Buyer's Remorse in Chiropractic as a Career Choice: What Can We Do?

According to Wisegeek.com, "Buyer's remorse is the term given to the feeling a person often gets after making a large purchase. Although excited at the time of the purchase, once they've spent a lot of money, many people feel a deep regret and concern that they made the wrong decision, referred to as buyer's remorse.

"Buyer's remorse takes many different forms, most of them typified by a high level of anxiety, usually about having made the wrong decision. Sometimes buyer's remorse strikes when a person makes a purchase they may not have actually had the money or credit for, and after buying it they begin to realize that they were living well outside of their means, and worry begins to grow over the consequences. This is especially true of purchases such as buying a new home, which is one of the most common triggers for buyer's remorse, due in no small part to the huge amounts of money usually involved."

Today's crisis in chiropractic identity may be due, in large measure, to this phenomenon as applied to chiropractic as a career choice. Chiropractic educational institutions actively encourage alumni to refer students and recommend chiropractic as a career. In the past, most chiropractic college applicants had a positive personal experience with chiropractic care, and wanted to share it with others. Many were "second career" students who left successful jobs and businesses to study chiropractic.

Today, more students are entering the profession who have little or no direct experience with chiropractic. They concluded that chiropractic was a good career choice for a variety of reasons. Some sought the title "doctor," but were unwilling to commit the time and resources required to complete medical school and residency training. Others wished to become doctors, but lacked the grades and other qualifications to enter medical school. And of course, there are those who saw chiropractic as little more than a way to earn an excellent living.

Today, some of those who wished to become medical physicians are attempting to transform chiropractic into medicine. They are seeking a far less burdensome route to primary care medical practice than med school rotations and years of 70-hour-per-week residency training. A few weekends in a hotel room should do. Morris Fishbein, a vitriolic critic of chiropractic, got one thing right when he wrote, back in 1925, "Osteopathy is essentially a method of entering the practice of medicine by the back door. Chiropractic, by contrast, is an attempt to arrive through the cellar."¹ His words were prophetic given the Doctor of Chiropractic Medicine movement and efforts to obtain prescriptive privileges following short courses in hotel rooms.

For those who wish to practice primary care medicine, I would encourage the establishment of MD, DO or NP programs that allow these individuals to receive advanced standing for their chiropractic education and clinical experience, permitting them to complete clinical rotations and qualify for licensure as plenary physicians and surgeons or nurse practitioners. This would avoid sullying the name and role of the chiropractor.

The second part of the problem stems, in part, from the high cost of chiropractic education. Many DCs graduate with a debt burden that may exceed $200,000. This graduate is faced with limited income potential as an associate, or the additional cost of purchasing or establishing a private practice. Opportunities in education and research are limited, and may require additional education.

Must chiropractic education be this costly? It is time to examine some basic premises and answer some questions that few seem willing to ask.

Does additional pre-professional education produce better chiropractors? I have been unable to locate any studies comparing the success (however defined) of DCs having two years of pre-professional study with those having four. Fortunately, there have been studies comparing medical doctors with two, three and four years of pre-professional education. These studies show that there is no significant difference in performance.

In the 1970s, because of a perceived physician shortage, several medical schools offered six-year combined liberal arts / medicine programs. Lazoni and Kayne reported the results of such a program:

"Graduates of a six-year combined Liberal-Arts-Medicine Program and their medical school classmates (traditional 'eight year' students) are compared as to their medical school performance and their professional postgraduate activities. On standardized examinations (Medical College Admission Test and examinations of the National Board of Medical Examiners) the six-year group was somewhat better than the eight-year group. In other aspects, such as class ranking, honors at graduation, and medicine clerkship grades, the six- and eight-year groups were similar. The two groups were remarkably similar in their postgraduate professional career choices and in achieving board certification."²

These findings were corroborated by a JAMA article that stated, "These data, together with additional information concerning postgraduate professional activities, indicate that the combined accelerated program has been successful."³

More recently, a group of Canadian investigators reached similar conclusions: "There were no significant differences between the three groups in the results of any of the subjective and objective outcome measures. Students who have completed 2 years of undergraduate study before admission to medical school were able to achieve a satisfactory level of competency and maturity by the end of medical school. The 2-year option for entrance into medical school should be reconsidered."⁴ And Doxey and Phillips, in comparing entrance requirements for health care professions, wisely observed, "The value of pre-professional requirements relating to success in practice is yet to be determined."⁵

All this leads me to believe that streamlining pre-professional education could significantly reduce the total cost of obtaining a DC degree. On that note, are there less costly alternatives to the current method of chiropractic education? Doctor of Chiropractic programs in the U.S. require full-time residential attendance. Students typically attend lectures and labs, and then obtain clinical training in college-run outpatient clinics. Some have suggested that a significant amount of coursework may not be relevant to developing the knowledge and skills necessary to practice chiropractic safely and effectively.⁶ We need to clearly define that body of knowledge and skills.

Chiropractic institutions should explore innovative methods for course delivery, such as distance education. A number of chiropractic institutions already offer graduate degree programs using distance learning. Could some of the courses in the DC curriculum be offered in this manner, reducing both cost and time required on campus? Would more clinical training in the offices of carefully screened practitioners potentially result in lower costs and less pressure to recruit patients? Could part-time and mixed-mode delivery systems be implemented to permit students to work while learning? Why must students be locked into a "one size fits all" time frame?

There is no simple quick fix to the issue of buyer's remorse in choosing a chiropractic career. We need to address the elephant in the room.

References

1. Fishbein M. The Medical Follies. Boni & Liveright, New York, NY, 1925:98.
2. Lanzoni V, Kayne HL. A report on graduates of the Boston University six-year combined liberal-arts-medicine program. J Med Educ, 1976;51(4):283.
3. Blaustein EH, Kayne H. The accelerated medical program and the liberal arts at Boston University. JAMA, 1976;235(24):2618.
4. Crockford PM, Gupta DM, Grace MG. Requirements for admission to medical school: how many years of university study are necessary? Can Med Assoc J, 1995;153(11):1595.
5. Doxey TT, Phillips RB. Comparison of entrance requirements for health care professions. JMPT, 1997;20(2):86.
6. McCoy M, Kent C, Decken W, et al. A survey of chiropractors attitudes and opinions regarding chiropractic college curricular content, length, relationship to practice success and recommendations for change. Chiropractic Dialogues, Sept. 8, 2011:10-11.