Perception of traditional Chinese medicine (TCM) among Chinese medical and non-medical students taking the all-English-taught TCM course

INTRODUCTION

With the acceleration of economic globalization, the internationalization of higher education has become a new trend. Internationalization is an important parameter of university education. Institutions such as Times Higher Education, U.S. News and World Report, Quacquarelli Symonds, and Academic Ranking of World Universities have listed the level of internationalization or international cooperation in their World University Rankings. Over the years, universities in various countries have been working diligently to promote educational reforms aimed at strengthening the internationalization of higher education.^1-4 With the backdrop of promoting world-class universities and first-class disciplines, the internationalization of higher education has become one of the key development strategies for each university in China.⁵ As one of the important measures of internationalisation of higher education, the construction of English teaching courses for undergraduates has received attention from major universities.

Traditional Chinese medicine (TCM) has played an irreplaceable role in the development of Chinese civilization for thousands of years. With the continuous development of TCM medical treatment, science, technology, and education, a large amount of work related to the internationalization of TCM has been done, and TCM has been increasingly recognized worldwide.⁶ About 30% of local people and more than 70% of Chinese people around the world receive TCM healthcare services every year.⁷ However, TCM in foreign countries is still dominated by acupuncture, and it is mainly used as a supplementary and alternative treatment.⁷ Therefore, there is still a long way to go to accelerate the internationalization of TCM.

Since the first batch of international students was enrolled in 1957, the cause of Chinese medicine education in China has developed rapidly. Many medical schools in China have listed TCM as a compulsory subject for international students majoring in clinical medicine, which has played an important role in promoting TCM culture and spreading its influence worldwide.⁸ According to statistics from the UNESCO Institute for Statistics (UIS), China has been the world’s largest source of international students for the past years (http://data.uis.unesco. org/). According to the 2020 employment report, the Chinese population in the USA has an employment rate of more than 60%. As the opportunities for Chinese students to study and work abroad have increased markedly, they are also crucial for the global spread of TCM. In the past, at most colleges and universities, Chinese students learned TCM courses in Chinese, which resulted in a lack of knowledge of international terms and expressions related to TCM. Teaching TCM in English to Chinese students may improve these conditions, but the teaching effect and student recognition still require further evaluation. With the vigorous development of TCM, an increasing number of ordinary people have gained a greater recognition of TCM, and non-medical students have also shown a strong interest in the field.

We evaluated the perceptions and learning situations of Chinese medical and non-medical students who enrolled in the TCM course taught in English, and proposed some new ideas and suggestions on how to improve the teaching of the TCM internationalization course and the international dissemination of TCM.

METHODS

A cross-sectional study was conducted at Zhejiang University, Kunming Medical University, Anhui Medical University, and Chongqing Medical University in the People’s Republic of China. In April 2022, through the web-based survey tool Sojump (Changsha ran Xing InfoTech Ltd., China), a structured, self- reported online questionnaire was distributed to Chinese medical and non-medical students studying the TCM course taught in English in these four universities.

Since there is no recognized authoritative TCM learning evaluation questionnaire, the contents of this questionnaire are based on the questionnaire we used to investigate the learning effect of TCM courses for international students.⁹ This anonymous questionnaire comprised 14 questions, including 4 demographic data questions about the student’s age, gender, major, university, and 10 closed-ended questions consisting of 9 single-choice and 1 multiple-choice (shown as Supplementary file 1). This questionnaire investigated Chinese medical and non-medical students’ perceptions on TCM in clinical practice, traditional Chinese culture and modern TCM research; to find out whether they have understood the theoretical concept of TCM and established TCM thinking through the TCM course; and to find ways to improve the teaching methods and learning models of this course. Chinese medical and non-medical students who were willing to participate in the survey completed and returned the questionnaire.

Categorical data are presented as frequency and percentage (%), while continuous data are expressed as mean (standard deviation [SD]). Data were analyzed using the Statistical Package for Social Sciences, version 26 for Windows, IBM Corp., Armonk, NY, USA. The Chi-square test was used to compare categorical data, and the t-test was used to evaluate the statistical significance of continuous data. For all the hypothesis tests, a significance level of p<0.05 was set.

RESULTS

A total of 98 medical and 43 non-medical students who underwent the TCM course in these four universities responded to the questionnaire. Among the participants, 54 (38.3%) were males. There was no significant difference in gender composition between the two groups (Table 1). The average ages of the medical and non-medical students were 20.69 (2.09) and 20.91 (2.18) years, respectively.

Similarities between medical and non-medical students Both medical and non-medical students believed that TCM had importance in clinical practice (100% v. 97. 7%). All the students believed that traditional Chinese culture should be fully integrated into TCM courses, and that modern research on TCM was valuable (Table 1). Most students believed they had a better understanding of the theoretical concepts of TCM (99.0% v. 97.7%), and demonstrated their ability to establish TCM thinking (99% v. 95.4%) in the TCM course. During the teaching process, both medical and non-medical students agreed to use the case teaching method (99.0% v. 100%), and believed that comparing traditional medicine in other countries with TCM could help them better understand TCM (100% v. 97.7%). More than 80% of students preferred face-to-face classroom instruction over watching webcasts and video replays (Table 1). Students believed that the most beneficial learning styles were the ‘teacher’s lectures’ (41.8% v. 44.2%) and ‘Practice’ (39.8% v. 32.6%; Fig. 1). Among all TCM forms, students were most interested in ‘Chinese herbal medicine’ (73.5% v. 76.7%) and ‘Acupuncture’ (76.5% v. 72.1%; Fig. 2).

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FIG 1.

The most beneficial learning method: (a) medical students («=98), (b) non-medical students («=43)

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FIG 2.

The traditional Chinese medicine contents medical and non-medical students were interested in acupoint stimulation TCM traditional Chinese music

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DISCUSSION

We found many similarities between Chinese medical and nonmedical students who received TCM English courses in terms of their cognition and learning of TCM, as well as their preference for the teaching methods of this course. Most of them believed that TCM was of great importance in clinical applications and that traditional Chinese culture should be integrated into TCM courses. Additionally, they considered modern TCM research to be of great value. Both medical and non-medical students had understood the theoretical concepts of TCM and established TCM thinking through the TCM internationalization course. In addition to Chinese herbal medicine and acupuncture, medical students and non-medical students had different interests in other forms of TCM. Medical students were more interested in moxibustion, massage, cupping and other traditional TCM forms, while non-medical students were more interested in exercise, diet, music and other TCM forms related to lifestyle.

TCM culture is an important part of traditional Chinese culture. It has always kept pace with ancient Chinese culture throughout the development process spanning over 2000 years. Although the classics of TCM cannot be regarded as philosophy in a strict sense, they can be considered one of the important types of classical texts in Chinese philosophy to a certain extent.¹⁰ Therefore, if students do not understand the philosophical basis of traditional Chinese culture and think the way of western medicine to understand TCM, it will not be easy to establish a TCM thinking model that emphasises the holistic concept and syndrome differentiation. We found that all students believed traditional Chinese culture should be integrated into the TCM course, and most of them could establish TCM thinking effectively. Integrating traditional Chinese culture into the TCM course is not only beneficial to students’ understanding of TCM, but also to the internationalization of TCM and the spread of Chinese culture around the world. To help students better understand how to express Chinese culture and philosophy in English, we apply the translation principle of ‘dynamic equivalence’ in the course, conveying source language information in a manner that conforms to the target language’s conventions.¹¹

Modern TCM research, as an important part of the internationalization of TCM, can reveal the academic nature and scientific basis of TCM, thereby enabling it to be understood and recognized by the international medical community. In the process of internationalization of TCM research, we should take the dominant diseases of TCM as the starting point, apply evidence- based medicine methods, and combine the pathophysiological research methods at the cellular and molecular levels to fully verify the effectiveness and safety of TCM. With the discovery of artemisinin¹² and related research on TCM in combating Covid-19,^13-15 TCM is gaining increasing recognition around the world. All students in this survey realised the value of modern TCM research. Therefore, by introducing modern TCM research in class, we can stimulate students’ interest in TCM research and encourage them to actively participate in it.

Against the backdrop of global economic integration, the internationalization of medical education is a key direction for future development. In the TCM course, we use English teaching to achieve the goal of not only imparting professional knowledge of TCM to students, but also improving their English application skills. Through the questionnaire survey, we found that medical and non-medical students had a similar understanding of TCM and a comparable preference for teaching. Through the study of the course, they can master the theoretical concepts of TCM and establish a TCM perspective. Therefore, we believe that the international TCM course has a positive teaching effect, and at the same time, it can strengthen students’ grasp of international terms in TCM, improve their oral English communication skills, and contribute to the dissemination of TCM. Additionally, nonmedical students also achieved good learning results in the TCM internationalization course. Therefore, this course should increase the participation of non-medical students in the future. On the one hand, it can cultivate non-medical students’ interest in learning TCM, enabling them to understand the subject more systematically and scientifically. On the other hand, it also contributes to the popularization and internationalization of TCM.

The outbreak of Covid-19 in late 2019 hindered the movement of people between countries and caused many difficulties to the development of international education. According to a survey on the impact of Covid-19 on higher education by the International Association of Universities, 64% of the universities surveyed believed that the epidemic had affected inter-school cooperation, and 51% thought it had weakened their communication with international partners.¹⁶ Online teaching, such as live classes and recorded classes, had become the main mode of student learning during the epidemic,¹⁷ but most students were inclined to participate in face-to-face classroom teaching in this survey. In the 1990s, Bengt Nilsson, vice president of international affairs at the University of Malmo in Sweden, first proposed the concept of ‘domestic internationalization’.¹⁸ It makes international education no longer limited to ‘cross-border flow and exchange of personnel in physical space’ in a narrow sense, but focuses on the means of local talent training for students. This concept coincides with the internationalization of the curriculum under the current situation. Moreover, TCM, as a traditional dominant discipline in China, is comprehensive in various forms, but currently, only acupuncture is generally recognized abroad.⁷ Therefore, the international teaching of TCM in China has many irreplaceable advantages.

We found that ‘Chinese herbal medicine’ and ‘Acupuncture’ were the most interesting topics for all students, likely due to their common applications in real life. However, in terms of ‘Moxibustion,’ ‘Massage,’ ‘Cupping,’ ‘TEAS’ and other forms of TCM, non-medical students were less interested than medical students, which might be due to the need to use instrument operation and strong professionalism. Meanwhile, non-medical students showed more interest in TCM forms closely related to life, such as ‘Exercise,’ ‘Medicated diet,’ and ‘Traditional Chinese music’. The different interests of medical students and non-medical students in the form of TCM give us the following insights: (i) it is necessary to strengthen the promotion of moxibustion, massage, cupping and other forms of TCM; (ii) strengthen the public’s understanding of TEAS and other modern TCM scientific and technological achievements; (iii) apply modern research and evidence-based medicine methods to more forms of TCM besides Chinese herbal medicine and acupuncture, enhance their scientific basis, and make them more recognized; (iv) vigorously develop TCM forms closely related to daily life, such as more scientific guidance on exercise, diet and music, to improve the effectiveness of TCM communication. While teaching the course, we also incorporated practical courses to enable students to understand the material more intuitively and deeply. In the presentation session, students can choose the TCM form that interests them and conduct a more in-depth study.

In conclusion, teaching TCM in English to Chinese medical and non-medical students can enhance the internationalization of TCM education, in which traditional Chinese culture, modern TCM research, and the development of various TCM forms play the most important roles.