Stephen M. Perle, DC, MS
Like most of the profession, I receive many postgraduate course listings in the mail,from a variety of sources. Some come from chiropractic colleges; others come from individual doctors or seminar companies - although these usually have the name of some chiropractic college on their brochure. The way the business of postgraduate chiropractic education works is that, in order for a program to be successful, it must be approved by state licensing boards for continuing education credit (or be on practice management). Each state board has its own standards.
For many boards, the only requirement is that a CCE-accredited chiropractic college that is somehow affiliated "accredits" the hours. Some states want to evaluate the program and the presenter's curriculum vita. The chiropractic colleges each have their own standards when deciding whether to "accredit" a program and extend postgraduate faculty status to a doctor.
The independently sponsored programs essentially pay the college a fee to accredit the hours. This is good business for the colleges. They have no downside risk, such as the expenses of advertising the program or guarantees to hotels. If the program is canceled, the college does not incur any bad will - the sponsor cancelled the program, not the college. Thus, without the risk, the college is able to make a profit, which I have been told sometimes helps the college put on its own high-quality programs.
I think most agree that the quality of the postgraduate programs varies dramatically. I have attended some that were very entertaining, but lacked substance; I was awake at the end, but didn't learn anything that made me a better doctor. Others were so boring I could barely keep awake, even though the information was useful.This is the balance between form and substance. I submit that it is the ethical duty of fidelity (meeting the reasonable expectations of the attendee) of both the sponsor and the presenter to ensure form and substance are balanced.
The real problem with postgraduate education is the validity of the substance of the seminar. Again, I submit that the presenter and sponsor have a fidelity duty to ensure the validity of the material taught. Just as doctors do not have the right to tell their patients their fringe ideas about health care, seminar attendees should not be subjected to such inanity. At the very minimum, presenters have the responsibility to inform those in attendance that there is no evidence to support what they have taught, outside of their own experiences or beliefs.
When I was a student at Texas Chiropractic College in the early 1980s, a chiropractic radiologist told me about a technique seminar he attended. The presenter showed pre- and posttreatment radiographs of people with scoliosis that he had treated using the technique he was teaching. As you might have guessed, each patient had a scoliosis that was completely corrected by this doctor's chiropractic care. The radiologist asked if it were possible that the reason the radiographs looked like each of the patients had a scoliosis initially was that the A-P films were shot with the patient rotated a bit, and the posttreatment films looked normal because the patient was no longer rotated. The rotation, he said, made the sagittal curves look like a scoliotic curve in the coronal plane. The presenter denied this, saying that he used a positioning device to ensure consistent positioning of the patient for both radiographs. However, the radiologist told me he knew this was not true because he could tell, from looking at the obturator foramina, that the patients were rotated in the pretreatment films - and not in the posttreatment films. There was also no positioning equipment evident on film.
Not too long ago, I went to a scoliosis seminar in which the presenter gave a definition of scoliosis he said came from a scoliosis foundation. That did not sound unreasonable, except that he decided to change the definition right there. I am not saying he realized that the definition he wrote down was wrong; I am saying he was the "foundation" (which he did not disclose) and therefore, he decided willy-nilly to change the "official" definition as he spoke. He also presented, as established fact, statistics about chiropractic's success rate in treating scoliosis of different degrees. When he was questioned about these statistics, it turned out they were not from any scientific study of his treatment method - just ones he said came from his office. (We could also buy reprints of the articles he published on the topic, in a chiropractic trade publication - not a scientific publication - sold by his wife in the back of the seminar venue.)
My favorite example of the bizarre was presented at a program offered by a chiropractic college by a doctor who said the treatment for hemorrhoids was to have the patient put half of a boiled potato on his or her forehead. I was told that a few years later, at the same seminar, one of the attending doctors asked where the potato should be placed for a headache. (I could go on and on with examples like these - but I suspect you have all seen or heard something similar.)
Another issue is the presenter's credentials. The proliferation of diplomates and certifications in the profession has become absurd. Many doctors have more degrees than a thermometer. The endless initials after one's name are fundamentally meaningless to patients and other doctors. How is it possible that someone is a specialist in sports, rehab, orthopedics, nutrition, radiology, pediatrics and philosophy? To me, this sounds suspiciously like a generalist. In our profession, the proliferation of certifications screams out for reform. Perhaps moving toward residency-only postgraduate certifications would clear this up.
However, while many practitioners legitimately earned these postgraduate certifications, others merely purchased their degrees and certifications from diploma mills. Others are doctors who, unable to pass the stringent requirements of a specialty board, created their own "board" to confer upon themselves a diplomate or certification in this or that "specialty." Colleges need to ensure that the experts they hire to teach postgraduate programs are legitimate experts in the field in which they teach and that their credentials are valid. It is rather embarrassing for a college to find out in the local newspaper that its so-called "expert" bought his or her certification.
The Federation of Chiropractic Licensing Boards (FCLB) has begun to establish standards that should deal with this problem. It is called Providers of Approved Continuing Education (PACE). PACE establishes uniform requirements for licensing boards to use when granting relicensure credit. It includes standards for much of the postgraduate education process.
Regarding the material taught, PACE says: "Continuing education programs must address topics and subject matter areas which are pertinent to the contemporary practice of chiropractic and well-balanced in presentation. Subject matter must be evidence-based, professionally credible, and educationally sound." Regarding the instructor, PACE says: "Providers must ensure that course instructors are qualified by education and experience to provide instruction in the relevant subject matter."
PACE is a great step forward. As we move our profession squarely into the 21st century, we need to rid ourselves of some of the nonsense in material taught and in the credentials of instructors. Our colleges cannot be in the position of perpetuating some of the antiscientific and pseudoscientific thinking that permeated the profession in the 19th and 20th centuries. We need to hold the colleges accountable for the material they teach and "accredit." We can't just put on any postgraduate program we can convince people to pay for. I know of one chiropractic college that created an "umbrella" technique club - one club encompassing all techniques. DCs called the college to find out where they could take the umbrella technique. I understand that we should be open-minded to new ideas in the profession; however, as a friend of mine often says, "Our minds should not be so open that our brains fall out."
Stephen Perle, DC, MS
Bridgeport, Connecticut
