Schizopractic

Student grades normally appear to cluster around a single central score (the mean or mode), with higher and lower grades dropping off on either side in a nice bell-shaped curve called a "normal" distribution. In chiropractic colleges, however, teachers usually see two distinct clusters of grades, what is called a bimodal distribution in statistics. The first group has most of the grades clustering around 85 percent (a B letter grade). The second, somewhat smaller group clusters around 65 percent (about a C- letter grade). The existence of these two distinctly different types of students is certainly not news to chiropractic educators, many of whom think that the more liberal academic entrance requirements in chiropractic colleges account for the lower group.

Accompanying this bimodal distribution of grades is a widespread belief that if a student is poor at verbal and/or mathematical tasks, i.e., academics, they must be good at non-academic tasks, e.g., good with their hands or good at dealing with people. Unfortunately, research does not support this idealistic notion, no matter how much it might appeal to people's sense of social justice. Apparently people who do well in academics most often do just about as well with motor and social skills; and, people who are poor at academics are likely to be poor at the other, although perhaps not quite as poor. The compensatory myth probably arose because of a statistical illusion called "regression to the mean" wherein any extreme score is statistically likely to be accompanied by one that is somewhat more average.

As I gained more experience with chiropractic students, I began to think that explanations based upon the skill/intelligence dimension were probably not adequate. There were just too many of the opposite kind of students in both groups. Increasingly, I began to notice other qualities: Students in the higher scoring group seemed more mature, hard-working, conscientious, and disciplined; students in the lower group seemed much less work oriented, more demanding, and self-centered. Students in the higher group attended more lectures, took notes, got assignments in on time; lower group students seemed to complain more to administrators, attend classes less or come late, spend less time in the library, and argue about grades.

In fact, I have become convinced that a better discriminator between these two groups is one of basic attitude. One group of students seems to be trying to do the most they possibly can, while the other group is trying to do the least they possibly can. One group is trying to do as well as they possibly can; the other, only as well as they have to.

The minimal-effort group exists for several reasons: some historical, some philosophical, and some economic. Because of historical reasons, school requirements (and legal regulation in general) are still seen by many as being imposed from outside the profession, antagonistic to chiropractic, and therefore best resisted. In addition, there is a philosophical tradition which considers academics (e.g., basic science) as irrelevant to practice, at best. In fact, academic excellence is occasionally still denigrated, if not actually ridiculed, within the chiropractic colleges themselves. At a recent graduation ceremony, for example, the main speaker, a very wealthy chiropractor who had made millions (by lending money to poor doctors at high rates of return, not by adjusting patients) bragged that he was academically one of the lowest in his graduation class. His unspoken message was clear: In chiropractic, academics don't matter at all.

The implicit fantasy is that when people who have been lazy, undisciplined, and unethical as students finally come into contact with real patients, they will somehow be magically transformed into conscientious, hard working, ethical, and professional doctors. But isn't it more reasonable to think that skills and attitudes learned as a student do not cease to exist when a student graduates; that students take all of their college experiences with them when they become doctors, and, more to the point, that these attitudes have an important impact on the character of the profession at large?

I think, for example, we can be reasonably confident that practicing doctors from the "most" group will continue to be conscientious and hard working, and will go the extra distance for their patients. I think that we can be just as confident that doctors from the "least" group will continue to cut corners and to do the absolute minimum.

Doctors from the "most" group will continue their education by taking postgraduate diplomate programs, subscribing to journals, reading, and acquiring new information of all sorts. Doctors from the "least" group will have passed their boards by means of a "cram" seminar which emphasizes memorization of stolen test information, and with the possible exception of reading an occasional popular chiropractic magazine, they will probably never crack another book. In a few years they will have forgotten so much of what they were supposed to have once known that they will be unable to converse intelligently with many other chiropractors, let alone with other health care professionals. They will thereafter complain that other doctors have an arrogant "medical" attitude.

Doctors from the "most" group will be in a better position to develop sound relationships with other health care professionals, and they will do so. Lacking this option, "least" effort doctors will, with others like themselves, gravitate toward flashy, pseudoscientific programs centered on ethically dubious patient recruitment and "education." Since such programs usually suggest scientifically unvalidated diagnostic methods, this minimal effort group may be disproportionately responsible for overutilization abuses of third-party payers. And the minimal-effort group will stress what is legal in practice rather than what is ethical, since laws define the minimum one must do, not the maximum.

For most of its history, chiropractic has been treated as a trade rather than a profession: Laws, practice regulations, and even ethical codes have been externally created and imposed. Although unfortunate, it is not really surprising that there have been reactionary traditions of minimal compliance in chiropractic education and practice. But as chiropractic emerges as a first class profession rather than a second class trade, the development and application of professional ethics and practice controls must become internalized. And, indeed, through the Consortium for Chiropractic Research, the chiropractic profession is becoming a leader in standards of care development, and other internal programs, e.g., to integrate new research into practice, etc.

But our largest challenge remains: to permanently eradicate the minimum-compliance attitude which, due to a century of external regulation, still affects some parts of the profession and its institutions, unnecessarily dividing chiropractic and making it appear schizophrenic. Self-determination as a profession carries with it the responsibility of doing more than the minimum; professional self-realization must include the objective of maximum effort and excellence.

Robert D. Jansen, Ph.D.
Executive Director,
Consortium for Chiropractic Research
Sunnyvale, California

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