The Changing Face of Chiropractic Education - A Corollary

I take the title of this article from a recent (March 1, 2004) editorial by Donald M. Petersen, Jr., editor and publisher of Dynamic Chiropractic. I do so partly because what was put into print is now out of date; it would appear the emphasis should be on "The Changing Face."

My goal is not to detract from the good words of Mr. Petersen, but rather, to add a second voice of concern from someone who stands a little closer to the fire. Mine is a voice of concern - for as our educational establishments go, eventually so goes the profession.

What is this "changing face of chiropractic education"?

Mr. Petersen commented on the declining enrollment within the chiropractic programs in the U.S., indicating it "... has dropped by more than 30 percent in the past seven years." Depending on the source of information, this percent of decline may vary from 20 percent to 40 percent, but the presence of a decline is constant. Furthermore, the precipitous nature of this decline seems to have been more severe in the past three years.

While the trend of continued declining enrollments could spell disaster for the future of the profession, it is often discounted with comments such as, "It is happening to all the health professions." This statement is certainly true (except in medicine, where there is a decline in inquiries, but not enrollments), but when used as justification for non-action, one is certainly adopting a "head-in-the-sand" attitude.

With the unprecedented acceptance of "alternative therapies" by the American public, it is befuddling that so few people are pursuing careers in chiropractic, one of the more recognized and scientifically substantiated of the "alternative therapies." There are many reasons (excuses) that might be offered by way of explanation for the decline in enrollments; I will focus on only one.

The Image of Chiropractic Education

We lay claim to being "doctors." I believe the public generally can distinguish between a doctor associated with health care and a doctor associated with academia. The social standard in health care in the U.S. is the MD, or medical doctor, while the social standard in academia is the PhD, or the doctor of philosophy in a particular field of study. A comparison of the DC and PhD degrees is not appropriate because of how they differ; thus, I will remark on the comparison between the DC and the MD.

Let's start with the fact that nearly 100 percent of students enter medical school with high scholastic performance and a bachelor's degree from a major university. Contrast this with the long-term debate in chiropractic education as to whether the profession should advance its entrance requirements from 60 units at the junior college level of training to 90 units leading toward a bachelor's degree, over which some chiropractic educational institutions/programs still complain.

For years, chiropractic has attempted to equate chiropractic education with medical education by drawing attention to the similarity in the number of classroom hours and subject matter. If chiropractic students sit in classrooms equal in time to the medical students, does that make the two programs equal? Seat time is a poor measure of quality education.

One could contrast (and the public probably does) the difference between the facilities, resources and experienced faculty in chiropractic and medical education. Yes, all chiropractic programs have regional accreditation (except two in California) by the same agencies that accredit the medical programs. One must remember that accreditation is an assurance that an institution and its programs are meeting a minimal level of acceptability. Accreditation is not a measure of achievement or excellence beyond that which is required.

How many Nobel Laureates are teaching in chiropractic education? None! How many chiropractic educational institutions have faculty who are conducting research funded by NIH, or at least NIH-level grants? A few! How many of the PhDs in our chiropractic programs are actually conducting research and publishing their work for the benefit and growth of the profession? And how many DCs in chiropractic educational programs are actually conducting research and publishing their work? A few! Conducting and publishing one's work is a requisite for continued existence in a medical educational institution; it is paid token homage in chiropractic education.

Since this article addresses the "changing face of chiropractic education," I should mention leadership. Of the 16 programs in the U.S., three (Life, Palmer and Palmer West) have named new presidents (or recycled previous presidents) in the past month (as of March 4). Five programs have installed new presidents since 2000 (NYCC, Sherman, Northwestern, TCC and Western States). By contrast, three programs have retained the same presidents since 1981 (Life West, Cleveland LA & KC).

I do not wish to infer that time in service for a president is a valid indicator of the quality of education in a program, but there is a relationship that can be looked at from either end of the spectrum. Can a president sit too long at the helm, causing the program either to lose its direction or be stuck in a rut and not seek new frontiers? Conversely, changing of a president can also be a disruptive process (and usually is, in chiropractic education), leading to a change in mission and vision, loss of other seasoned administrators, financial costs in finding a new president, and many other ramifications that make it a difficult and challenging process.

Now, a bit more about the problem of image: How many readers can name the president of the UCLA School of Medicine? What about the president of UCLA? My point is, chiropractic educational programs historically, and to a lesser degree today, hang on the reputation of the president, e.g., Janse, Napolitano, Haynes and others. While these and others were bright, energetic and dedicated warriors of the cause of chiropractic education, they may have carried their programs more on the basis of their individual charisma than their contributions to the advancement of the profession. There may well be charismatic leaders in medical education, but they also display a high profile of academic achievement, contribute to the growth of new knowledge in their field, and demonstrate their ability to succeed in the academic/clinical arena over which they preside. While chiropractic program presidents come from backgrounds in practice and teaching, only two have achieved the academic credentialing looked upon by the public, as well as the scientific and health care community, as a necessary qualifier to lead an "academic" institution - something chiropractic educational programs claim to be.

Chiropractic education is beset by its high dependence upon the tuition dollar to cover operational costs. As enrollments decline, resources to support the educational endeavor likewise decline. This financial crunch leads to a decreased work force (without an equal reduction in the workload); pay scales below those from non-tuition-dependent programs; less research; and hence, less external funding support and a strain on existing resources and facilities.

Finally, while chiropractic education ends at the conclusion of 10 semesters (and some after nine) of training, medical education, at the end of four years of medical school, typically transitions to a three- to five-year training experience focused in an area of specialty. This advanced residency training experience is an intensive time of supervised teaching, hands-on patient experience, application of knowledge and skills to serious decision-making, and an enculturation experience of the novice trained practitioner into a journeyman. Chiropractic has nothing comparable in the training of its practitioners.

Image is a problem in chiropractic education, but the greater problem is the accumulation of issues previously discussed which germinate and perpetuate our less-than-satisfactory image. My experience chairing the Chiropractic Advisory Committee of the Veteran's Administration is a foreboding example of this problem.

In determining a job classification for the doctor of chiropractic in the Veteran's Health Affairs system, a job analysis was conducted by an independent agency. Close scrutiny of practice patterns and behavior, typical case scenarios covering not only presenting conditions, but also actual treatment protocols (and yes, chiropractic education) provided data that was compared to other health professions currently functioning within the VHA system. It was concluded that the complexity of decision-making in chiropractic practice was considerably less than that of a medical doctor (probably because of the limited case mix seen in chiropractic practice), but more complex than a physical therapist who works under medical prescription. Chiropractic education was determined to be less rigorous and comprehensive than medical education, and most similar to that of the optometrist. I remind the reader that these decisions were arrived at based on the data collected; thus, the basis of our image is largely our own doing (or undoing).

Our image has also been tarnished by the bashing of the Council on Chiropractic Education (CCE) in public forum. Chiropractic publications that accuse the CCE of exercising bias and prejudice are read by more than the devotees of the publishers. The very organization that has brought credibility to chiropractic education is strong and will withstand such blows, but the image of chiropractic and chiropractic education in the eyes of our skeptics has been confirmed. Even in our own profession, those distant from the facts must depend on what they read. When smothered with innuendos, accusations and inaccurate statements of the facts, they too pause to ponder the credibility of our "professional academic enterprise."

The Changing Face of Chiropractic Education

Those of you who graduated pre-CCE (1974) have probably rehearsed (on numerous occasions) the challenges faced by the chiropractic programs of your day. There was no enforcement of educational standards; schools taught what the president said would be taught. Facilities were old, in need of repair, and lacked necessary teaching aids, especially in laboratories. Libraries (now "learning resource centers") were small, isolated from the rest of the library world, and lacked adequate holdings to offer opportunities for expanded learning. There were no computers. Faculty and administrators often earned their living in clinical practice or other enterprises external to the chiropractic educational program, because the program could not pay a sustainable wage (many faculty were volunteers). Few if any faculty came with an earned graduate degree of any sort, and the basic science courses were often taught by a recent graduate reading to the students from a book. Research was virtually nonexistent.

Therefore, even though we can find much fault with our current situation in chiropractic education, comparatively, chiropractic education has made miraculous historical improvements. Educational standards are enforced fairly and without bias, despite frequent commentaries from overactive pariahs. They have become the "sounding brass and tinkling cymbals" (Corinthians 1:13) of our profession.

Academic freedom is required of every program accredited by the CCE. Academic freedom does not imply an "anything goes" attitude. Propriety and respect must be maintained. The president cannot dictate to the faculty what they shall teach, even though some may still try. While facilities are in need of constant maintenance, and technology continues to advance at light speed, chiropractic educational programs are required to meet these needs in a timely manner. Learning resource centers are connected to the world of cyberspace; technology is everywhere; holdings are current and relevant; and staff is qualified with specialized training in information acquisition and distribution. Faculty and most senior administrators come with experience outside the chiropractic educational world. They enter our portals with graduate degrees in hand. Their experience in higher education brings rich dividends to our programs. Research has become an integral (albeit limited) part of the fabric of each accredited institution.

Conclusion

From an historical perspective, the "face of chiropractic education" has changed in ways that members of the previous generation could only dream of. Are we satisfied? I think not!

We expound with rhetoric regarding unfairness, if not outright discrimination, when we experience the cultural privileges granted to one group of "doctors" and not the other (us). Two cases in point: efforts to eliminate chiropractic from participating in the California State Work Comp system, and restricting doctors of chiropractic from performing physical examinations on commercial drivers because we are "... not trained adequately to assume such responsibility."

If we want parity (and I believe we do), we must first define it. It does not mean that we want to become medical doctors. But I fear we seek parity of benefits without sharing the parity of responsibility. We desire equal respect and recognition, but some in our profession, who are quite vocal, deride educational standards and attainment in the name of "philosophy." (Kant and Hegel must be disgusted.)

If this profession is to thrive (and I think it will always survive because of the good it provides), we must assume the responsibility of being accountable to the public we serve. We (the profession) cannot speak with a "forked tongue" and expect the social acceptance and legitimization we desire. Chiropractic education must rally behind a banner of integrity, willing to submit to the review of our peers (that's what accreditation is all about) and seek to be not only good teachers (which is very, very important), but also purveyors of new knowledge.

Chiropractic education has changed in a dramatic way over the years, and it (and the profession it feeds) must continue transforming its image.

Reed Phillips, DC, PhD
President, Southern California University of Health Sciences
Whittier, California