Abstract
This paper reports on a research project that aims at identifying knowledge sharing (KS) barriers between traditional and western medicine practitioners co-existing and complementing each other in Chinese healthcare organisations. The study focuses on the tacit aspects of patient knowledge, rather than the traditional technical information shared through patient records. The project adopted a grounded theory approach as the overarching methodology to guide the analysis of data collected in a single case-study research design. A public hospital in central China was selected as the case-study site, at which 49 professionals were interviewed by using semi-structured and evolving interview scripts. The research findings reveal four main categories of KS barriers, namely philosophical divergence, interprofessional tensions, lack of interprofessional common ground, and insufficient interprofessional education and training. The conclusion advocates the establishment of top-down policies for mutual understanding and the creation of an interprofessional common ground between the two types of healthcare professionals. It is proposed that these policies should have two strands. The first strand should be at the grass roots of Chinese Healthcare Higher Education and should actively introduce complementary teaching and practice in these programmes. The second strand should take place in the hospital environment, through interprofessional dialogue, seminars and teamwork, as well as professional training. This paper contributes to the fields of KS and interprofessional collaboration in healthcare heterogeneous groups.
Keywords
Introduction
In 1950, immediately after the establishment of the People’s Republic of China (PRC), and as advocated by the first communist president Chairman Mao Zedong, the First National Healthcare Conference approved the creation of a national healthcare system, based on the provision of two very different types of medicine, namely traditional Chinese medicine (TCM) and western medicine (WM) (Hillier and Jewell, 1983). TCM has been a consistent element of the Chinese culture (Wong et al., 1993) and was developed as the result of the accumulation of experience and medical practices for over 2300 years (Cheng, 2000). Hyatt (1978) asserts that TCM is not just ‘folk’ medicine, but a highly developed art and science. However, at the beginning of the 20th century, TCM lost the dominant position it had held for thousands of years over the Chinese public health systems to WM. WM, based on the scientific paradigm and evidence-based practice, was developed in Europe and North America after the industrial revolution and is largely considered to be the main component of today’s Chinese healthcare system, despite its coexistence with TCM (Chi, 1994).
The political decision for the collaboration between TCM and WM was particularly important to the Chinese Communist Government. Taylor (2004) points out that, after the establishment of the PRC, the Chinese Communist Government used TCM as a strategic tool to distinguish the new communist China from its superstitious and feudal past as well as to illustrate the Chinese cultural heritage. Therefore, in 1954, two main strategies were formulated, not only to bridge the two distinct professional communities, but also to explore possible areas of collaboration. First, a number of TCM universities were established all over the country to provide formalised TCM education and to conduct systematic and scientific research on both TCM and its collaboration with WM. Second, a nation-wide search was conducted to selecting 2000 good WM professionals, who were pulled away from their jobs for full-time study of TCM and to explore approaches to collaboration (Taylor, 2004). These initial political decisions encouraged the two medical communities to work together and created the condition for a complementary relationship that still exists today.
Nonetheless, and since then, the coexistence and the complementary relationship between TCM and WM communities have not always been harmonious and stable. Not long after the formulation of the complementary relationship and the establishment of specialised higher education (HE) in TCM, TCM was put under stress during the ‘Great Cultural Revolution’ (1966–1976), since the Government at that time considered TCM as a feudal product of the old China, which needed to be eliminated (Chen et al., 1999; Fruehauf, 1999). In this period, not only was the number of Chinese traditional medicine colleges dramatically reduced from 21 to 11, but also the practitioners of TCM were criticised as feudalists and some were even persecuted (Fruehauf, 1999). On the other hand, during this crisis in TCM, WM reinforced its dominance over the Chinese healthcare system and services.
Mao Zedong’s death in 1976 brought an end to the Great Cultural Revolution as well as the crisis of TCM (Hesketh and Zhu, 1997). The position of TCM was reinstated by The Official Document no. 52 issued by the central government in 1978 (Lv, 2005). According to this author, the official document emphasised two points, namely, equality in the support of western medicine and traditional medicine and equal development of the two types of medicines. Since then, the official political statements have consistently declared that TCM and WM should be equally supported, despite the dominance of WM (Liu, 2003). Again, a recent public statement made by Chen Zhu, the Minister for Health, restated that the Chinese Government supported both TCM and WM equally in the national healthcare system (Cai and Ju, 2009).
Nevertheless, and despite the political nature of the decision creating this interprofessional relationship, many researchers (e.g. Fruehauf, 1999; Hyatt, 1978; Taylor, 2004) have claimed that this collaboration was unexpectedly successful, since it created a complementary relationship between the two types of professionals working cooperatively against a number of diseases deemed to be untreatable solely by WM doctors (Taylor, 2004: 103).
In any case, the complementary relationship and the collaboration of the two types of healthcare professionals should be patient centred. However, these policies, arrangements and statements are often made more for political purposes, and their implementation does not necessarily benefit the patient. In fact, this politically minded collaboration and complementarity does not guarantee per se that the interests of patients are always protected and placed at the centre of the collaborative processes. If the benefits to the patient are not very well protected by these political decisions, then there is a contradiction with the patient-centred care advocated by the Chinese central government.
In order to ensure that the collaboration between TCM and WM is patient centred, it is essential for healthcare professionals to communicate and share technical and patient knowledge with each other. This is necessary to protect the needs, requirements and benefits of the patient (Maizes et al., 2009; Steward, 2001). Nonetheless, in practice, the two types of healthcare professionals do not necessarily communicate and share knowledge (Zhou et al., 2010). In truth, there are barriers impeding the processes of sharing knowledge. This paper identifies, criticises and discusses these knowledge-sharing barriers in the context of Chinese healthcare organisations.
Theoretical sensitisation
Complementarity of TCM and WM
As discussed above, the current Chinese healthcare system fully integrates TCM and WM healthcare methodologies and incorporates both communities in the same hospitals.
TCM emphasises the integrity of the human body as a whole and its close relationship with the environment (Cheng, 2000). According to the study of Ma (1999), traditional Chinese healing practice is intended to enhance the immune system of the human body, antiviral effects, anti-inflammation, balance of mind and body, aches and pain relief, and cholesterol reduction. There are four main categories of Chinese medical treatments, namely herbal medicine (oral intake and external use), heat therapy (moxibustion, and cupping), massage (oriental massage, Gua Sha and magnets) and acupuncture (Sherman et al., 2005).
Conversely, WM employs a scientific attitude in diagnosis and treatments (Dally, 2003). Unschuld (1985) claims that achievements from intensive and evidence-based fundamental scientific research have brought WM to an unchallengeable dominant position in world health care as well as in China. In fact, and despite the plurality, WM takes the primary position in the Chinese healthcare system, being complemented by TCM as an alternative healthcare therapy. It is widely accepted in China that WM is more effective in the acute stage of many diseases and works much faster than TCM in treating these acute diseases (Ma, 1999). However, it is also acknowledged that WM creates more adverse side effects (Kaptchuk, 2000). Nevertheless, healing herbs, acupuncture, massage and other health methods from TCM may be more appropriate in health promotion, prevention, treatment and rehabilitation. Moreover, TCM may be used as a last resort, when western medicine is either too toxic or unable to provide any further expected benefit (Chen, 1989).
The advantages and benefits of integrating TCM and WM services into a single healthcare system, as well as the implementation of complementary treatment, have become evident. However, this very specific healthcare system demands effective interactions between TCM and WM practitioners on a range of aspects not limited to technical medical knowledge. These interactions are an essential and indispensable foundation to the provision of efficient combined patient-centred services.
Patient-centred healthcare
There are many different definitions of patient-centred care. A very succinct and clear one is provided by Maizes et al. (2009):
Care that informs and involves patients in medical decision making and self-management, coordinates and integrates medical care, provides physical comfort and emotional support, understands the patients’ concept of illness and their cultural beliefs, and understands and applies principles of disease prevention and behavioural change appropriate to diverse populations.
In 2006, the Chinese central government announced that the patient-centred approach should be taken as the most essential guideline for healthcare professionals and organisations (Zhong, 2009). The adoption of the patient-centred approach reinforced the principle that the role of the patient must be maintained at the centre of all medical procedures and entails that patients’ rights, benefits and requirements should be ensured in the collaboration between TCM and WM. Therefore, effective communication and adequate KS between TCM and WM healthcare professionals is the centrepiece of the implementation of patient-centred care (Maizes et al., 2009).
Knowledge sharing in patient-centred healthcare
KS is an effective strategy to build competitive advantages for all types of organisations (McEvily et al., 2000). In the health sector, there is a universal perception that appropriate processes of KS, based on good practices of knowledge creation, storage, transfer and utilisation, are fundamental to resolving daily medical problems challenging healthcare professionals, and, more importantly, can dramatically improve the quality of healthcare services (Abidi, 2007; Nicolini et al., 2008; Zhou et al., 2010). KS in healthcare was defined by Abidi (2007: 69) as follows:
Healthcare knowledge sharing can be characterised as the explication and dissemination of context-sensitive healthcare knowledge by and for healthcare stakeholders through a collaborative communication medium in order to advance the knowledge quotient of the participating healthcare stakeholders.
To develop this definition further, according to the needs of this research project, KS can be defined as the interaction of patient knowledge between WM and TCM healthcare professionals. In this case KS should occur through collaborative communication channels so that patient knowledge is always available and is used to provide the best possible healthcare services to patients, to improve the quality of patient care and to achieve patient satisfaction.
Patient knowledge can be defined by the following typology:
Technical Knowledge – includes identification of patient conditions and problems, reasons and objectives of patient care, patient background, agreement to treatment strategy, and explicit patient requirements and needs (Smith, 1996).
Ethical and Emotional Knowledge – focuses on ethically dealing ethically with patient feelings, emotions, and psychological status, approaches to communication, persuasion and management of individual patients, and ultimately maintaining trusting and collaborative professional-patient relationships (Fennessy and Burstein, 2007).
Social and Behavioural Knowledge – is concerned with anticipating how others will behave, and perception of patients’ implicit requirements, as well as their behaviour, reactions and expectations (Fennessy and Burstein, 2007).
Of the three types of patient knowledge, the sharing of technical knowledge is the least problematic, since this type of knowledge is easier to share and is usually recorded explicitly in the patient records. Moreover, as discussed above, the two types of healthcare professionals adopt two entirely different medical systems and their philosophical beliefs and technical insights do not seem to be paramount in the complementary provision of medical services (Guo, 2006; Yang, 2005).
On the other hand, ethical and emotional knowledge and social and behavioural knowledge consist of the experiences and perceptions of individual professionals, which are accumulated through processes of dealing and interacting with individual patients, their families and their communities. Therefore, when compared with the technical knowledge, the sharing of these two types of tacit patient knowledge among healthcare professionals is much more difficult and more important. Thus, this project focuses on the sharing of ethical and emotional knowledge and social and behavioural knowledge between the TCM and WM healthcare professionals.
Research methodology
General research approach
The general aim of this project is to identify, characterise and discuss KS barriers between TCM and WM practitioners in the context of the Chinese National Healthcare. Ultimately the intention behind the project is to seek understanding of these barriers and propose strategies to improve collaboration and patient-centred care.
Due to the very specific characteristics of the Chinese healthcare environment it was very difficult to establish a base theory for the problem. In fact, there are other examples of coexistence between WM and traditional medicines (e.g. homeopathy, herbal medicine, chiropractic, etc.). However, in no other circumstances are these different health professionals working together by political design and in the same hospital, sometimes even in the same building. This makes it almost impossible to use a deductive approach.
Therefore, the research approach selected for the project is inductive in nature. Specifically, and among the different possible choices, grounded theory (GT) was adopted. GT is widely recognised as particularly useful for theory generation purposes (Strauss and Corbin, 1998). Nonetheless, Pickard (2007) points out that GT is a series of qualitative analysis processes, rather than a complete research methodology. Therefore, GT is usually applied in a combined approach with other research methodologies, such as ethnography and case study (Pickard, 2007). Many researchers suggest that case study and GT are not just compatible with each other, but are in fact a combination that is ideal for establishing a valid and reliable inductive theory (e.g. Allan, 2003; Eisenhardt, 1989; Glaser, 1978; Glaser and Strauss, 1967; Pickard, 2007; Tellis, 1997). Consequently, this project adopted a combined approach of grounded theory (GT) and case study. Finally, it is important to stress that a Straussian GT approach (Strauss and Corbin, 1998) was employed as the overarching research methodology to guide the data collection and analysis.
Research design
The basic research design for this project was based on a single case study to contextualise the application of GT in the Chinese healthcare system. Case-study approaches enable the investigation of contemporary phenomena in real-life contexts (Yin, 1994), and are useful for exploratory purposes and for initiating a theory (Benbasat et al., 1987). Therefore, a case-study approach is suitable for this project, because this study investigates a contemporary problematic situation existing in the current Chinese healthcare system. Moreover, considering China is one of the largest countries in the world, with a population exceeding 1.3 billion, it would be virtually impossible to generate a theory that would encompass the whole nation.
Consequently, since this project aimed at generating a first set of insights into this problem, a single case-study design was adopted. A public hospital in the city of Xiangfan, in the province of Hubei, was selected for the case study. This hospital was chosen for two main reasons. First, it provides both WM and TCM services to patients and has done so for several decades. Second, the researcher obtained guaranteed and management-supported access to the informants and the project.
Implementing of GT in the context of this case study was planned according to a three-stage design, namely: a pilot study, a main study and a follow-up study.
The pilot study
This study aimed to confirm if the KS problems anticipated did present themselves in the reality of practice of a Chinese hospital, and to identify early results and insights to guide the remaining research stages. Overall, seven healthcare professionals and workers were purposively approached and interviewed. These participants were two WM doctors, one WM nurse, two TCM doctors, one ICT manager and one hospital administrator. Findings from this stage suggested that different departments in the hospital exhibit very different patterns of KS behaviour between the two medical communities. The study also showed that very different levels of integration of complementary treatments may be found in different departments. This resulted in the decision to choose one specific department, the Department of Neurosurgery. This department has a proven history of using WM and TCM compound treatments for rehabilitating patients after craniotomies.
The main study
The purpose of the main study was to identify KS barriers between the two communities when dealing with problems from neurosurgical patients. At this stage, 11 neurosurgeons, eight neurosurgical nurses and six TCM doctors were selected as participants, approached and interviewed. The data collected were analysed using open and axial coding through the constant comparison method of analysis. The findings indicated a need for further study on the external influences on KS.
The follow-up study
This study aimed at exploring these external influences on KS. Furthermore, it aimed at exploring and studying those categories for which theoretical saturation could not be achieved in the previous stage. Theoretical sampling, further coding and constant comparison analysis were used at this stage. This exercise of gaining a deeper understanding implied the interviewing of specific informants, namely two neurosurgeons, two TCM doctors, three neurosurgical nurses, one TCM educator, one public administrator in the local healthcare department, and eight patient carers.
Data collection, analysis and theoretical saturation
Overall, data collection followed the theoretical sampling strategy, and included 46 interview participants in a total of 49 interviews. The demographic profile of the participants is illustrated in Table 1.
Demographic profile of participants (N = 46).
These informants were sampled by the emerging theory and were interviewed by using semi-structured and evolving interview scripts. The data analysis used the GT analysis approach, which is widely recognised as particularly useful to generate theory closely related to the context of the phenomena being studied (Creswell, 1998). Therefore, the questions in the interview script changed and evolved as new and sometimes unexpected codes emerged and other concepts became fully explained or saturated, that is new questions were added to script while some were actually withdrawn or refocused.
As required by the GT methodology, the processes of data collection and analysis were operationalised. That is, immediately after each individual interview, the collected data were transcribed and analysed. Results from this analysis were used not only for the theory building, but also to direct subsequent interviews, as proposed by Strauss and Corbin (1998).
The practice of data analysis adopted two GT analytical techniques, namely coding (open, axial and selective) and constant comparative analysis, which Strauss and Corbin (1998) emphasise as critically essential to the GT data analysis. The coding and data analysis instrument that supported constant comparison for this project is illustrated in Table 2.
The presentation of emerging main themes, barriers and representative quotations.
Consequently, data collection and analysis coexisted until theoretical saturation was achieved, that is, until no new open codes emerged from the data analysis. The evolution of this emergence of new open codes and the theoretical saturation can be demonstrated in Figure 1.
Coding and theoretical saturation.
As shown in Figure 1, the burgeoning emergence of new open codes in the pilot study suggested a more focused data collection in the main study. The new codes that emerged in the 21st to 31st interviews suggested new areas to be explored in the follow-up study. The theoretical saturation was considered as achieved after the 41st interview, but the process was continued until interview 49 in order to obtain a better degree of certainty.
The emergent theory saturated on four main categories: philosophical divergence, interprofessional tensions, lack of interprofessional common ground and insufficient interprofessional education and training. A tabular presentation of the emerging main categories, barriers and supporting quotations is shown in Table 2.
Research findings
From the data collected it became clear that neurosurgical and TCM professionals were actually collaborating with patient interests and needs in mind. When dealing with patient problems, WM is the primary methodology for the patient treatment and was always used in the first instance. TCM methods are usually considered as more effective at the post-craniotomy and rehabilitation stages. Thus, TCM healthcare professionals are frequently invited by neurosurgical practitioners for intervention at these stages. The two teams have now established a strong complementary and collaborative relationship.
Knowledge-sharing process
Interaction and collaboration usually occur in consultation sessions, which are also the main vehicle for the sharing of patient knowledge. A consultation is usually requested by a neurosurgeon, when a patient’s condition is perceived to be more suitable for treatment by TCM doctors. The nurse in charge usually initiates the process at the request of the neurosurgeon and contacts the TCM doctor directly to make an informal enquiry. If the TCM doctor agrees his/her commitment to the patient, the neurosurgeon initiates a consultation note as a formal invitation for collaboration. The consultation note records all procedures and medical decisions that are made during the consultation session. After this consultation session, WM and TCM professionals never meet again to discuss that particular patient, except in the case of emergencies. The consultation note must be signed by doctors from both sides and documented in the patient records.
Both sides perceive these consultation sessions as a relatively good communication channel for KS. However, as a communication channel, these meetings can only play a very limited role in real KS between the two professional groups.
In reality, as expressed by a number of informants, the meetings usually last no more than 20 minutes, during which the diagnosis of the patient is presented by the WM professional and a brief discussion occurs between all participants. This is of course not conducive to in-depth interprofessional discussions.
Moreover, all the participants, as in any other hospital in the world, are extremely pressed for time. This was evident from a number of informants’ statements:
[In the consultation] usually they do not ask many questions, and we do not talk that much. We all are very busy. As long as we can treat the patient, that is all right. We all are too busy to actually sit down and to have a deep conversation. (Interview TCM 37.63) [In consultation] sometimes neurosurgeons can introduce patient conditions. But normally they [neurosurgical professionals] are very busy. Therefore, we mainly rely on the patient records. (Interview TCM 15.23)
Thus, the consultation meeting becomes a formal handover of patients and not a vehicle for the interchange of knowledge and interprofessional communication.
Also, the knowledge on which this research is focused, is inherently tacit and centred around patient needs, requirements and expectations. Crucially, the healthcare professionals that usually possess more of this knowledge, the nurses, are mere spectators in these consultation meetings.
Nurses, as the closest healthcare practitioners to the patient, are the ones that have a better understanding of the ethical and emotional knowledge about a particular patient as well as the social and behavioural knowledge pertaining to their family, social and even religious background. However, due to a combination of Chinese and hospital culture their role in the consultation meetings is secondary at best. Nurses, although present in the meetings, very rarely intervene and never have direct contact with their counterparts on the other side.
I rarely get into deep conversation with TCM doctors. We [neurosurgical nurses] never talk in such details [for the purpose of sharing patient knowledge]. (Interview WMN 33.15) We after all are just nurses. If a patient needs help from TCM doctors, it is entirely the neurosurgeon’s responsibility. They need to make decisions. Then, we just work on those decisions. (Interview WMN 31.13)
Thus, all the knowledge accumulated by direct care and interaction with a particular patient is lost and never transmitted to the TCM professionals.
Finally, these very rushed and short consultation meetings will never be a vehicle for the two professional groups to resolve the KS barriers identified in this research and discussed in the next sections.
Knowledge-sharing barriers
The research findings point to four main categories of KS barriers. These categories are: philosophical divergence, tension of philosophical conflicts, lack of interprofessional common ground and insufficient interprofessional education and training.
Philosophical divergence
The collaboration between TCM and WM united the two types of healthcare professionals, who have entirely different basic philosophical perspectives and beliefs. From the data gathered, it became evident that these divergent philosophical foundations result in two KS barriers, namely (1) different conceptual systems and (2) discrepancy in terminology.
1. Different conceptual systems. A number of the healthcare professionals who were interviewed, for instance in Q1 in Table 2, stated that TCM and WM do not just have very different theoretical foundations, but also have extremely distinctive diagnosis and treatment methods.
It is almost impossible to integrate both TCM and WM methods into one medical procedure. It is because TCM takes a holistic view of the human body, which is the philosophical foundation for TCM. (Interview TCM 18.07) Because we are WM practitioners and we were educated as WM practitioners, we are used to analysing from the WM perspective. But TCM is very different. Sometimes I think TCM makes sense. WM always localises diseases into particular parts of the human body. If you have a head problem, then treat the head. If you have problems with your feet, then treat the feet. However, TCM treats a patient as a whole. They [TCM doctors] are not just dealing with the disease itself. Therefore, WM is from a micro perspective, TCM is holistic. (Interview WMD 24.9)
TCM doctors adopt a holistic view of the human body as an integral entity in a close relationship with the environment. Very differently, WM practitioners are more interested in localising a specific health problem at a specific area of the human body. Moreover, WM doctors rely almost exclusively on tangible and explicit evidence (e.g. radiology, lab tests), whereas the practice of TCM largely depends on doctors’ perceptions and judgements and their accumulation of personal medical experiences.
This significant philosophical divergence poses severe difficulties in understanding each other’s diagnosis, clashes in indications for treatment, difficulties in interpreting requirements for complementarity of treatments and difficulties in understanding interpretations of healthcare problems. These difficulties may result not only in different discourses that may not be entirely compatible, but also in a professional reluctance in accepting each other’s opinions, diagnoses and interpretations.
TCM diagnosis uses inspection, listening and smelling examination, inquiry, and palpation. These methods are far different from ours. Sometimes we suspect how accurate these methods are. (Interview WMN 27.15) They [TCM doctors] have a totally different theoretical system, which we [WM professionals] do not understand. They have very special understandings of some common problems. Why they have those understandings, I don’t know. But their methods are effective [to patients]. Undeniably, there are a number of conflicts between the two theoretical systems, but their [TCM] methods are effective. Nevertheless, WM is probably more effective and as a WM doctor, I believe in our system. They believe in theirs. There are clear conflicts. (Interview WMD 9.25)
Moreover, the philosophical divergence and different professional discourses may result in the use of entirely different, sometimes conflicting professional terminologies.
2. Terminology discrepancy.
Most of the time, when TCM doctors are proposing their ideas, we can’t understand. We ask for further explanation, but still, we can’t understand. It’s not like in WM, very demonstrative and clear, such as in some cases we focus on the evidences. (Interview WMN 7.135)
This quotation clearly shows that there are important difficulties in communication, let alone knowledge sharing. It was apparent from a number of interviews (e.g. Q2 in Table 2) that the differences in philosophical foundations actually result in very different discourses, terminologies and technical jargons, which make the processes of sharing patient knowledge extremely difficult.
If I talk TCM language to WM doctors, it would be like they are reading a sealed book [Chinese expression that implies a book that is impossible to understand]. None of them can understand. (Interview TCM 4.106)
Interprofessional tensions
Also, arising from the combination of the historical process described in the introduction and the philosophical divergence discussed above, two very different types of interprofessional tension seemed to have developed since the beginning of last century, namely (1) philosophical and (2) professional tensions. These tensions emerged very strongly across the data collected and seem to be one of the important barriers preventing the necessary interprofessional interactions.
1. Philosophical tension. During the interviews, TCM and WM healthcare professionals showed a consistent lack of belief in each other’s practices. Attitudes ranged from respectful disbelief to entire disregard of the other’s roles in the healthcare system. This latter attitude was more evident in WM practitioners who often harshly criticised TCM beliefs and methodology, describing them as useless ‘superstition’ (Interview WMD 6.44).
Theories of TCM and WM are very different; for example, TCM requires thinking by heart, but as we know actually thinking is by brain. TCM does not have a clear definition and description about the brain. I think TCM and WM are two different systems. I can generally understand TCM, but from a professional point of view I think TCM is not good, not accurate, not rich. (Interview WMD 39.13)
As asserted by many of the neurosurgical interviewees, for example in Q3 in Table 2, WM is seen as pure scientific methodology and ‘superior’ (Interview WMN 14.15) to TCM, which is perceived to be based exclusively on ‘personal experiences instead of scientific evidences’ (Interview WMD 2.96) and ‘lacks a scientific foundation’ (Interview WMD 2.101).
Conversely, many TCM doctors (e.g. Q4 in Table 2) defended their methodology as a ‘solid medical methodology’ (Interview TCM 4.9), which consists of a systematic and consistent set of diagnostic and treatment methods, and that it has a credibility and an understanding of the human body that has been revised through an evolution of thousands of years. Consequently, many TCM interviewees disagree with some of the WM beliefs and methods, which they find are not always appropriate and which sometimes have adverse effects on patients’ well-being.
In many cases, we have different opinions from WM doctors. For example, when dealing with a patient with symptoms of urination difficulty, we think acupuncture would be the best solution. But WM doctors think differently, they always use methods to force the patient to urinate. It is wrong, very wrong. (Interview TCM 15.25)
Therefore, the philosophical divergence at the core of the two professional groups’ beliefs has created an ongoing professional tension between the two groups. These tensions have fuelled conflicts of opinions and perspectives, which in turn have created a climate of distrust, disregard and unwillingness to communicate in the two communities.
Some WM doctors, who think they are very good at what they are doing, are so arrogant. Even though they do not understand TCM at all, they consider TCM is a lie and a superstition. [In fact, WM is not perfect], when treating a patient, we would use the traditional herbal medicines as much as possible. We normally do not suggest the patient to take any WM drugs, which are bad for the heart and the liver, because they are all chemicals. (Interview TCM 19.39)
2. Professional tension. In addition to the philosophical tension, the two medical communities showed evidence of substantial asymmetries of positional power and professional standing. The analysis of the transcribed data clearly revealed that neurosurgeons have a relatively higher professional standing and almost complete control over patients. Therefore, as stated in Q5, they often explicitly instructed and regulated TCM doctors in what they should do about the patient.
If a neurosurgical patient needs acupuncture treatments, neurosurgeons would initiate a consultation note and telephone us. Then we go to treat the patient with acupuncture. […] In this process, we do not have decision power. For example, this patient clearly needs TCM treatment, but we cannot do anything about it, because neurosurgeons need to make this decision, not us. (Interview TCM 16.17) In collaborative patient treatments, we of course have the decision making power, because the patient is in our department. We just need TCM doctors to help us. (Interview WMD 8.31)
In contrast, TCM doctors have a lower professional standing and hold less power. Therefore, TCM doctors (as shown in Q6) are most likely to maintain a passive position, avoid any confrontations and to follow instructions, instead of actively, spontaneously and voluntarily proposing their understandings and treatment suggestions. For them, even if they intend to share knowledge, there are probably very few occasions for them to do so, and they hold very little power to have their views recognised.
This professional tension prevents KS, not only because the tension reinforces the professional boundary and distance, but also because it creates an atmosphere of professional distance and, at times, hostility between the two professional communities.
Insufficient interprofessional education and training
The research findings indicate that the lack of interprofessional common ground was related to (1) inadequate interprofessional education in Chinese healthcare HE and (2) the absence of interprofessional training in the hospital environment.
Inadequate interprofessional education in healthcare HE. It is important to note that Chinese healthcare HE consists of two parallel and almost insulated educational systems, one for TCM practitioners and the other for WM ones. Interviewees from both educational systems, for instance Q9 in Table 2, stated that there were very few interprofessional modules, lectures, and practical sessions concentrating on the possible overlap of the healthcare systems. There is therefore virtually no education to support interprofessional collaboration and communication. In this case, students from either system had very limited mutual knowledge and interprofessional common ground, and more importantly lack motivation for interprofessional collaboration and communication.
Absence of interprofessional training.
We have many training activities. But training for WM practitioners is only in WM. There is no requirement for WM practitioners to learn TCM. We are only required to learn professional knowledge in our subject. (Interview WMD 19.06) The hospital management established several professional training strategies. But none of them concentrates on us to learn WM, or on WM professionals so they can have better TCM understandings. (Interview TCM 17.81)
Therefore, in addition to the insufficient interprofessional education in healthcare HE, it was clearly identified that there is also a significant absence of interprofessional training schemes, sessions and programmes to bridge the gap in understanding between the two professional communities and to develop an appropriate interprofessional common ground.
As expressed by the neurosurgeon in Q10, the professional training programmes are mostly focused on their respective professional subjects and methods, rarely on the interprofessional areas. This reflects a perception that hospital management and leadership places very little importance on communication and professional cooperation between the two groups, thus reinforcing philosophical divergence and educational problems. In this case, healthcare professionals not only begin with very limited common ground to facilitate KS, but also are actively demotivated to engage in interprofessional activities and the sharing of patient ‘real needs’ (Interview WMN 14.35).
Lack of interprofessional common ground
As discussed above, it is evident that neurosurgical professionals and TCM doctors have entirely different conceptual systems, philosophical foundations, educational systems and training programmes. Therefore, and despite governmental policies and a genuine interest in supporting patient needs, the two professional communities are collaborating to treat the patients with a clear lack of interprofessional common ground to facilitate their communication and KS.
[Communication and collaboration] depends on how much a WM doctor knows about TCM. If you know less, you are less motivated. If you know more, you are more motivated. According to our current situation, WM practitioners do not know TCM very well. (Interview WMD 9.21) [Communication and collaboration] requires WM practitioners to accept TCM. For instance, doctor A accepts acupuncture, therefore he invites us for collaboration. He introduces patients to us. If a WM doctor has no basic TCM knowledge, he would not trust TCM, therefore no [collaborations]. (Interview TCM 16.18)
As discussed by medical practitioners from both groups (Q7 and Q8), this interprofessional common ground could be conceptualised as a knowledge base of overlapping interests and mutual conceptual understandings. This lack of interprofessional common ground exacerbates the philosophical divergence and results in conflicting understandings of patient symptoms and conditions. Moreover, the lack of interprofessional common ground reinforces the philosophical divergence and the professional boundary and distance, as well as philosophical and professional tensions.
I do not have a deep understanding of the TCM system. I am taking a suspicious attitude toward TCM. I think there is something that cannot be explained in TCM. I do not have a deep understanding about TCM, because I do not believe in TCM. In this case, I am not particularly interested in it. Once you enter the [metaphoric professional] door of WM, you have nothing to do with TCM. (Interview WMD 24.29)
Conclusions
The research reported in this paper shows that, despite a strong governmental commitment and the implementation of national policies that placed TCM and WM practitioners in the same hospitals and healthcare organisations, KS between the two groups is very limited. A clear absence of interprofessional common ground causes and aggravates identified KS barriers shaped mainly by philosophical divergences, very different medical practices, conflicting understandings of patient symptoms and conditions, insulated HE systems and lack of integrative training programmes. Moreover, the lack of interprofessional common ground reinforces rigid professional boundaries and inequalities in status and power within the hospital, and therefore creates philosophical and professional tensions.
These strong interprofessional tensions alienate the TCM and WM healthcare professionals, who are supposed to work together, side by side, and to communicate unconditionally in order to provide the best possible medical treatments to patients. While technical information will always be present in patient records due to stringent healthcare system regulations, this alienation and the consequent lack of knowledge sharing will be particular crucial in tacit aspects of patient knowledge, namely in terms of the two categories identified in this paper: (a) ethical and emotional and (b) social and behavioural.
Thus, the key to improving KS and reducing the effect of the identified barriers lies in creating working environments and training programmes in the hospitals that develop the interprofessional common ground. It is clear that it is critically important to embed and increase interprofessional education programmes in both TCM and WM universities and educational institutions. Nevertheless, the effect of these changes in HE will need a considerable amount of time to permeate the national Chinese healthcare system. Therefore, the short- and medium-term changes need to be carried out at the hospital level by establishing very specific interprofessional training schemes and activities. This solution must be supported by the hospital management and medical professional leaders, who should realise that the collaboration between TCM and WM is not just a political imperative, but may bring tangible benefits through mutual trust with the aim of maximising the patients’ welfare.
Footnotes
Funding
This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.