Hugh MacPherson, principal of the Northern College of Acupuncture, York, looks into the issue of continuing education, assessment of standards and competence, and the support of practitioners moving from dependency at colleges to autonomy in practice. He covers the future role of the professional body and the prospect of professional reaccreditation, and stresses the need for involvement of individual practitioners in future planning.

Introduction
In this article, I will outline why the debate on continuing education should involve everyone in the profession. By continuing education, I mean all education and learning that takes place after registration as a professional acupuncturist. There are many knotty and controversial aspects to this debate and I will identify some of these. I will also put forward some suggestions towards how we might establish a profession-wide debate on continuing education. Such a debate is crucial if we want to develop continuing education in the UK in a way that carries the support of the membership of the acupuncture profession.

These issues around continuing education are being debated not just in the acupuncture profession but in many other professions too, particularly the medical profession in the UK as I will discuss later. Many professional organisations are setting up systems to encourage, provide, monitor and evaluate continuing education for the profession. The positions taken by professional bodies often tend to develop along a spectrum that ranges initially from acknowledgement of the importance of continuing education, through actively encouraging self-monitoring, through making recommendations to finally establishing minimum requirements.

This article deliberately does not put forward specific proposals for continuing education because this would undermine precisely the sort of debate that I believe to be necessary for our profession as a whole to undertake. Rather I would see proposals evolving out of the process of debating what we want for the acupuncture profession.

A shift of focus
For the last decade the focus of attention in acupuncture education in the UK has been on the pre-registration phase which necessarily has been a priority. As a result of the work of the British Acupuncture Accreditation Board, we will be ensuring minimum standards of training and competence in order to attain entry to the profession. These minimum standards will need to be seen by external bodies to be credible (Shifrin, 1993). However, relative to the post-registration phase, the pre-registration phase occupies a comparatively short time period in the continuum of a practitioner's working life. For this reason it makes sense for our professional body to begin to give more attention to the post-registration phase. We have as yet no procedures for monitoring and evaluating this post-registration phase. We also need to acknowledge that there are both external pressures and internal motivations for us to continue learning.

External pressures
Recent developments in the acupuncture profession in the UK are leading inexorably to the question of how we as practitioners maintain and improve our standards over the years. As political pressure grows for continuing education to be formally monitored, we as a profession have the opportunity to decide for ourselves what we want before it is decided for us. The issue of continuing education is a politically sensitive one within the profession, and particularly so if it involves any inherent threat to the status of current practitioners.

Given that external pressure is one of the ingredients that is fuelling moves to formalise standards in continuing education, our professional body will need to be sure that the strategy will be seen to be credible from the perspective of the external agencies, such as the government, the British Medical Association or the community. And a longer view may be helpful here, because of the steadily rising expectations that we continue to experience. We need to assess not just what is the minimum acceptable now, but what will be accepted as credible in ten and twenty years time.

As a profession largely made up of individualists who value autonomy and independence, the setting of standards, the monitoring of them and perhaps even the imposing of sanctions may well be seen as authoritarian and controlling. However, such opinions may need to be balanced by those who recognise the current political pressures to regulate ourselves as a profession, as a failure to do this may in the longer term lead to the even more authoritarian and controlling influence of the State.

Internal motivations
There are a number of strong reasons for us to continue our learning and be interested in maintaining and improving our standards. Among these can be counted a genuine concern to give our patients the best possible treatment, a desire for excellence in our work, a wider recognition for the profession, a need for increasing accountability to the public, and a political imperative that as a profession we can only maintain our autonomy if we are seen to be genuinely self-regulating.

Remembering that the purpose of our work is to serve the needs of our patients, we clearly have a responsibility to sustain the quality and safety of our treatments, to continue to learn and develop our reservoirs of experience, and to ensure we work with the best interests of our patients at heart. For these reasons, our strategies for continuing learning need to be informed by the central role that patients have in our work.

In Oriental medical practice, it has always been part of the tradition to continue to learn and develop skills and expertise. We know that senior acupuncturists patiently and steadily add to their reservoir of experience. Diagnostic skills are slowly refined over the years. Subtle nuances in the clinical encounter are more deeply understood and appreciated. It is in this context, that we can understand the great respect accorded to the lao zhong yi, or senior Chinese doctors and be inspired by the words of Lao Zi when he wrote that "great talents ripen late" in the Dao De Jing (Gia-Fu & English, 1973).

Some issues in continuing education
The debate about continuing education is also one where we need to willingly engage in the following issues: What do we mean by education? How do we assess standards and competence? How do we support practitioners moving from dependency at colleges to autonomy in practice? How do we ensure that informal learning as well as formal inputs are valued? How do we know what benefits flow from formal inputs? And how do we ensure that continuing education has a positive and enhancing effect on the profession, and not just a controlling and limiting effect? All these questions relate to how we want to see the profession developing. In particular, can we ensure that the answers will serve the acupuncture community that includes part-timers and those that are returning to the profession after some time out? Can we ensure that our learning curve can include what is necessary for us to meet the increasing demand for our services in the National Health Service and from referrals from GPs? Can we continue to foster the diversity in acupuncture styles and approaches that is the hallmark of the work at pre-registration level of the British Acupuncture Accreditation Board? And how can we craft together a plan for continuing education that meets both the requirements of the external agencies and also attends to our own internal motivations and needs? In the following sections I will outline two polarities where we will need to carefully assess what we might want from a new and formalised structure for continuing education.

Teacher-centred vs. learner-centred
Imbued in our culture is the implicit assumption that in order to learn anything we need to be taught. However, as proponents of adult education will often point out (Jarvis, 1988), learning is part of our lifelong journey and we are inherently motivated to continue learning about whatever activity we are engaged in. A willingness and openness to learning can be seen as part of being balanced and in harmony. A consequence of this perspective is that it makes sense to focus on the learning rather than the teaching, and to put the learner at the centre of the educational process. In previous centuries, this approach has always been part of the apprenticeship systems, both in China and the West, with its strong emphasis on peer culture interaction as well as supervised learning.

More recent developments, both in the West and more recently in China, have seen the growth and dominance of the didactic teaching tradition based around colleges and schools where theory dominates practice, thinking dominates feeling and matter dominates the spirit. It includes formalised inputs such as lectures and seminars and relies heavily on uniform assessment through set tests and examinations. As the professions have become closely aligned with the institutions of higher education, developments in continuing education in the professions have tended to follow the didactic teaching tradition.

In responding to external pressures, the monitoring of didactic teaching inputs may be straightforward. However, professional development largely takes place by learning on the job. In this context, important influences include peer interaction, mentor relationships with more senior practitioners, reading of journals and books, reflection on and evaluation of knotty cases, self-directed learning about a difficult disease or condition, and projects to build or extend one's practice or to liaise and work alongside other health professionals. A key ingredient here is that learning opportunities and directions arise naturally out of the everyday experience of the work.

Superficial vs. deep
A simple and superficial approach to the provision of continuing education is to require the attainment of a certain number of hours or units (for example Continuing Education Units or CEU's for the acupuncture profession in the United States). As editor of the British Journal of General Practice, Wright (1994) writes, "Many conscientious practitioners locked into day-by-day struggle for survival find it difficult, if not impossible, to resist bland, low-cost unchallenging ‘refresher' courses which do not, however, contribute to long-term professional development". Research by Davies et al (1990) shows that the number of hours attendance at seminars and conferences is not a good predictor of performance. Nevertheless, superficial requirements such as a record of hours attended at approved seminars may be a good place to start the monitoring of continuing education standards, because administratively this is a simple option.

While the superficial approach may be sufficient to justify to external bodies that we are maintaining our standards, deeper approaches may well result in a more meaningful personal and professional development for the practitioner. For general practitioners, the variety of deeper approaches that have been tried or proposed include self-directed learning (Stanley et al, 1993), portfolio-based learning (Royal College of General Practitioners, 1993), problem-based learning (Foldevi et al, 1994), practice-based audit, performance-based assessment, self-assessment and peer review visits. Other possibilities for practice-based learning could include in-depth case-history analysis, peer supervision (Hawkins & Shohet, 1989), one-to-one supervision (MacPherson, 1993), mentorship and the reflective approach (Schon, 1987). Characteristic of these is an acknowledgement that professional development is a complex process, and to do justice to evaluating standards and the quality of care, we need a more sophisticated and broader perspective than simply measuring attendance. Such a perspective could recognise that personal development is often inextricably linked to one's development as a practitioner, that a shift in values can have a profound effect on the quality of one's practice, and that a growing awareness of ethics, say for example becoming aware of our prejudices, could significantly influence the way our practice grows.

Some consideration will be needed to assess where the boundary between personal and professional development lies. Obviously personal therapy, or training in tai chi or qi gong can have benefits for the individual. However at what point does this personal work become relevant and beneficial for professional practice? Criteria for assessing benefit in these areas will not necessarily be simple. Nevertheless, this is no reason to undervalue the role they can play in the maturing of our life experience and professionalism.

A role for the professional body
Our professional body, the British Acupuncture Council, will need to play a crucially important role in the field of continuing education. In the first instance, it can create a favourable climate of opinion, encouraging debate and discussion, thereby giving a strong message of encouragement to the membership that their views and opinions are valued and relevant. This is particularly important given that so many of our members work on their own and in relative isolation from their peers.

In addition, the British Acupuncture Council can have a central role in establishing standards of competence and care. While the case for minimum standards of competence as a prerequisite for professional membership is now widely accepted, the question as to what constitutes an acceptable standard for ongoing practice is open to debate. What is clear is that the standards of the average acupuncturist will tend to rise after graduation and it may take several years for what might be called 'full' competence to be established. Though the work of osteopaths is significantly different from acupuncturists, a recent evaluation of professional competence by the General Council and Register of Osteopaths concluded that 'a fully competent' practitioner would require five to eight years experience of professional practice (GCRO, 1993). So some recognition of the need for additional inputs and monitoring during the challenging first phase in a practitioner's working life would seem appropriate.

The British Acupuncture Council could also have a role in monitoring and assessing standards in continuing education. Such monitoring must adopt one of two approaches: either measured input, by formalised learning through attendance at seminars or courses; or measured output, by assessing the competence or standards of the practitioner. Given the complexity of the latter, it may make sense to start with the former, but be aware of its limitations. Formalised learning may also be important for other reasons. Newly graduated practitioners may need extra support in making the transition from dependence to autonomy. Practitioners who are lacking in confidence or who are geographically or socially isolated may also be attracted. And indeed some individuals may simply have a preference for this particular mode of learning.

A broader perspective on learning would encompass the informal learning that spontaneously takes place in the professions (Gear et al, 1994). Increasingly evidence is showing that continued learning results from a 'collective' of many different elements; such as the influence of colleagues, individual reading, and personal effort to fill gaps in knowledge (Coles & Holm, 1994). This informal learning is altogether more elusive and harder to regulate, yet plays a significant role in professional development. Going beyond the formalities of attendance, the professional body could also give some value to the learner-centred and deeper approaches described above. While these approaches will be more meaningful in terms of outcomes, it needs to be acknowledged that they will be more difficult, and probably more expensive to implement.

Our acupuncture profession in the UK has moved significantly towards unity over the past decade without sacrificing the strengths of diversity. This diversity among practitioners stems from our different practices, our different trainings and backgrounds, the strengths and weaknesses of our varied styles, the different geographic areas in which we work, and the differences that seem to arise spontaneously within our patient populations. A practitioner-centred approach to continuing education could support and value this diversity.

The thorny issue of professional reaccreditation
With requirements for minimum standards we raise the potentially threatening issue of professional reaccreditation. In the medical professions, it will increasingly be becoming the norm. Reaccreditation has been defined as 'a system of assessing a practitioner's competence to practice at regular intervals during her or his career' (General Medical Services Committee, 1992). The Royal College of General Practitioners now require voluntary reaccreditation, while the Royal College of Obstetricians and Gynaecologists has recommended compulsory reaccreditation for specialists based on continuing medical education (Sylvester, 1993). Remarkably, the principle of reaccreditation for general practitioners was implicitly accepted by nearly two thirds of those GP's responding to a survey by the General Medical Services Committee (1992).

Given that our profession is responding in part to external pressure to regulate itself, then the thorny question of what to do when an acupuncturist's standards fall below the minimum requirements will need to be addressed. Is there a point to monitoring continuing education if the profession could not assure external agencies (the government, the community) that incompetent practitioners, who failed to achieve the minimum standard, would have sanctions imposed, such as requirements to retrain in specific areas, or in extreme circumstances have their professional membership withdrawn?

Our professional body will need to determine where to put the emphasis on a spectrum that ranges from the identification of incompetence at one end, to the fostering of competence at the other. Following Berwick (1989), who was writing about the medical profession, the emphasis on the former tries to identify the 'bad apples', while emphasis on the latter tries to keep the 'good apples' in optimal condition. This latter approach is known by the Japanese as kaizen; that is, the continuous search for each and every process to be done better. A strategy for continuing education will probably need to incorporate both of these emphases. For example, while the primary focus could be to foster excellence in all acupuncturists, some attention could be paid to identifying the minority who fail to maintain minimum standards of competence.

Undoubtedly, the positive (enhancement of excellence) aspect would more easily gain wider acceptance within the profession than the negative (identifying sub-standard practice). Perhaps the implementation of sanctions could only be taken seriously when we have statutory self-regulation and protection of title. Nevertheless, there is an argument that moves by our professional body to address this area of continuing education will in itself help pave the way for a regulatory structure that we as a profession control. And it will help prevent regulation of our professional activity from outside the profession.

Whatever strategy is taken, it is essential that it is seen by the membership to be fair. This means that no grouping of practitioners can be seen to be particularly advantaged or disadvantaged by the strategy. It needs to be equally applicable to practitioners who work inside or outside the National Health Service, who work on their own or with others, or who are involved in schools or colleges or not, and so on. And fairness is an essential pre-requisite if the support of the membership is to be retained.

Implications for the schools and colleges
The pre-registration phase for an acupuncturist is just the beginning of a lifelong journey of learning. Students will have attained a 'minimum competence' for safe practice at graduation, and will continue to develop their competence throughout their lifetime. Consequently, schools and colleges should prioritise the development of motivated and enquiring individuals who are willing and able to continue their own learning after starting out in practice.

The development of post-registration studies is already well developed at some schools and colleges. An increasing number of students are becoming interested in further training, such as in a speciality, or in research. Over the next few years or so, it is likely that this trend will continue. Indeed, the schools and colleges are probably the best placed institutions to provide the seedbed for practitioner-based research. And the more research that takes place within the profession, the higher the research profile of the profession as a whole.

In terms of continuing education provision in the UK the schools and colleges are an important resource. They can make available their expertise through offering courses and seminars and through providing educational resources. Continued learning opportunities from the schools and colleges make most sense if they are geared towards developing the practitioner's autonomy and independence. It is in the long-term interests of practitioners to develop their own individual and unique style and exposure to different traditions and influences can only support this process. So the schools and colleges can play an important role in supporting practitioners in exploring the richness and diversity within Oriental systems of medicine. This could involve work experience trips to China or Japan, attending open seminars for practitioners at other schools of acupuncture in the UK, forming peer supervision groups with practitioners from different backgrounds, and so on.

However, the schools and colleges need to consider whether and in what way they want to be involved in continuing education. It might be useful to establish a forum for involving schools and colleges with the British Acupuncture Council in order to assess what could be provided and to evaluate the benefits.

Opening up the debate
A creative starting point may be to involve the profession in an open dialogue and debate on how best to establish and implement a strategy for continuing education. And if the debate is prolonged and intense all the better to explore the many aspects to this issue. As a result of this open-ended process, the professional body is much more likely to both establish an acceptable strategy and sustain the support of the membership.

As part of the debate, a survey of the membership may prove useful. It would provide valuable information on what we as practitioners are already doing in the way of continued learning, both through attendance at seminars, courses and other events, and also through the informal avenues that have been discussed above. A survey could also be a useful vehicle to lay out before the membership the main options which are being considered, and elicit opinions and constructive feedback. It would also raise awareness of the issues, and involve the membership in the initial step towards a consultation process. To be most effective the survey should probably be undertaken at an early stage in the debate on what our best strategy might be for continuing education.

Conclusion
Given the history of the acupuncture profession, with its divisions and conflicts, the debate on possible strategies for continuing education probably needs to be unhurried and wide-ranging. A key challenge is for us to develop our structures in a way that meets both the needs of external bodies as well as meets our own intrinsic needs as individuals within the acupuncture profession. This will be an interesting balancing act, but if we can do it, then it will carry the support of the profession as a whole. And our profession will be all the stronger if our strategy for continuing education continues to support our existing diversity while at the same time ensuring our strength in unity.

Acknowledgements to Richard Blackwell, Mike Fitter, Alison Gould and Nicholas Haines for help in preparing this article.

Hugh MacPherson
Hugh MacPherson is the Principal of the York-based Northern College of Acupuncture. He has been closely involved with the College’s successful application for university validation of a four year part-time Master of Science (MSc) degree in acupuncture.