A. Chiropractic College Profile

    In 1996, there were 16 colleges of chiropractic in the United States (Table 3). The geographic distribution of chiropractic educational institutions demonstrates concentrations in the Midwest and the West with five colleges in each region. Ten of the colleges were established prior to 1945, though they may have gone through several reorganizations or mergers before achieving their current name and status. The most recently established college in the U.S. is the University of Bridgeport College of Chiropractic in Connecticut.

Table 3. Chiropractic Colleges in the United States (1996)

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    Since 1974, standards for chiropractic education have been established and monitored by the Council on Chiropractic Education (CCE), a not-for-profit organization located in Scottsdale, Arizona (CCE, 1995). Recognized by the U.S. Department of Education as the specialized accrediting agency for chiropractic education, the CCE sets standards for the curriculum, faculty and staff, facilities, patient care, and research. One of the CCE's major functions is to assess chiropractic institutional effectiveness and outcomes. This involves a periodic cycle of accreditation where member institutions perform a self-study of their strengths, weaknesses, and educational outcomes as they relate to CCE Standards. A visitation team made up of educators and practitioners conduct a site visit to review compliance with CCE Standards and the institution's mission and goals. The visitation team to the CCE Commission on Accreditation generates a report. The Commission holds a hearing for the institution for further clarification and verification of information and then renders a decision. The maximum length of accreditation is 7 years. Member institutions file yearly reports of their activities as they relate to CCE Standards.
    All 16 chiropractic educational institutions currently have accredited status with the CCE. Regional accrediting bodies such as the North Central Association of Schools and Colleges also accredit 13 of the colleges. Admissions requirements of chiropractic colleges are influenced by CCE Standards and chiropractic licensing board requirements. A minimum of 2 years of undergraduate education are required with successful completion of courses with a grade of "C" (a 2.5 grade point) or better in Biology, General Chemistry, Organic Chemistry, Physics, Psychology, English/Communication, and the Humanities (CCE, 1995). Each required science course must include laboratories. The cumulative grade point average must not be less than 2.25. The total college preprofessional credit units must be at least 60 semester units. Two colleges currently require 75 semester units and one requires 90 semester units. Four colleges will soon require a bachelor's degree for admission. Currently, six State Licensing Boards require a bachelor's degree in addition to the doctor of chiropractic degree for licensure (Federation of Chiropractic Licensing Boards, 1997).
    The chiropractic college admissions process usually includes an application review, assessment of academic transcripts, letters of reference, and an interview. Currently, there is no standardized admissions test. At most chiropractic colleges a "rolling" admissions process is used with qualified applicants being admitted on an ongoing basis. The "typical" (median) successful applicant has completed more than 90 college credits with a "B- " (2.7) average (Coulter, submitted).

B. Chiropractic Students

    Total enrollment in the United States chiropractic colleges in the fall of 1995 was 14,040. The mean enrollment per college was 878. Between 1990 and 1995 enrollment increased by 44 percent. During the same period the total number of graduates per year increased 13 percent, from 2,529 to 2,846 (CCE Report, 1996).
    Wardwell described the characteristics of a chiropractic student in his comprehensive historical account of the chiropractic profession, Chiropractic: History and Evolution of a New Profession, published in 1992. Studies conducted more than 40 years ago found that students often pursued chiropractic as a second career. A 1978 study reported that chiropractic students are primarily from working and middle class backgrounds (Wardwell, 1992). A more recent study reported that the predominant reason students decided to pursue the DC degree was influence from a family member or friend who was a chiropractor (Kaynes, 1992). Secondary reasons were interest in health care and personal health interests. Wardwell concluded his profile of the

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chiropractic student by stating that today's students are most attracted to the profession of chiropractic by its holistic, drugless, and natural approach to health.
    In an inventory of preadmission requirements comparing schools of medicine, dentistry, osteopathy, podiatry, chiropractic, and optometry (Doxey, 1997), chiropractic students scored the lowest of all professions evaluated on four outcome measures (minimum number of semester hours, completion of 4-year bachelor's degree, minimum GPA required on entrance, and average GPA of previous year's entering class). The study examined printed resources collected during 1995 from 17 medical schools, 16 chiropractic schools, 15 dental schools, 16 optometry schools, 16 osteopathic schools, and 7 podiatric schools. All of the included colleges were located in the United States and represented a broad geographic distribution. Table 4 compares the various professions in terms of entrance requirements. The authors were careful to note that although the data reflect differences among health care professions on a limited number of entrance criteria, they do not explain the causes of the differences nor do they offer any insight as to how these measures correlate with successful practice or patient care.

Table 4. Comparison of Four Preentrance Requirements Among Professional Training Programs

Average Minimum Semester Hours on Entrance  Average % of Applicants with Bachelor’s Degree on Entrance  Average Minimum GPA Required on Entrance  Average Cumulative GPA on Entrance Allopathy 100.9 99.4 3.16 3.56 Chiropractic 64.1 42.2 2.38 2.90 Podiatry 90.0 89.4 2.76 3.06 Dentistry 80.0 66.9 2.79 3.13 Osteopathy 95.6 97.0 2.68 3.26 Optometry 90.0 76.9 2.55 3.30

Source: Doxey TT, Phillips RB. Comparison of entrance requirements for health care professions. J Manipulative Physiol Ther 1997;20(2):86-91.

C. Curriculum

1. Program Length

    A chiropractic program consists of 4 academic years of professional education averaging a total of 4,822 hours, and ranging from 4,400 hours to 5,220 hours in the 16 colleges.¹ This includes an average of 1,975 hours in clinical sciences and 1,405 hours of clinical clerkship. The minimum hours for accreditation by the Council on Chiropractic Education is 4,200 hours.

1 Center for Studies in Health Policy, Inc., Washington, DC. Personal communication of 1995 unpublished data from Meredith Gonyea, PhD.

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2. Structure and Organization

    The program of study at all chiropractic schools is divided into Basic and Clinical Sciences. The average total number of basic science contact hours is 1,420, which accounts for 30 percent of the entire chiropractic program.² Basic sciences education includes an average of 570 hours of anatomy (40 percent of all basic science hours), 305 hours of physiology (21 percent), 205 hours of pathology (14 percent), 150 hours of biochemistry (11 percent), 120 hours of microbiology (8 percent), and 70 hours of public health (5 percent).
    On average, 70 percent of the program is composed of clinical education. Chiropractic schools devote an average of 3,380 contact hours to clinical education: 1,975 hours (58 percent) are spent in chiropractic clinical sciences and the remaining 1,405 hours (42 percent) are spent in clinical clerkships. These contact hours are in lectures, laboratories, and clinics. Table 5 shows the distribution of hours in these three settings for both basic and clinical sciences.

Table 5. Chiropractic Education in Terms of Average Hours of Lectures, Laboratories, and Clinics in 16 Chiropractic Colleges

Source: Center for Studies in Health Policy, Inc., Washington, DC. Personal communication of 1995 unpublished data from Meredith Gonyea, PhD.

    There are five curricular areas that are emphasized in chiropractic education: adjustive techniques/spinal analysis (averaging 555 hours or 23 percent of the clinical program), principles/practices of chiropractic (averaging 245 hours or 10 percent), physiologic therapeutics (averaging 120 hours or 5 percent), and biomechanics (averaging 65 hours or 3 percent).
    The clinical courses offered in chiropractic colleges are shown in Table 6. Subjects dealing with diagnosis and chiropractic principles are given the most time, followed by orthopedics, physiologic therapeutics, and nutrition. Three areas within the clinical sciences shown in Table 6 (adjustive techniques/spinal analysis, physical/clinical/laboratory diagnosis, and diagnostic imaging) account for an average of 52 percent of the education in clinical sciences. Thus the emphasis in chiropractic clinical sciences is clearly on diagnosis and manipulative therapy.

3. Content

    The sequencing of subjects in two chiropractic colleges are illustrated in Tables 7 and 8 (Coulter, submitted). Table 7 represents a year-round trimester program and Table 8 illustrates a semester program. Both programs are representative of other colleges in terms of total numbers of hours of clinical and basic sciences. The program from Table 7 is spread over 4 years with 10 trimesters. The first 2 years of the program are heavily focused on the basic and clinical sciences. In year 1 (three trimesters of 15 weeks each) there are a total of 1,515 contact hours (960 hours

2 Source: Center for Studies in Health Policy, Inc., Washington, DC. Personal communication of 1995unpublished data from Meredith Gonyea, PhD.

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in basic sciences and 555 in clinical education), of which 585 are spent in lectures and 930 in the laboratory. This represents an average of 34 contact hours per week for the students.
    In year 2, the focus is again on basic sciences (375 hours) and clinical sciences (1,110 hours). There are a total of 1,485 contact hours in year 2 (795 in lectures, 690 in laboratory), and there are an average of 33 contact hours per week. In year 3, all of the contact hours are spent on clinical education (which includes clinical sciences and clinical clerkships). Year 3 has a total of 1,410 contact hours (330 in lectures, 300 in laboratory, 780 in clinic), an average of 31 contact hours per week. Year 4 is given over to a clinical internship for 15 weeks (one trimester) for a total of 450 hours or 30 hours per week.

Table 6. Average Total Contact Hours in Specific Clinical Subjects Taught in 16 Chiropractic Colleges (Includes lectures and laboratories).

Clinical subject Hours % of Total Adjustive technique/spinal analysis 555 22% Physical/clinical/laboratory diagnosis 410 17% Diagnostic imaging, radiology 305 12% Principles of chiropractic 245 10% Orthopedics 135 6% Physiologic therapeutics 120 5% Nutrition/dietetics 90 4% Professional practice & ethics 65 3% Biomechanics 65 3% Gynecology/obstetrics 55 2% Psychology 55 2% Research methods 50 2% Clinical pediatrics & geriatrics 50 2% First aid & emergency 45 2% Dermatology 30 1% Otolaryngology 25 1% Other 160 7% Total hours of clinical training 2460 100%

Source: Center for Studies in Health Policy, Inc., Washington, DC. Personal communication of 1995 unpublished data from Meredith Gonyea, PhD.

4. Faculty

    Despite a growing body of literature about chiropractic education, the role of faculty has received little attention. As a result of standards set by the Council on Chiropractic Education (CCE) for chiropractic college faculty, all basic sciences faculty members at chiropractic colleges have earned university degrees of MS or PhD in their discipline, and many of the D.C. faculty also hold higher degrees (Wardwell, 1992). Clinical sciences faculty must either have a baccalaureate degree, several years of chiropractic experience, or teaching experience at an institution of higher education (CCE, 1995).

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Table 7. Subjects Taught in a Typical Trimester-Based Chiropractic Program, by Year and Numbers of Contact Hours

Year 1 Year 2 Year 3 Year 4 General anatomy (210)* Pharmacotoxicology (30) Integrated chiropractic clinical application (90) Clinical internship (450) Functional anatomy and biomechanics (210) Clinical microbiology (90) Physiological therapeutics (30)   Histology (90) Pathology (135) Chiropractic principles (75)   Human biochem. (105) Chiropr. principles (60) Practice management (75)   Chiropr. principles (90) Chiropr. procedures (300) Imaging interpretation (90)   Clinical chiropractic (60) Physics and clinical imaging (90) Radiological position and technique (30)   Palpation (120) Clinical orthopedics and neurology (180) Differential diagnosis (90)   Neuroscience (120) Nutritional assessment (60) Clinical application of manual procedures (60)   Normal radiological anatomy (90) Community health (60) Clinical internship (390)   Human physiology (135) Physiological therapeutics (105) Dermatology (15)   Fundamentals of nutrition (60) Clinical nutrition (60) Clinical psychology (15)   Introduction to physical examination skills (120) Research methods (30) Obstetrics/gynecology (15)   Chiropractic procedures (105) Practice management (30) Pediatrics (15)     Imaging interpretation (75) Geriatrics (15)     Differential diagnosis (90) Clinical laboratory clerkship (15)     Clinical chiropr. applied (90)     Total hours: 1,515 TOTAL HRS: 1,485 TOTAL HRS: 1,410 TOTAL: 450

*Number of contact hours is noted in parentheses.

Source: Los Angeles College of Chiropractic, Whittier, California.

5. Recent Trends and Innovations

    Within the health sciences in the past decade there have been numerous innovations in educational principles and practice. In chiropractic, most of the teaching institutions are involved in curriculum reform. Key innovations include the move to problem-based learning, self-directed learning, computer-assisted learning, the use of standardized patients, and the use of objective structured clinical examinations (Adams, 1991; Traina, 1994).
    Unlike most public- and private-sector institutions of higher learning, limited external education and research funding have hindered chiropractic institutional development thereby contributing to excessive tuition dependence. Recent Federal initiatives focusing on developing and prioritizing research within the chiropractic profession have highlighted this issue, emphasizing the need for directed educational research and faculty development (Adams, 1997). A number of chiropractic schools are well aware of the challenges confronting their programs and attempts are under way to fund innovative ways of enhancing chiropractic educational programs (Adams, 1997). However, if significant improvement is to occur, substantial resources will need to be identified and earmarked for educational enhancement.

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Table 8. Subjects Taught in a Typical Semester-Based Chiropractic Program, by Year and Number of Contact Hours

Division

First Year

Second Year

Third Year

Fourth Year

Biologic. Sciences

Human Anatomy

Pathology

Lab. Diagnosis (II)

Clinical Nutrition

Microscopic
Anatomy

Lab. Diagnosis (I)

Toxicology

Community Health

Neuroanatomy

Microbiology & Infectious Dis.

Neuroscience (I)

Neuroscience (II)

Biochemistry

Nutrition

Physiology (I)

Immunology

Chiropr. Sciences

Chiropractic Principles (I)

Chiropractic Principles (II)

Chiropractic Principles (III)

Integrated Chiropractic Practice

Basic Body Mechanics

Chiropractic Skills (II)

Clinical Biomechanics

Jurisprudence & Pract. Development

Chiropractic Skills (I)

Spinal Mechs.

Chiropractic Skills (III)

Aux. Chiro. Therapy

Intro Jurisprudence & Practic. Develop.

Clinical Science

Normal Radiographic Anatomy

Intro. Diagnosis

Orthopedics & Rheumatology

Clinical Psychology

Rad. Biophysics & Protection

Intro. Bone Pathology

Neurodiagnosis

Emergency Care

Normal Roentgen Variations & Roentgenometrics

Differential DX.

Child Care

DX. & Symptomatol.

Female Care

Radiological Techn.

Geriatrics

Arthritis & Trauma

Abdomen, Chest, Special X-Ray Procedures

Clinical Education

Observer (I)

Observer (II)

Observer (III)

Internship

Auxiliary Chiropr. Therapy Clerkship

Clin. Lab Clerkship

Clin. X-Ray Techn.

Clin X-Ray

Interpretation

Chiropr. Mgmt.

Observer (IV)

Research

Applied Research & Biometrics

Research Investigation Project

TOTALS

Source: Canadian Memorial Chiropractic College. Toronto, Ontario, Canada.

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D. Specialty Training

    Specialty training is available through U.S. chiropractic colleges for part-time postgraduate education programs or full-time residency programs. Postgraduate education programs are available in family practice, applied chiropractic sciences, clinical neurology, orthopedics, sports injuries, pediatrics, nutrition, rehabilitation, and industrial consulting. Rehabilitation has become a particularly popular program (Liebenson, 1996). Residency programs include radiology, orthopedics, family practice, and clinical sciences (Christensen, 1993). A typical residency program is 2-3 years in duration and includes ambulatory care and inpatient clinical rotations at chiropractic and medical facilities, along with didactic and research experiences. Other less rigorous postgraduate training programs may take 1-3 years to complete on a part-time basis. Both the residency and postgraduate programs lead to eligibility to sit for competency examinations offered by specialty boards recognized by the American Chiropractic Association, the International Chiropractors' Association, and the American Board of Chiropractic Specialties. Specialty boards may confer "Diplomate" status in a given area of focus upon successful examination. Chiropractic orthopedics and sports chiropractic are the most prevalent specialty certifications.
    Opportunities for chiropractors to participate in medical and multidisciplinary residencies are currently limited. Some fellowship programs exist in orthopedics and radiology and new opportunities in occupational medicine and physiatry may be on the horizon. Some chiropractic schools are pursuing joint training opportunities in the areas of public health, epidemiology, and health care administration.

E. Continuing Education

    Participation in Continuing Education by chiropractors is commonplace as 47 of 50 States have mandatory continuing education requirements to maintain or renew a license to practice (FCLB, 1997). The annual number of required hours ranges from zero in 3 states to 50 in Kansas (FCLB, 1997) (see Table 12 in Chapter V). The most prevalent requirement is 12 hours per year (25 of the 50 States). In addition, a number of States specify that topical content areas are to be included in annual continuing educational requirements. Examples include diagnostic imaging, chiropractic technique, risk management, public health (infection control and AIDS prevention), and professional boundaries issues. Several State Licensing Boards limit who may sponsor continuing educational activities (e.g., accredited chiropractic colleges or approved associations) and what the program is about (e.g., practice management seminars are typically excluded).
    Chiropractic continuing education programs often involve a 1- to 2-day seminar or conference (8-16 hours) focusing on a variety of topics related to chiropractic principles, clinical skills development, diagnosis, patient care, and practice management. These programs are usually sponsored by chiropractic colleges and other educational institutions, professional associations, and sometimes by commercial vendors or individual entrepreneurs. There is a growing interest in practice-based continuing education and distance learning (Jamison, 1991; Ebrall, 1995). Several colleges and publishers have created opportunities for chiropractors to participate in distance learning activities including the use of self-directed learning modules with audiovisual support and computer-enhanced learning. In addition, several States grant continuing education credits for self-directed learning.

Chiropractic in the United States

F. Comparison with Medical Education and Training

A recent study comparing chiropractic and medical education collected data on all chiropractic and medical schools in North America and performed an in-depth analysis of three chiropractic and three medical schools (Coulter, submitted). Three States providing a broad geographic representation of the United States were chosen: California, Iowa, and Texas. These States account for almost half of the chiropractic colleges in the United States. A single chiropractic college and school of medicine were studied in each State.
    The chiropractic schools included in this study had enrollments of 521, 773, and 1880, compared with a mean enrollment for all colleges of 878 (CCE Report, 1996). The three medical schools had enrollments of 691, 734, and 745, all moderately above the national average of 536 (JAMA, 1995).

1. Program Length

The chiropractic programs consist of 4 years of undergraduate education totaling approximately 4,800 contact hours. The medical programs consist of 4 undergraduate years, with approximately the same number of contact hours (4,667), but typically with an additional 3-year residency to meet the requirements for practice.

2. Selection of Students
    Medical schools require at least 3 years of college education prior to admission, while chiropractic colleges require a minimum of 2 years. In fact, most medical students complete 4 or more years of college (Coulter, submitted). However, national data on graduate chiropractors show that 78 percent have degrees other than chiropractic, of which 54 percent are Bachelor's or higher. Most chiropractors completed these degrees prior to the D.C. degree (Christensen, 1993).
    A recent study found the grade point average of students entering chiropractic schools is 2.7 compared to 3.5 for those entering medical schools (Coulter, submitted). Medical schools use the results of a standardized examination, the MCAT, as part of the selection process. Chiropractic schools have no standardized equivalent.

3. Prerequisites
    There is considerable overlap in the two professions in terms of the courses they require as prerequisites for entrance. Both require biology, general inorganic chemistry, organic chemistry, and general physics. In medicine it is common to require mathematics, which is not required in chiropractic. Both require a humanities prerequisite with chiropractic also requiring a social science/psychology credit as well as English and/or communication skills.

4. The Curriculum
    Two questions are of paramount importance in comparing the curricula of the two professions; what subjects are taught and how much is taught? The two programs are relatively similar in total student contact hours: an average of 4,822 hours in chiropractic schools compared with 4,667 hours in medical schools (Coulter, et al, submitted).
    Basic science comprises 25-30 percent of the total contact hours in both the chiropractic and medical programs (Table 9) and the two programs have roughly similar contact hours in biochemistry, microbiology, and pathology (Table 10). Chiropractors receive substantially more hours in anatomy education and physiology but many fewer in public health.

Table 9. Comparisons of the Overall Curriculum Structure for Chiropractic and Medical Schools

Chiropractic Schools Medical Schools   Mean Percentage Mean Percentage Total Contact Hours 4822 100% 4667 100% Basic science hours 1416 29% 1200 26% Clinical science hours 3406 71% 3467 74% Chiropractic science hours 1975 41% 0 0 Clerkship hours 1405 29% 3467 74%

Source: Center for Studies in Health Policy, Inc., Washington, DC. Personal communication of 1995 unpublished data from Meredith Gonyea, PhD.

Table 10. Comparison of Hours of Basic Sciences Education in Medical and Chiropractic Schools

Subject Chiropractic Schools Medical Schools Hours % of Total Hours % of Total Anatomy 570 40 368 31 Biochemistry 150 11 120 10 Microbiology 120 8 120 10 Public Health 70 5 289 24 Physiology 305 21 142 12 Pathology 205 14 162 14 Total Hours 1,420 100 1,200 100

Source: Center for Studies in Health Policy, Inc., Washington, DC. Personal communication of 1995 unpublished data from Meredith Gonyea, PhD.

The contrast between the two programs is dramatic in the area of clinical clerkships, which averaged 3,467 hours in medicine versus 1,405 hours in chiropractic. In medicine this comprises, on average, 74 percent of the total contact hours, while in chiropractic it comprises only 29 percent (Table 9). Part of the difference can be explained by the way in which the programs are structured. In chiropractic 41 percent of the program (averaging 1,975 hours) is allocated to chiropractic clinical sciences, which consists of extensive laboratory and hands-on training in manual procedures and has no equivalent in medicine. Combining the chiropractic clinical sciences with the clinical clerkships, the percentage of a chiropractic program devoted to clinical education is 70 percent compared to medicine's 74 percent. The major difference therefore is in didactic teaching and clinical experience.

Thus, on average, medical students receive twice the number of hours in clinical experience but receive over 1,000 fewer hours in lectures and laboratory education. If the medical residency is included, the total number of hours of clinical experience for medicine rises to 6,413 (Coulter, submitted).

References

Adams AH, Beckman J, Miller GA. The development and implementation of an innovative curriculum in chiropractic education: the LACC experience. J Chiropr Ed 1991;March:122-7.

Chiropractic in the United States

Adams AH, Gatterman M. The state of the art of research on chiropractic education. J Manipulative Physiol Ther 1997;20(3):179-84.

Christensen M, Morgan D (eds). Job Analysis of Chiropractic: A Project Report, Survey Analysis and Summary of the Practice of Chiropractic within the United States. Greeley, CO: National Board of Chiropractic Examiners, 1993.

Coulter I, Adams A, Coggan P, Wilkes M, Gonyea M. A comparative study of chiropractic and medical education (Submitted for publication).

Council on Chiropractic Education. Educational Standards for Chiropractic Colleges. Scottsdale, AZ: Council on Chiropractic Education, 1995.

Council on Chiropractic Education. Biennial Report, Feb. 94-Jan. 96. Scottsdale, AZ: Council on Chiropractic Education, 1996.

Doxey TT, Phillips RB. Comparison of entrance requirements for health care professions. J Manipulative Physiol Ther 1997;20(2):86-91.

Ebrall P. Chiropractic and the second hundred years: a shiny new millennium or the return of the dark ages? (Commentary). J Manipulative Physiol Ther 1995;18:631-5.

Federation of Chiropractic Licensing Boards. Official Directory of the Federation of Chiropractic Licensing Boards: 1997-98. Greeley, CO: Federation of Chiropractic Licensing Boards, 1997.

JAMA. Medical schools in the United States. Journal of the American Medical Association 1995;274(9):745-52.

Jamison JR. Motivational factors in continuing self-education? Euro J of Chiropr 1991;39:27-32.

Kaynes H. Career choice and the chiropractic student. J Chiropr Ed 1992;Sept:47-53.

Liebenson C. Rehabilitation and chiropractic practice (Commentary). J Manipulative Physiol Ther 1996;19:134-40.

Traina AD, Gour NM, Traina TM. The use of the standardized patient in chiropractic education (Commentary). J of Manipulative Physiol Ther 1994;17:489-98.

Wardwell WI. Chiropractic: History and Evolution of a New Profession. St. Louis, MO: Mosby Year Book, 1992.

 
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