The Chiropractic Future

When Daniel David Palmer founded the first school of chiropractic in 1897, the goal was to teach others how to help those in need overcome various ailments by addressing subluxation.

Today, chiropractic schools find themselves at a crossroad as changing health care laws, increased patient needs and a challenging job market up the pressure on recent graduates.

If they want to survive, the schools must respond to the new realities of the 21st century, a position that puts them on the cutting edge of where the profession is going.

So what does the future look like for chiropractic practices? Where is the field headed? And what do you need to know to keep in front of the curve?

To find clues, we interviewed the current presidents of the top chiropractic schools in the country.

Common Themes

A number of common themes emerged, including a significant movement away from solo practice by young doctors just starting out in the profession. As part of this general pattern, more students are demanding, and getting, advanced degrees.

And, as several of the educators told us, a major goal now is to expand the focus of the profession so that it has a larger presence in the overall health care system within the next decade.

The Disappearing Solo Practitioner

Attempting to start a solo practice right out of school is far less common today than it once was, the college presidents told us. Instead, many of the thousands of chiropractic students entering the field every year are joining a group practice. Graduates are embracing this trend in a conscious effort to avoid debt, work with a smaller staff, and pick up new skills from experienced DCs.

Fabrizio Mancini, president of Parker College, said many graduates are getting their DC degrees at a younger age than in the past, do not have experience in business or finance and may not be able to stay financially afloat on their own, at least at first.

"We are seeing a lot of our graduates going to work as independent contractors," Mancini said. "We recommend they associate with a place where they can gain from that experience, but not stay too long."

At the National University of Health Sciences (NUHS), as many as 30 percent to 40 percent of chiropractic graduates are entering integrated or collaborative practices, said James Winterstein, the university's president.

The emergence of more DCs who are cost-sharing of X-ray equipment, reception and office staff services, as well as participating in shared marketing is a pattern that Winterstein and other administrators think will have a positive impact on the future of chiropractic practices.

"I see this more and more often and I believe this is vital to the continued viability of the profession," Winterstein said.

Gerry Clum, president of Life Chiropractic College West, agrees, noting that shared office settings are a positive trend since it not only lowers overhead among several practitioners, but also allows each practitioner greater personal and professional flexibility while maintaining a high level of practice coverage.

"In my day, a DC would find an office, equip it and begin practice. This may be a simpler way of doing things but it is a relatively inefficient approach to start-up costs and maximum utilization of physical facilities and human resources," Clum said.

By working in collaborative practices, new DCs also have the opportunity to be part of strong multidisciplinary teams that often include physical therapists, nutritionists and sometimes, medical doctors.

Winterstein notes that in order for graduates to continue to have more opportunities in these new integrative settings they will need to embrace new forms of health care delivery, which includes being on the same page as other health care colleagues from different disciplines.

"Success in these arenas is dependent upon the ability of our graduates to 'speak the language,' understand their colleagues from other professions, and explain what it is they do from an evidence-based perspective," said Winterstein. "They must be excellent diagnosticians, fine historians and outstanding examiners."

Much of that preparation begins before graduates head into these integrated practices, which has started another trend on various campuses - advanced degrees and education.

[pb]Aiming Higher

Winterstein said his administration at NUHS understands it will take more than articular manipulation education to meet the needs of the patient population of today. In addition to chiropractic training at the school, all of the students also receive 90 hours of pharmacology and 105 hours of basic and advanced botanical medicine.

Students at Parker College have done the same by supplementing their education model with additional classes.

"We have beefed up our curriculum. We have more on wellness and nutrition, so our students can go into those fields," said Mancini.

The increased emphasis on wellness mirrors the findings in a survey done last year by the Department of Health and Human Services, which found that patients named "lack of emphasis on prevention" as one of their highest health care concerns.

Parker College is also among the schools following another major trend these days: going from small, chiropractic-focused schools to becoming universities that offer more degrees.

Mancini said this change is essential if graduates are to be well-equipped for the demands of the real world and increase the value of the profession by expanding the scope of practice, which has remained unchanged for over a century.

"What we have done in our profession in the last 150 years has not advanced our profession," Mancini said. "Society has not been able to embrace us because we have been sitting out there as an island."

Last year, Parker College went to its students to find out if an advanced degree and more education would benefit and encourage them. Of those surveyed, over 67 percent said they desired to begin a master's degree program within the next two years, Mancini said.

The students noted the degree would allow them to have more opportunities when they graduate and would open the doors to careers in nonprofit organizations, governmental agencies and corporate entities.

This year, Parker College will give students what they asked for by becoming a university and offering more undergraduate degrees and master's degrees.

"There is tremendous potential for us to advance our profession further with this new model," Mancini said. "This will allow students to integrate into society and fill the void where the needs are in the health care system."

The goal is also for more high schools to be able to view Parker as a referral source for undergraduate programs where more students will be exposed to a chiropractic education.

Examples of degrees that will be offered include a health promotion undergraduate degree and a master's of public health - a degree that is required by many government health care jobs.

Other schools, like Cleveland Chiropractic College and the Northwestern Health Sciences University, are also offering their students more options for advanced degrees.

Cleveland Chiropractic College launched its master's in health promotion degree program in the fall 2010 with the objective of certifying graduates as health leaders in their respective communities, providing educational programs in healthy lifestyle choices and workplace wellness.

"All health practitioners should share a role in prevention and health promotion, and this is an area where chiropractors can take the lead in patient education advocating 'living a chiropractic lifestyle,'" said Carl S. Cleveland III, president of Cleveland.

At Northwestern Health Sciences University, administrators are developing new master's degree programs in clinical specialty areas that are designed to broaden the knowledge and skills of new and currently practicing doctors of chiropractic.

Health care Reform

Like all health professionals, new DCs are anticipating changing health standards under the Patient Protection and Affordable Care Act, better known as Obamacare.

Many chiropractic schools are keeping a close watch on the law and its potential impact to the careers of recent graduates.

"Practice style five years down the road will be dictated, for better or for worse, by the role of the chiropractic under the Affordable Health Care Act," said Clum, who feels this is the most important factor that will affect his graduates.

[pb]For DCs, the proposed changes have the potential to substantially influence the way they practice and how they are paid. (See related story, "Obamacare: Threats and Opportunities" on page 17.)

It will also open opportunities to provide care in new interdisciplinary delivery models, said Dr. Mark Zeigler, president of Northwestern Health Sciences University.

"It (health care reform law) may create opportunities for chiropractic doctors to collaborate with medical and other health professionals in providing primary care as members of community health teams," he said.

Zeigler points to the fact that there are numerous references in the law to "integrative health" and "integrative health care practitioner," illustrating a growing interest in creating new delivery models that have the potential for increasing access to primary care and improving care coordination.

Dr. William Meeker, president of Palmer Chiropractic College, said the one aspect of the law he is excited about is that it removes the discriminatory language that prevented chiropractors from participating fully in the health care system in the past.

"As long as chiropractic care is reasonably included in the essential benefit packages, we might have some real opportunity there," said Meeker.

The impact of this law won't be seen for a while - and its future is still uncertain. Since Obama signed the legislation into law in March 2010, two judges have rejected legal challenges and recently a federal judge in Richmond, Va., ruled that the law was unconstitutional, saying federal government has no authority to require citizens to buy health insurance.

The Republican majority in the U.S. House of Representatives have also promised to try and repeal the law. Short of that there may also be attempts to "de-fund" some of its provisions.

Meeker said his hopes are that the law won't be too gutted and instead will open new health plans to DCs of the future to be able to create a larger patient base. "I think there is a lot of opportunities, but it's a real murky picture at the moment," said Meeker.

Embracing Technology

Health care reform is not the only major development expected to change the way chiropractic graduates - and you - do business in the future. By 2014, the Obama administration is also calling for all doctors and hospitals to go digital with electronic health records.

"The requirement for electronic health records in 2014 will drive a major expansion of outcome-based care, force practitioners of all disciplines to embrace technology, and foster a level of multidisciplinary collaboration between health practitioners," said Cleveland.

As chiropractic outcomes data enter the system and when health researchers evaluate the evidence alongside other health care methods, Cleveland said he believes the introduction of chiropractic care in the overall analysis will inform the broader health care community regarding chiropractic's effectiveness.

This would then also form a basis for far greater multidisciplinary collaboration.

College officials feel the new DCs going out into the field will need to be well equipped to embrace this new method to enhance the current business model in practices today.
"This may result in rewardingly symbiotic and effective practice partnerships in this new world of electronic health records technology," said Cleveland.

Beyond its impact on improved patient care, the introduction of electronic health records may also assist in resolving the Medicare error rate that has plagued the chiropractic profession. It should also bring consistency in claims reporting and follow-up, Cleveland added.

Other aspects of technology that new graduates will be working more with are new enhanced tools, such as the transition from film-based radiography to digital imaging.

Mancini believes many of the new tools will help validate the need for future care, as patients will be able to see their progress with the help of technology.

"Technology is playing a very important role in the development of chiropractic," said Mancini.

"Now you have visuals where you can show dimensions," he said.

"You have machines that evaluate you before and after the adjustment."

Interesting Times

Overall, when considering the combined effect of the opportunities for participating in multidisciplinary facilities with mandated electronic health records, there is expected to be a growth of data that researchers will be able to utilize to objectively evaluate the outcome of chiropractic care.

All of these changes are proving to redefine the profession for graduates of the future along with the practice.

"The potential long-term benefit to the profession and the patients it serves may be far greater than any of us can currently envision," Cleveland said.

"We are living in very interesting times."