How Can Non-Academic TCM Practitioners Obtain a Medical License?

Some articles I wrote a few days ago caught the attention of several readers, who asked me how non-academic TCM practitioners can obtain a physician license. I am writing this article to explain in detail, for everyone's reference. I hope it helps those who, like me, want to dedicate themselves to TCM.

By the way, kind friends have also offered all sorts of advice about credentials and medical exams over the past few days. I am grateful for their warmth, but most of the advice is quite uninformed, and I have no time to reply to everyone, so please forgive me. I myself have studied the medical-licensing policies for years and have also worked in hospital administration, so I know every step of the licensing process intimately.

China has a large number of self-taught or family-transmitted (apprenticed) TCM practitioners who work in the community; people habitually call them "folk TCM doctors," and their practice is often noncompliant. The state does not simply crack down on them; it has provided many pathways to certification, but some local governments implement them very poorly. As China's legal environment improves, if these practitioners do not obtain a physician license soon, they may be phased out in the near future.

First, those who wish to study and practice TCM should understand China's health laws. Health law is the body of laws and regulations, enforced by state power, that governs social relationships arising in the course of health activities. Article 21 of the Constitution stipulates that the state develops medical and health services, develops modern medicine and traditional Chinese medicine, encourages and supports rural collective economic organizations, state enterprises and institutions, and neighborhood organizations in running various medical and health facilities,and carrying out mass health campaigns to protect people's health. The Constitution is the fundamental law of the state, the mother of all laws. So this article is the general principle underlying all health regulations; the original intent of health law is to protect people's health.

China has more than ten health-related laws. Those most relevant to TCM physicians include: the Law on Traditional Chinese Medicine of the People's Republic of China, the Physicians Practice Law, the Drug Administration Law, the Interim Measures for the Filing Administration of TCM Clinics, the Interim Measures for the Physician Qualification Examination, the Regulations on the Administration of Medical Institutions, the Law on the Prevention and Treatment of Infectious Diseases, the Maternal and Infant Health Care Law, the Occupational Disease Prevention Law, and the Basic Medical Health and Health Promotion Law. In addition, in 2010 the Chinese government issued the Ethical Review Administration Norms for TCM Clinical Research, which set specific requirements for respecting the rights of trial subjects and protecting their safety in TCM clinical research.

China operates a physician-qualification-examination system. Any citizen who wants to practice clinically must take the physician-qualification exam; only by passing it does one have the legal right to practice. TCM apprentices may work clinically under a supervising teacher, but with many restrictions. I am currently a TCM apprentice myself, so seeing patients requires me to think hard about avoiding legal problems.

Who is eligible to take the TCM physician (including assistant physician) qualification exam? Under China's Interim Measures for the Physician Qualification Examination, three categories of people may take it: (1) those with a medical-related degree (secondary vocational, junior college, or bachelor's) who have worked in a medical institution for more than a specified number of years; (2) TCM apprentices who have studied under a teacher for three full years, passed the qualifying graduation exam organized by the provincial TCM administration, and obtained a graduation certificate; and (3) those with many years of clinical practice who have been certified as having proven specialty skill, passed the assessment for such practitioners organized by the provincial TCM administration, and obtained the specialty-skill certificate.

One clarification: these three groups are governed by the principle of local administration. When I registered my apprenticeship in 2012, I misread "local administration" as meaning I had to register and take the exam in my place of household registration. In fact, any citizen of the People's Republic of China can complete the relevant procedures and register for the exam in any province. "Local administration" means you take the exam in whatever province you work in a medical institution or register your apprenticeship.

Personally, I advise those who want to go the apprenticeship or specialty-skill route to choose developed regions like Beijing or Shanghai—especially Beijing—because administration there is standardized, TCM resources are rich, the local health authorities do not discriminate against TCM, and they hold the relevant exams on schedule every year.

Beijing generally holds the apprenticeship and specialty-skill exams at the end of April each year, at the Beijing Tibetan Hospital. Those who want to take the TCM physician exam through this route can find the relevant policy on the official website of the Beijing TCM Administration.

By national law, the provincial TCM administration should hold the apprenticeship graduation exam every year. I registered my apprenticeship in our province in August 2012, so in theory I could have taken the graduation exam after August 2015. But I have waited from 2015 until now, and our provincial TCM Administration has not held a single apprenticeship graduation exam.

I have been doing physician-exam questions every year, for six straight years, and my accuracy now exceeds 85%; we only need a passing score (60%) to pass the physician-qualification exam and get the certificate. But I was stuck for six full years because of the provincial TCM Administration's inaction. I once very much wanted to report the direct leaders of the provincial Health Commission, but after last year's outbreak they were all held accountable and punished as they deserved. So holding them accountable now no longer means much; one must bear one's own losses, forget the past, and start over.

TCM apprenticeship has one hard requirement: the apprentice must have a high-school diploma or above. Those without a high-school diploma must find another way—attend a medical secondary vocational school or take the specialty-skill route. The supervising teacher must hold the title of associate chief physician or chief physician, or be a TCM physician who has worked clinically in a medical institution for at least fifteen years. Apprentices and teachers must sign a Traditional Medicine Apprenticeship Agreement and have it notarized; at the graduation exam, the hospital where the teacher works must also affix its seal. The Beijing TCM Administration's rules are very detailed: during the three-year apprenticeship, the apprentice must keep complete study notes (500 class hours per year, 1,500 over three years) and record no fewer than 100 cases per year.

As far as I know, Beijing's TCM apprentices are generally of high caliber, many with bachelor's degrees or above; quite a few are master's or PhD holders in other fields. One apprentice I know has a master's degree from Peking University. They switched fields to study TCM via the apprenticeship route. Most such apprentices have family obligations and cannot leave their existing jobs to complete a full medical degree, so they take this path out of necessity.

China's health laws change frequently. Under the latest policy, after a TCM apprentice passes the graduation assessment, he must work in a medical institution for one full year (showing social-insurance records from the institution at application) before he can apply for the assistant-physician exam. After passing the assistant-physician exam, he must work in a medical institution for five more years (again with social-insurance records) before taking the physician-qualification exam. Generally, once you pass the licensed assistant-physician exam you can practice legally at a township-level hospital.

So nowadays a TCM apprentice needs at least nine years to obtain the physician-qualification certificate. By comparison, a medical bachelor's graduate needs only one year of internship in a medical institution before taking the physician-qualification exam directly. A medical junior-college graduate needs one year of internship before applying for the licensed assistant-physician exam, and after obtaining the assistant certificate and working two years in a medical institution, can sit the physician-qualification exam. A medical bachelor's program takes five years and a junior-college program three; whether bachelor's or associate's, the fastest route to the physician certificate is six years.

That is why I have now chosen to retake the college entrance exam and attend a medical junior college. For me, this is the fastest route to certification. To avoid going back again, I burned all my application materials except the apprenticeship agreement and the notarization. I kept those two because they still offer me some protection. Under Chinese law, it is reasonable and legal for a TCM apprentice to participate in clinical practice under a supervising teacher; in fact, one must participate in the diagnosis and treatment of at least 100 patients per year.

For adults who have families to support, a medical bachelor's degree is not cost-effective, because it wastes five years at university. Many who want to pass the physician exam have already studied on their own for years but are barred by eligibility. Their goal in completing a medical degree is precisely to gain eligibility to sit the exam, so a three-year junior college is the more reasonable choice. A junior-college degree also makes future professional-title exams much easier—though personally I have no interest in titles; patients' recognition matters far more than any title. Many patients trust me, a mere TCM apprentice, far more than they trust a chief physician. Over the years I have deeply realized that, at least in medicine, the hard credential of formal education matters enormously.

The physician-qualification exam only recognizes full-time, nationally enrolled junior-college or bachelor's degrees. If your bachelor's was not in a medical major, even a graduate degree in medicine does not let you sit the exam. In special cases, long-time medical workers with a secondary-vocational degree may be allowed to take the exam, but the secondary-vocational route is being phased out; in a few years such students may no longer be admitted.

Obtaining the TCM specialty-skill certificate is also not easy; it requires submitting many supporting documents. But in many provinces this certificate can be bought, with some corrupt officials profiting from it, so in those provinces the certificate is highly diluted. Over the years I have not been unaware of this route; many people could have arranged it for me. But I strongly reject doing so; I would never do something that would stain my lifelong integrity just to get a certificate. I can wait and endure, but I will not take that road.

Moreover, since the Law on Traditional Chinese Medicine took effect, the state has also allowed folk TCM practitioners with a particular skill to take the TCM (specialty) physician exam. This exam must be taken in the candidate's province of household registration and cannot be taken across provinces. Rules and assessment methods differ by province. Beijing currently has the most standardized and scientifically designed assessment, which reflects its richest TCM resources.

According to feedback from many candidates who have taken this assessment, the exams organized by other provinces all need to improve. The TCM (specialty) physician certificate is also not comparable to the regular TCM physician license. Holders of the specialty certificate may, in principle, only practice locally and treat a single category of disease. There is no written exam—only a half-hour interview—so the result is highly arbitrary. Five or seven examiners assess the candidate on site; if more than half pass the candidate, the candidate passes. Most examiners know little about the candidate's specialty and ask irrelevant questions; a candidate who gets nervous during the exam has a hard time passing. Though I write well, I am poor at face-to-face communication and easily nervous, so I am at a disadvantage in this kind of exam. But the system is still new and may become more standardized over time, with better organization.

Candidates from other provinces who have passed this exam tell me that, two-plus years after getting the certificate, they face discrimination when opening clinics or seeking jobs. So the TCM (specialty) physician certificate is currently a chicken-rib—neither here nor there—and will take a long time to gain social acceptance.

A TCM (specialty) physician who has practiced medicine for five years with no malpractice incident may apply for the regular TCM physician license. Because no province has offered the specialty exam for five years yet, no one has obtained the regular license through this route. The pass rate for the specialty exam is astonishingly low: in Guangdong it is only about 1%, and of 600 candidates in Guangxi, only 46 passed, most of them treating minor complaints. This cannot be compared with the roughly 30% pass rate of the regular physician exam, which gives a sense of how hard this road is.

The Beijing TCM Administration has issued dedicated rules for the TCM (specialty) physician exam. Beijing now has two kinds of apprenticeship agreements: the traditional three-year agreement and a special five-year agreement for TCM (specialty) physician candidates. After notarization and hospital recognition, an apprentice who studies under a teacher for five years, accumulating sufficient annual study records and clinical cases, may apply for the TCM (specialty) physician exam. Detailed assessment methods are on the Beijing TCM Administration's website. One detail: Beijing apprentices must now register promptly on the TCM Administration's official website after completing their apprenticeship; previously they filed with the Beijing Association of Chinese Medicine, but now they register directly on the Administration's website.

Many Beijing hospitals offer apprenticeship education, including Beijing Hospital of Traditional Chinese Medicine, Wangjing Hospital of the China Academy of Chinese Medical Sciences, Dongzhimen Hospital and Dongfang Hospital of Beijing University of Chinese Medicine. Wangjing Hospital's apprenticeship program is the most established, though under its rules apprentices pay 6,000 yuan per year in tuition, and this fee may change.

Beijing has few apprentices—only dozens to a bit over a hundred take the exam each year—but many supervising teachers. So if you register your apprenticeship in Beijing and look patiently, you can find a master's or PhD supervisor as your teacher. But be prepared: apprentices are much like graduate students and will be asked to do a lot of work for their supervisor.

TCM is in decline. Although the state now strongly supports it, the number of people truly committed to TCM is falling year by year. TCM university graduates struggle to find jobs, and non-academic TCM practitioners have it harder still. My shifu once told me that the number of registered TCM physicians locally has been shrinking over the years. The TCM licensing exam is also very hard, so those who want to practice TCM clinically must be tough and resilient. Do not believe the inflated claims of agencies that promise easy certification.

I actually regret having taken the apprenticeship route ten years ago. Back then my wife saw how determined I was to study TCM and could not dissuade me—actually she always wanted to; medical work carries huge risk, and she did not want me to become a doctor, but she had no choice. Ten years ago she strongly advised me to retake the college entrance exam and enter a TCM university, which she saw as the most practical route. Given my high-school grades, I could have gotten into any TCM university in China. But by the time I was over thirty, I lacked confidence in retaking the exam, and I was not yet financially free, with heavy family obligations, so I chose the apprenticeship path.

The master's and PhD holders I know who went the TCM apprenticeship route—even those who took the Beijing exams—have not yet completed the journey or obtained a physician license. The road is longer than anyone imagines. I sincerely hope China's TCM law is further improved to create a more reasonable path for those of us who went to university for other majors and later want to switch into TCM, giving us a chance to take the autonomous enrollment exams of TCM universities and redo a junior-college or bachelor's education. There really are people like me—university graduates in other fields who are interested in TCM—and these are exactly the talents TCM should attract. But hampered by legal restrictions, they find the road into TCM especially hard.

Under current Chinese law, the physician-qualification exam only recognizes full-time, nationally enrolled medical junior-college or bachelor's degrees; self-study exams, adult-education gaokao, and bachelor's graduates in other majors who go on to a medical master's are all ineligible. So for a university graduate who wants to switch into TCM and obtain a formal TCM physician license, the only ideal road is to grit one's teeth and retake the college entrance exam.

Choosing to retake the gaokao was, after weighing all the pros and cons, my least-bad option. As an elder of mine put it, this is a road I cannot avoid. If you want to build a legitimate career in TCM, you have to take the exam.

Of course, though this road is hard, it is actually feasible. Any Chinese citizen aged 25 or older with a high-school diploma or equivalent may register as a social candidate for the gaokao. Registration dates vary by locality but are generally around November; interested candidates can register at the admissions office of the education bureau in their place of household registration, bringing their household register, ID card, and high-school diploma, and submitting the required documents and medical exam as the bureau directs.

I personally now want a TCM junior-college degree—a bachelor's would waste too much life. Junior college takes three years on campus, a bachelor's five. For a middle-aged person, time is the scarcest resource; we still have families to care for, so we will not consider flashy options. I am completing this education only as a stepping stone to the medical exam. I know there are many people in China with experiences similar to mine; the road I have taken, and the roads other TCM apprentices I know have taken, have not been easy. For those of us capable of scoring into a junior college on the gaokao, the best option is not apprenticeship or specialty-skill certification, but retaking the gaokao. To make the three years count, I hope to minor in clinical medicine at the junior college and learn Western medicine as well.

In our province, retaking the gaokao to enter a TCM junior college requires around 350 points. Beijing candidates are lucky—they need only about 200. With the right strategy, 350 is attainable. Both clinical medicine and TCM programs favor science-track students, so the best subject combination is Chinese, math, English, physics, chemistry, and biology. I myself plan to focus my scoring efforts on Chinese, English, and biology, and do my best on the rest.

Chinese and English are each out of 150 points and are relatively the least difficult to study. Biology is easier than math, physics, and chemistry, and it is a very important subject for medical students. Those with some medical background pick up biology easily, because we constantly use biology in clinical practice, and we find it a fascinating subject. So I will focus on these three: if I can score around 250 on them and another 100 on the remaining three, I can reach the 350 cutoff.

There are many excellent high-school lecture videos online, on Bilibili and on national education platforms. The biology videos I use were recommended by a biology postdoc; he found a high-school biology course on Bilibili that is very popular with students. After I started watching, I got into it easily. My classmates, friends, and former high-school teachers also gave me plenty of reference materials and videos. So a self-disciplined adult preparing at home has no shortage of learning channels.

I have set aside a year and a half, planning to finish one semester's curriculum every three months, focusing on the basics. On exam day I will not aim to score on the hardest problems; I plan to skip the hardest finale questions outright. The current gaokao emphasizes basics, which make up more than half the paper, so nailing the basics gets you about half the points. A classmate of mine who teaches high school told me that students at their school who sleep at their desks all day still score over 300. After university expansion, getting into a junior college is indeed not that hard.

High school has five semesters in total; the last is review and drilling. I have planned fifteen months to cover the five semesters, using the last three months for practice problems. We adult retakers do not need to take the proficiency exams, so we have fewer subjects, and we all have some foundation, so a year and a half should basically suffice. But inevitably we must work and support our families while preparing, so time is tight. Studying at home requires great self-discipline; if you cannot manage it, consider enrolling in a cram school for the final half year.

So it is truly hard for a non-academic TCM person to become a legal, qualified TCM physician. Even after becoming a formal TCM doctor, the career will not be smooth. Many TCM graduates of proper medical schools switch careers because they lack patients and earn little. So middle-aged people who dream of switching to TCM are being unrealistic; only those with sincere resolve can walk this road. I do not recommend it for the weak-willed or those whose circumstances do not allow it. State policies have created opportunities for agencies to get rich; many people have been cheated out of large sums by agencies and ended up with nothing.

I once cured a patient with rhinitis; after he recovered he gave me 500 yuan as a thank-you. One thing he said moved me deeply: he said those who stick with TCM have it hard, and he was glad to give a little thank-you money to support me on my way. Over the years I have met many wonderful patients; it is their support that has kept me going. But people also question us from time to time, so those who switch into TCM must be strong of heart.

Writing this long article cost me dearly, but I hope it genuinely helps those who want to study TCM. I also hope the legislature will consider our real situation and improve the law. More than that, I hope the people who enforce the law will not imitate those deadbeat scum; please truly serve the people wholeheartedly. We have it hard enough; do not artificially block our road forward.

Those who want to discuss switching into TCM with me, please forgive me for not having time to chat one by one. Where there's a will there's a way; let us not disturb one another and each strive on. What I have to say is already set out very clearly in this article.

One of my uncles by apprenticeship is both a chief physician and a leader at our local Health Commission, with an intimate knowledge of medical law. He has constantly urged and spurred me on; he admires my diligence and hopes I will not fear hardship, aim high, and one day become a great TCM master. So he kept urging me to make up my mind, overcome present difficulties, retake the gaokao, and see this road through. It was with his help and encouragement that I finally decided to complete a medical degree. I am very grateful to him; in middle age, to still have someone spurring us on is rare. Over the years it has been the care of many elders like him that has let me overcome my inertia and keep pushing forward in my studies even in my forties.