CCE Reaffirms Neutrality of Standards

Editor's note: Normally, a rebuttal to an article would appear as a "letter to the editor" in the publication which featured the original article. Unfortunately, this has not be happening in one particular publication (please see "Are You Being Censored" in the January 17, 1992 issue of DC). Letters to the editor of the publication in question have been submitted but never printed, presumably because they disagreed with the opinion of the article and/or the publisher.

Due to the timely nature of the CCE/SCASA issue and the historic refusal on the part of the other publication to print alternative opinions to feature articles, DC has accepted this rebuttal for publication. The rebuttal by the Council on Chiropractic Education (CCE) was submitted to Dynamic Chiropractic with the following request:

Dear Mr. Petersen:

It is requested that you publish the attached article in your next issue of Dynamic Chiropractic. It is my opinion that the Chiropractic Journal would not print this article giving the Council on Chiropractic Education a clear opportunity to offer rebuttal to the article printed in their January 1992, Volume 6, No. 4 issue.

Thank you for your cooperation in this matter.

Sincerely,

Ralph G. Miller, Ed.D.
Executive Vice President

At a special meeting of its board of directors on August 23, 1991, the Council on Chiropractic Education (CCE) approved a set of amendments to its "Standards for Chiropractic Institutions (standards) that reaffirmed CCE's openness to the full range of chiropractic philosophies and clarified the neutrality of the accreditation process with regard to philosophies of practice. The board also directed its Commission on Accreditation (COA) to extend a formal invitation to the three chiropractic colleges not presently holding CCE status to begin that process.

The changes to the CCE standards arose out of recommendations by a joint CCE-Straight Chiropractic Academic Standards Association (SCASA) task force. When informed of this action, however, SCASA officials flatly rejected the changes. SCASA claimed that since CCE board failed to adopt every one of the changes recommended by the joint task force, the board had failed to go far enough to satisfy SCASA's concerns.

Expressing surprise over the SCASA action, CCE President John Miller noted that the recent changes in the CCE standards codified a longstanding principle that recognition is not based on adherence to any particular philosophy of chiropractic. "As CCE has stated through the years," Dr. Miller said, "the organization does not deal with philosophies." He pointed to an amendment to the CCE standards adopted at the August meeting at the recommendation of the CCE-SCASA task force as clarifying that position. The standards do not seek to define any philosophy of chiropractic; this is the responsibility of the profession and each educational institution, giving consideration to requirements of the jurisdiction within which the professional may practice, professional associations, and, in the final analysis, the practitioner's own philosophy of chiropractic. Despite the adoption of this and other substantive amendments by the CCE upon the recommendation of the joint task force, SCASA and its supporters have continued unabated their charge that the CCE has systematically sought to exclude its institutions.

The history of the relationship between CCE and SCASA belies such a claim. Dr. Miller expressed the view of his organization's leadership at the SCASA rejection: "While we have long wondered why these colleges have not even sought to apply to CCE recognition, SCASA's rejection of CCE's latest efforts leaves serious doubts as to the sincerity of that organization's leadership in joining the mainstream of chiropractic." Dr. Miller added: "This action makes clear that the refusal of these schools to seek CCE recognition has nothing whatsoever to do with chiropractic philosophy."

The CCE-SCASA joint task force was established by the two organizations at the behest of the U.S. Department of Education (USDE), after the department's National Advisory Committee on Accreditation and Institutional Eligibility voted to recommend to the secretary of education that SCASA's expiring federal recognition not be renewed. USED asked CCE representatives to meet with SCASA to seek to provide a mechanism for the schools recognized by SCASA to become recognized by CCE before the secretary completed action on his order to "show cause" why SCASA's federal recognition should not be renewed.

While Dr. Miller and others told the USDE that those schools were already welcome to participate in the CCE, Dr. Miller agreed to organize the meetings with a goal of convincing the present SCASA schools of CCE's commitment to the fair and unbiased application of the educational standards of the council.

The joint task force met twice, and prepared a set of recommendations for consideration by the CCE council. CCE attorney Michael B. Goldstein characterized the recommendations as almost entirely in the form of clarifications of existing CCE policy, and with only a few exceptions the recommendations were adopted by the council and incorporated into the CCE standards. Mr. Goldstein said that a suggestion to make the changes in the standards conditional on SCASA acceptance was rejected by the council, which voted to implement the changes regardless of SCASA action. "Some thought that making the changes conditional would encourage SCASA to accept them," Mr. Goldstein noted, "but the overwhelming majority of the council agreed that if the changes were good for chiropractic education, they should be adopted without conditions."

The rejection of the CCE's actions caps a long and costly history of distrust of the organization and assault on its processes and integrity by SCASA and its followers. The focus of the attack has been CCE's consistent position that chiropractic colleges have a responsibility to the public and to the profession not only to educate their students as practitioners of chiropractic but also to provide them with basic diagnostic skills to enable them, upon graduation, to assess whether the problem presented by the patient is in fact susceptible to chiropractic care or whether the patient should be referred to another health professional. While the SCASA representatives to the joint task force agreed that chiropractors must be educated to serve as primary care providers, in rejecting the CCE action their organization clearly demonstrated its commitment to a far narrower concept of chiropractic education.

The history of disagreement between the CCE and the two schools that organized SCASA (Sherman College of Straight Chiropractic and Pennsylvania College of Straight Chiropractic, formerly the ADIO Institute of Chiropractic), has been of an adversarial nature since Sherman was unable to obtain initial status with the CCE in 1976. Although Sherman was invited to resubmit a self-study, rather than work toward resolving the four concerns of the CCE Commission on Accreditation (COA) and then reapply, Sherman chose to disassociate itself from the CCE and go its own way. (It is notable that Sherman did appeal the adverse decision to an independent panel, which supported the COA's adverse decision.)

Although CCE's 1978 application for renewal of recognition by the U.S. Secretary of Education (then the commissioner) was opposed by Sherman, ADIO, and by the newly formed SCASA, CCE's recognition was renewed for a period of three years. SCC and ADIO then sued the commissioner in U.S. District Court for the District of Columbia to remove the CCE from the commissioner's list of recognized accrediting bodies. CCE entered the lawsuit as an intervener and the case was decided in favor of the department and CCE.

Sherman, ADIO, and like-minded organizations then asked the antitrust division of the U.S. Department of Justice to investigate alleged anticompetitive activities by CCE, the American Chiropractic Association (ACA), and the National Board of Chiropractic Examiners (NBCE), who joined in an alleged conspiracy against what Sherman and ADIO called "straight" chiropractic. On October 30, 1987, the department of justice closed its investigation with a finding that it had not identified any activities warranting government legal action.

In 1981, Sherman, SCASA, and two students filed a civil antitrust action in the U.S. District Court for the northern district of Georgia against the ACA, CCE, NBCE, and Dr. Sid E. Williams, president of Life College of Chiropractic. The plaintiffs' alleged that the defendants violated the Sherman Antitrust Act by engaging in acts to restrain chiropractic trade and commerce among the states, asserting that the defendants prevented them from teaching and practicing chiropractic as they wished. The case was tried in 1985, during which the defendants successfully argued that the plaintiffs were improperly using the antitrust laws to prevent the CCE from expressing the view that doctors of chiropractic should be adequately trained in clinical diagnosis before they are licensed to practice chiropractic, a view concurred in the vast majority of the states. In a lengthy opinion on January 9, 1986, the court upheld CCE's requirement of diagnostic training. The court rejected and dismissed plaintiffs' claims that requiring diagnostic training for chiropractors had no relevance to quality chiropractic care and that the use of diagnostic procedures by chiropractors was against the public interest.

SCASA and its followers continued their legal battle to the U.S. Supreme Court. On October 5, 1987, the court rejected Sherman and SCASA's antitrust conspiracy claims and declined to set aside the initial trial court decision.

In 1985-86, CCE submitted a joint application to COPA and USDE for renewal of its recognition. Despite opposition by Dr. Thomas Gelardi, representing SCASA and Sherman, COPA/COR extended CCE's recognition for an additional five years.

CCE's recognition by the secretary of education was renewed on September 27, 1987 for a period of two years which was later extended to an additional two years through September 28, 1991. Noting the public feud, the secretary asked both CCE and SCASA to attempt to find common ground so that there would be one accrediting body for the profession.

As a result of the secretary's request, the president of Sherman and Pennsylvania (Dr. Thomas Gelardi and Dr. William Volk) were invited to meet with the CCE board of directors in January 1988. In addition to concerns expressed by these two presidents over specific parts of the CCE standards, they suggested that there was a perceived barrier when colleges applying for status have to "furnish the Commission on Accreditation with a certified copy of a formal action taken by its governing board at a legally constituted meeting indicating subscription to the standards, rules and policies of CCE as set forth in article 3.01 (1) of its bylaws." The CCE agreed to consider a modified time line which could facilitate the applications of the institutions as well as consider changes to the CCE standards recommended by the SCASA colleges.

A number of other issues regarding CCE's process and standards were raised which dealt with the concepts of diagnosis and chiropractic clinical impressions. The CCE board directed its president to meet with SCASA representatives to seek a resolution. A series of letters were exchanged between CCE president Dr. E. Maylon Drake and SCASA president Dr. Thomas Gelardi. At least two meeting were held between CCE and SCASA representatives.

During the same 1987-88 time period, SCASA made application for USDE recognition. The National Advisory Committee on Accreditation and Institutional Eligibility (NACAIE) recommended, by a vote of 10 to 2, that the secretary of education defer action on SCASA's application for recognition. However, in direct contradiction of the NACAIE recommendation and before any results could be arrive at in the CCE/SCASA negotiations, the acting assistant secretary of education recommended to Secretary William Bennett that he award SCASA an initial two-year period of recognition. As a direct result, the continuing negotiations between CCE and SCASA were broken off by SCASA.

In a report at the Fall 1988 meeting to the COPA constituencies, COPA President Thurston Manning carefully covered what he viewed as the unusual and unprecedented set of circumstances which took place with regard to the recognition of SCASA. President Manning charged that in recognizing SCASA, the secretary "blew apart rational administration of the present regulations, and raised the specter of equally irrational administration of the new regulations after they become effective."

Problems arose in one case (SCASA). On May 17, the advisory committee, after having received the usual staff report on the agency's submission and holding extended hearings, voted 10-2 to recommend that consideration be deferred until the agency had time to respond to a length list of deficiencies identified in the staff report. On August 30, the secretary notified the SCASA agency: "Acting Assistant Secretary Whitehead has recommended that I reject the recommendation of the (advisory committee) ... Acting Assistant Secretary Whitehead bases his recommendations on his determinations that (the agency) ... meets the criteria for recognition..."

In short, the secretary rejected the recommendation of his own advisory committee (for deferral, not denial of recognition), to accept in its place the finding of a single individual that the agency meets the secretary's criteria. This is outrageous behavior in a public official. The National Advisory Committee and its elaborate public process have developed over many years to provide equity to accrediting agencies and assurance to the public. The private musings of an individual, regardless of title or position, are not a satisfactory substitute for orderly procedures, fairly and honestly applied.

Dr. Manning further characterized Acting Assistant Secretary Whitehead's analysis, which supported his conclusion that the recognition criteria were met by SCASA, as specious and riddled with errors.

Dr. Manning concluded that this action should not be acceptable to the accrediting community:

"We have consistently taken the posture the use of accreditation for purposes of eligibility for federal funds is desirable in the public interest. Associated with this is the position that the listing of accrediting agencies must be done by a fair, equitable, and public process that correctly holds an accrediting agency to reasonable standards related to federal eligibility purposes. For more than 35 years such a process has been developed -- not a perfect one, to be sure, but certainly a respectable one. It is not in the public interest, nor in the interest of accrediting bodies, that this process be replaced in even a single instance with the private, personal decision of a single individual, whether well-supported or, as in the present case, supported so poorly as to be ludicrous.

"So far as precedent is concerned, we must stand clearly on the position that this one case is an aberration: a mistake that should not be repeated, not a precedent that will destroy the federal eligibility system. In the immediate time, we need to yell and scream to make sure that the message of outrage at this offensive behavior is understood in all places."

In early 1990, SCASA made application for renewal of its initial recognition by the secretary of education. Consideration of that application by the NACIE took place on November 12, 1990. Based on determination that SCASA did not comply with two key criteria and without dissenting vote, the NACIE recommended that SCASA's recognition not be renewed. On April 11, 1991, the secretary of education wrote SCASA stating that the NACIE recommended that he withdraw their recognition based upon non-compliance with criteria requiring regard to decisions of states and other accrediting agencies and national recognition, and offering SCASA the opportunity to show cause why its recognition should not be withdrawn.

In the intervening time and in keeping with the USDE's continuing efforts to have one accrediting organization for chiropractic, in December of 1990, CCE's president and CCE's commission chairperson contacted SCASA representatives and SCASA colleges. They stated the CCE's and the commission's willingness to consider the process by which SCASA colleges could make application to obtain status within the CCE process. Further correspondence stated that efforts would be made to expedite procedures for evaluating the institutions and that the commission would consider any recommendations by SCASA colleges that could facilitate the process.

Noting that the CCE/COA chairman invited SCASA to investigate "significant changes" made in CCE standards, in a letter dated May 1, 1991, SCASA President James Healey, D.C., indicated that the SCASA board met and voted on April 26, 1991, to authorize a good faith effort toward engaging in talks with the CCE to investigate whether or not one set of standards may accommodate all chiropractic colleges.

In a letter dated May 22, 1991, CCE President John Miller asked the new SCASA President Dr. Ralph Boone, president of Southern California College of Chiropractic, that he and his colleagues "very carefully review the 'CCE Standards for Chiropractic Institutions' and indicate to us, in advance of the meeting those specific provisions that you believe merit either revision or interpretation to reflect the interests" of the SCASA chiropractic colleges and those of SCASA.

President Boone responded that SCASA was prepared to propose changes regarding those standards which in SCASA's estimation should be revised, particularly with regard to SCASA's concern regarding what it saw as a need "to accommodate more than one concept of a chiropractor," as well as to deal with the "clinical competencies" in a manner which would coincide with the mission and objectives of each institution.

On June 17, 1991, the CCE-SCASA joint task force met in Denver. At the meetings it was agreed that implementation decisions would have to be made by the respective governing boards, leaving the respective commissions to deal with the actual accrediting process issues. CCE indicated that SCASA's concern over the issue of concept of chiropractic pointed to a need to clarify the documents that guide the conduct of the CCE and its institutions.

CCE reiterated that nothing in the CCE standards is intended to in any way define the "concept" of a chiropractor. Based upon their concern with the definition of a "concept" that appeared to be contrary to the constituency that SCASA represented, CCE again asked SCASA to identify what it saw as the offending provisions and recommend changes. CCE also noted that if its documents appeared to skew clinical competencies in a way that would be objectionable, CCE would need to know the specific objections and what cure SCASA would suggest. The task force met again on July 18, 1991, and worked on specific language clarifying the CCE standards.

It is important to note that at the inception of the recent discussions, both CCE and SCASA agreed that prior discussions between the two organizations did not succeed in large measure due to an inability on the part of both parties to get beyond a philosophic debate. While CCE noted that as an accrediting body, it is bound to adhere to its published standards, policies and procedures, the CCE task force members made clear that if any aspect of those standards, policies and procedures offended the sensibilities or concept of fair play of SCASA representatives, CCE would be prepared to resolve those differences. Indeed, CCE reviewed the changes suggested by SCASA and prepared a set of counter proposals which sought to accommodate SCASA's concerns, consistent with maintaining appropriate standards for education, expected competencies and program expectations of the colleges. After further discussion and revisions, the proposals were adopted by the joint task force and recommended to the CCE board for consideration at a special meeting called on August 23, 1991. Before considering the proposed revisions, the CCE board invited the major organizations representing the chiropractic profession to offer their views.

The process by which the revisions were formulated was endorsed by the two major professional associations in the field, the ACA and the ICA. The president of the Federation of Chiropractic Licensing Boards, which represents the state agencies responsible for the licensing of doctors of chiropractic, cautioned that revisions to the standards must not in any way diminish the responsibility of colleges to produce thoroughly competent chiropractors fully capable of providing skilled chiropractic care and serving as portals of entry to the health care system.

The CCE board of directors then approved revisions to the standards for the accreditation of chiropractic colleges that explicitly recognizes the range of instructional approaches that characterizes chiropractic education. The revised standards were made immediately effective and govern the conduct of the 14 institutions accredited by CCE as well as any school subsequently applying for status.

The revisions codified long-standing practice that affords each institution significant latitude in the definition of its program, so long as it could satisfy the CCE's Commission on Accreditation that its graduates have obtained the requisite breadth and depth of skills to ensure the provision of the highest quality chiropractic care.

The revised CCE standards continue to emphasize the role of the doctor of chiropractic as a primary care provider, while making it abundantly clear that there is no favored philosophy of chiropractic to which a college must adhere in order to be accredited by the CCE. These changes are consistent with the current trend among accrediting agencies to look at the outcome of the educational process -- that is, what did the student learn -- rather than how that learning took place.

The unconditional actions taken by the CCE board in significantly amending the CCE standards and the explanations offered by the chairman of the CCE's Commission on Accreditation (COA) respecting the applications of the standards, eliminate any possible doubt that the three SCASA colleges have open access to the CCE accreditation process and a completely fair opportunity to achieve status with CCE. There is no "litmus test" of chiropractic orthodoxy, no requirement that specific procedures be made a part of a college's clinical program, and no prescribed curriculum. CCE has also unequivocally affirmed that while there is a set of educational expectations, including "clinical competencies" that must in some fashion be incorporated into the curriculum of an accredited institution, it also made clear that the incorporation of those elements must be in accordance with and informed by the scope and mission of the institution.

CCE also stressed that the role of the CCE/COA is to work with the colleges to help them meet the standards. This begins with a review of a college's scope and mission and is completed through an evaluation of how the college's academic program (and other support elements) achieve the college's self-enunciated goals. COA Chairman Matthew Givrad's lengthy explanations of the implications of the changes in the standards, as well as the CCE's willingness to act in extraordinary session to materially revise the standards in response to the concerns expressed by the SCASA colleges, as well as its decision to make the changes absolute instead of conditioned on a SCASA/CCE agreement, made it clear that it is CCE's intent that any remaining perceived barriers be forever banished.

Unfortunately, after CCE's board of directors voted to revise the standards, CCE was advised that SCASA President Dr. Ralph Boone was still not satisfied that the revised standards met those concerns. However, Dr. Boone is mistaken in his conclusion that the colleges presently accredited by SCASA would be caught in what he terms a paradox. The wide diversity among CCE accredited colleges as to philosophy, scope, mission, and program belies any such conclusion.

In lieu of the present CCE standards, Dr. Boone proposes that the standards be structured so as to require only those competencies required by every licensing jurisdiction. This "lowest common denominator" approach is neither realistic nor educationally sound. Indeed, the vast majority of chiropractic educators and practitioners, as well as state licensing officials, would reject such a basis for the establishment of educational standards.

The task of an accrediting agency is to ensure educational quality and integrity, not to encourage institutions to teach the minimum legally allowable requirement. To do so would render an accrediting agency no more than an adjunct to professional licensure boards, a role clearly not in harmony with the concept of institutional accreditation. Nor would adopting such a standard speak to the need to support an educational program that is widely accepted by the profession and by the public agencies charged with the licensure of chiropractors.

Although the negotiations between CCE and SCASA have presently drawn to a close, that does not in any way impair the ability of the three colleges to seek and obtain CCE status. The SCASA/CCE negotiations were only intended to develop a mechanism to facilitate the application of the three colleges to CCE. Even absent such a negotiated mechanism, the CCE board and COA are firmly on record as welcoming the application of these colleges, and regardless of the suspension of the SCASA/CCE discussions, we are committed to working with the colleges to assist in ensuring their continued viability through the process of voluntary accreditation.

Dr. Miller stated that he believed that CCE has sought to aggressively address concerns and perceptions among some in the chiropractic community without sacrificing its commitment to the integrity of the accreditation process and the educational standards that undergird that process. "Thus," he added, "while these negotiations have not resulted in an agreement between CCE/SCASA, much good has come out of it to the benefit of chiropractic educational generally and to help assure the future of the three SCASA colleges in particular."

"The CCE is vigorous in its support and the concept of ensuring quality in the education of doctors of chiropractic," said Dr. Miller. "The revisions adopted by the board will strengthen chiropractic education and in doing so further enhance the chiropractic profession and the service it provides to the public."