impairment. 18 Because of the increase in the number of schools for students with normal vision, the proportion of AMists with visual impairment in AM communities continues to decline.
NATIONAL AM EXAMINATION
In 1988, the law was revised, and the qualification of AMists, which had been authorized by prefectural governors, was changed to a national qualification. 19 Therefore, a national examination has been held once a year since 1993 to qualify as “acupuncturists” and “moxibustionists.” 20 In Japan, since the national qualifications for “acupuncturists” and “moxibustionists” are independent, there are two national examinations, one for “acupuncturists” and the other for “moxibustionists.” Of the 180 questions in the examinations, 160 are common whereas the remaining 20 consist of 10 questions on acupuncture theory and 10 on moxibustion theory. The examinations are conducted on the same day.
The numbers of examinees and those who passed the 1st, 11th, 21st, and 31st national examinations for AMists are presented in Table 3. 21 The number of examinees increased due to the rapid increase in the number of AM vocational schools in the 2000s, whereas the pass rate decreased.
The Number of Examinees and Passers and the Pass Rate of the National Examination for “Acupuncturists” and “Moxibustionists” in Japan
GRADUATES AND POSTGRADUATE TRAINING
Physicians Program
After passing the national medical examination, physicians receive initial clinical training for at least 2 years. They can receive Kampo medicine education in clinical settings from supervising physicians; however, opportunities are limited because of the lack of Kampo specialists. Over 70% of residents are aware of the need for postgraduate Kampo medicine education and expect lectures and instructions on how to use it to treat common diseases. 22
After completing the initial training, physicians proceed to training in one of the basic area specialists. The 19 basic areas are internal medicine, pediatrics, dermatology, psychiatry, surgery, orthopedic surgery, obstetrics and gynecology, ophthalmology, otorhinolaryngology, urology, neurosurgery, radiology, anesthesiology, pathology, clinical laboratory medicine, emergency medicine, plastic surgery, rehabilitation medicine, and general medicine. 23 During this period, physicians learn Kampo medicine through job training with supervisors or self-learning; however, there are very few opportunities to learn AM.
In addition to the aforementioned Kampo specialty training, some universities offer graduate programs in Kampo medicine. For example, the comprehensive medicine course at the Tohoku University Graduate School of Medicine includes research and studies on disaster, community, and Kampo medicine. A bachelor’s degree or higher and a national medical license, such as that of a medical doctor, dentist, pharmacist, nurse, or AMist, are qualifications required to take the entrance examination and enter the curriculum. Physicians or AMists enrolled in the course can proceed with credit acquisition for 4–6 years in the curriculum, conduct clinical or basic research, and undergo degree examination and evaluation. 24 After acquiring a PhD in “medicine,” they take on the role of teaching staff in universities or hospitals to train the younger generation.
Acupuncture Courses at Graduate Schools in Universities
Nine of the 12 universities with an undergraduate course in AM have graduate schools that specialize in AM research. These nine graduate schools confer a “Master’s” degree, whereas six confer a “PhD” Of these, two confer a “Master of acupuncture and moxibustion” degree, and two confer a “PhD in acupuncture and moxibustion.” Other graduate schools confer a Master’s degree or PhD in “Health Sciences.” Since the beginning of this century, many graduate schools have accepted candidates who wish to conduct AM research, regardless of whether they have a major in AM.
With the exception of a very few classics-based studies, AM research in graduate schools is basically bioscientific in approach, and both basic and clinical research are conducted to generate evidence through Western medical interpretation.
Other Postgraduate AM Programs for AMists
In Japan, there is no license renewal system for AMists similar to the case of physicians and other medical professionals. Academic societies and professional organizations implement a system of postgraduate continuing education to update AMists’ knowledge and improve their skills. However, these educational systems are not mandatory, and whether to participate is at the discretion of individual AMists.
The Japan Society of Acupuncture and Moxibustion (JSAM) holds many educational programs at its annual meetings and several workshops at local branches to provide AMists with new knowledge about clinical practice, safety management, research findings, and treatment techniques. To encourage attendance at these workshops, JSAM is attempting to create incentives by establishing a certification system. Notably, some AM professional organizations offer similar courses.
Furthermore, several large university-affiliated hospitals/research institutes or public hospitals have postgraduate training programs for AMists who have recently obtained licenses, providing them with 2–3 years of clinical education. However, few AMists undergo such postgraduate training programs, and the remaining learn during their daily clinical activities at their places of employment. As of 2024, the total number of newly accepted intern AMists at the 23 postgraduate training facilities on the JSAM list was only 80. Compared to the number of newly licensed AMists per year (Table 3), it is obvious that very few AMists receive postgraduate training in official educational programs; however, the number of JSAM-designated training facilities will likely increase in the future to accommodate more trainees.
KAMPO SPECIALIST (PHYSICIAN) AND CERTIFIED ACUPUNCTURIST/MOXIBUSTIONIST OF THE ACADEMIC SOCIETIES
Kampo Specialist in Japan
After acquiring a basic area certification, physicians can participate in the program for Kampo specialty doctors, which is certified by the Japan Society for Oriental Medicine (JSOM). They learn about Kampo medicine, its diagnostic procedures, and prescriptions through job and off-the-job training with supervisors in the core clinical training hospitals for Kampo training. They can receive the qualification for the examination after 3 years of training under the supervisor’s guidance and after submitting the summary of cases they have experienced. AM is included in the Kampo specialty curriculum of the JSOM; however, there is no system to certify clinical competence in AM. As of 2024, the number of Kampo specialists is 1,979.
Certified Acupuncturist/Moxibustionist in Japan
JSAM established its accreditation system in 1999 to improve academia and the quality of AM treatments. Since then, the domestic and international environments surrounding AM and public awareness have changed significantly, and the certified AMist system was revised in 2022. To become a certified AMist, one must register as an AM trainee, complete clinical training for at least 3 years (720 h at a designated training facility), complete academic training of at least 80 credits, take e-learning courses, submit a list of 40 cases, 2 case reports, 10 medical interview reports, and perform at least 1 conference presentation as first author. At the end of the training, the trainees must undergo written and oral examinations. As of 2024, the number of certified AMists was 330.
JSAM aims to raise awareness of the certified AMist system to ensure the public can choose to receive safe and reliable AM treatment. Currently, JSAM is preparing a system of more specialized AMists (such as certified lower back pain, headache, or palliative care specialists) who will require more specialized knowledge, skills, and experience. In addition, preparations for a certification system for physicians who have studied AM are underway.
CONCLUSION
AM education for medical students and physicians is actively provided in some medical universities and affiliated hospitals but not in many other universities. Kampo medicine education, including AM, is expected to become more widespread in medical universities and training programs for other medical professions. An AM certification system for physicians is required in the future.
Modern Western medicine and traditional Japanese AM are taught in a balanced manner in education for AMists; however, many schools focus on vocational education and do not have a system for pursuing AM science. To further develop traditional Japanese AM, the number of universities for AMists should increase; consequently, their research systems and academic contributions should be advanced.
Footnotes
ACKNOWLEDGMENT
The authors would like to thank the 23 postgraduate training facilities on the JSAM list for their cooperation in presenting statistics on the number of intern AMists.
AUTHORS’ CONTRIBUTIONS
M.K.: Drafting of Chapter 3 and funding acquisition. H.Y.: Conceptualization, drafting of Chapters 1, 5, 6, and 8, and editing and finalizing the article. N.F.: Drafting of Chapter 4. F.F.: Drafting of Chapter 7. R.T. Reviewing and editing. S.T.: Drafting of Chapters 2, 6, and 7. I.W.: Supervision, conceptualization, drafting of Chapters 1 and 8, and finalizing the article. All the authors have read and approved the final article.
ETHICAL STATEMENT
No ethical approval was required because this study did not involve human participants or laboratory animals.
AUTHOR DISCLOSURE STATEMENT
I.W. is a member of the editorial board of this journal but was not involved in any way in the decision to accept or reject this article. The authors have no financial conflicts of interest to declare.
FUNDING INFORMATION
This work was supported by JSPS Grants-in-Aid for Scientific Research (KAKENHI) (grant numbers: 22K02220 and 19K10503).