Prior to the establishment of the Council on Chiropractic Education (CCE) as the sole accrediting body in the profession, our educational institutions were accredited by either the International Chiropractors Association or the American Chiropractic Association. In an effort to gain federal recognition both organizations decided to pursue federal recognition for their respective accrediting bodies.
The ICA and ACA initially agreed to defer submitting formal applications through the Department of Education in the hopes they could resolve their differences and approach the federal government with one agency. Unfortunately, the CCE (ACA’s accrediting body) submitted their application without waiting. Since that time a number of very significant events have transpired that have changed the substance of chiropractic education.
One very serious issue is the adoption of the CCE as the sole accrediting body of the profession by the majority of the state licensing boards. This means that without changes in the law and/or board rules one could not get a license unless their education was provided by a CCE accredited school. The profession saw the dire effects of such actions when schools such as Pennsylvania College of Straight Chiropractic and Southern California College of Straight Chiropractic were forced to shut their doors due to these policies.
Graduates of Sherman College in the late 80’s also suffered the effects of these laws and rules. Many graduates during that time were refused licensure because an alternative accrediting agency had been formed (Straight Chiropractic Academic Standards Association – SCASA) to address the inequities and intrusion on the missions of schools not wanting to adopt a medically oriented educational program.
Political maneuvering led to the demise of SCASA, the domination of the CCE standards and the mandate of a primary care training program including full body diagnosis and related treatment strategies. Even as recently as the late 90’s and early part of 2000 these mandates were challenged as Life University went through an accreditation crisis which included questioning the authority of the CCE to mandate the mission of chiropractic educational programs.
A great deal of damage was done on both sides during this debacle, Life changed its mission to include primary care and physician related terminology and other schools followed suit not wanting to suffer the same fate.
The adoption of the roles and responsibilities of a primary care physician in the chiropractic educational system is now complete – at least on paper.
Whether or not the current clinical educational and training experiences qualify graduates to serve as primary care physicians is open to debate and there is broad disagreement on this issue within the profession.
The controlling faction of the profession does however use the educational focus on primary care as mandated by the CCE to argue for chiropractic’s inclusion in a variety of provider situations.
As recently as June of 2009 the ICA, ACA and COCSA put forth a policy document representing a unified stance asserting that chiropractors were trained as primary care providers and ready to fill the gap in the primary care physician shortage in the United States.
What is wholly absent in these discussions, policies and standards is the allowance for educational institutions to express their autonomy in regards to the mission of their educational programs. Even though there is serious debate as to whether or not chiropractors can fulfill the role of a primary care physician, educational institutions seeking to offer the Doctor of Chiropractic degree must comply with the primary care mandate or else its graduates cannot be licensed in the majority of the jurisdictions in the United States.
To be sure, the argument is not that training in aspects of primary care should not be offered, it is the concern that primary care has become the mission and that individual institutions are not allowed the autonomy to have any other focus. And/or, so much time is spent on teaching primary care, medical diagnosis and medical management that there is little time left in the curriculum to teach subluxation related analysis and management.
As chiropractic has increasingly become adopted by other care providers as an additional technique in their therapeutic armamentarium it has become crucial that the unique service (correction of vertebral subluxation) provided by the chiropractor be protected.
Training for this unique service should not be pushed aside in a curriculum top heavy with medical diagnosis and management but instead should form the core curriculum around which the necessary knowledge and skills needed to practice as a portal of entry provider are taught. Relegating the core service this profession provides to humanity to the sidelines for the sake of expediency, acceptance and inclusion in a third party pay system is short sighted and selfish. It is a gross abdication of our responsibility to the founders, future practitioners and the patients we serve.
The focus of a chiropractic education must return to one of imparting the knowledge, skills and attitudes necessary to manage patients with vertebral subluxation.
Will you join us on this mission?
Philosophy can be divided into five branches which address the following questions:
Metaphysics: Study of Existence. What's out there?
Epistemology: Study of Knowledge. How do I know about it?
Ethics: Study of Action. What should I do?
Politics: Study of Force. What actions are permissible?
Esthetics: Study of Art. What can life be like?
There is a hierarchical relationship between these branches. At the root is Metaphysics, the study of existence and the nature of existence.
Closely related is Epistemology, the study of knowledge and how we know about reality and existence.
Dependent on Epistemology is Ethics, the study of how man should act. Ethics is dependent on Epistemology because it is impossible to make choices without knowledge.
A subset of Ethics is Politics: the study of how men should interact in a proper society and what constitutes proper behavior.
Esthetics, the study of art and sense of life is slightly separate, but depends on Metaphysics, Epistemology, and Ethics.i
CCE International Standards
Of particular interest are epistemology, which relates to evidence and clinical decision making, and ethics.
The Councils on Chiropractic Education International INTERNATIONAL CHIROPRACTIC ACCREDITATION STANDARDS ii
provide, inter alia:
2.3 The program must comply with generally accepted standards of professional ethics…
Ethics is a branch of philosophy (supra).
Furthermore, Section 3.1.3 lists the following among the required competencies for a chiropractic graduate:
3.1.3 [A]ppreciates chiropractic history and the unique paradigm of chiropractic health care…
The “unique paradigm of chiropractic care” has been articulated by the Association of Chiropractic Colleges (ACC), and accepted by major chiropractic organizations, including:
• The Council on Chiropractic Education
• The International Chiropractor's Association
• The American Chiropractic Association
• The World Federation of Chiropractic
• The Congress of Chiropractic State Associations
• The Association of Chiropractic Colleges
• The Federation of Chiropractic Licensing Boards
• National Board of Chiropractic Examiners
• The National Association of Chiropractic Attorneys
• The Council on Chiropractic Practice
The ACC Paradigm states the following concerning the subluxation:
Chiropractic is concerned with the preservation and restoration of health, and focuses particular attention on the subluxation.A subluxation is a complex of functional and/or structural and/or pathological articular changes that compromise neural integrity and may influence organ system function and general health.A subluxation is evaluated, diagnosed and managed through the use of chiropractic procedures based on the best available rational and empirical evidence.” iii
The role of epistemology, a major branch of philosophy, addresses the study of knowledge, and is at the heart of evidence-based practice.
The CCE International Standard 3.2.4 requires a knowledge of epistemology and the rules of evidence, as it requires the chiropractic graduate “acquires the ability critically to appraise scientific and clinical knowledge…” iv
The U.S. Council on Chiropractic Education’s Standards for Doctor of Chiropractic Programs and Requirements for Institutional Status[v] require that the curriculum include “clinical decision making,” and “professional practice ethics” (p. 18), and that the student must demonstrate an ability to “ recognize the professional and ethical boundaries expected of the doctor/patient relationship” (p. 30).
Furthermore, the student must “exhibit reasoning and understanding in using sources (such as the available literature and clinical experience) to support the diagnosis” (p. 36), and must “be aware of the ethical standards expected of a doctor of chiropractic” (p. 48).
These standards clearly require study of at least two branches of philosophy, epistemology and ethics.
World Health Organization (WHO) Guidelines on Basic Training and Safety in Chiropractic
The World Health Organization (WHO) has promulgated guidelines for basic training and safety in chiropractic.vi
This document discusses philosophy and the basic theories of chiropractic, noting that:
The concepts and principles that distinguish and differentiate the philosophy of chiropractic from other health care professions are of major significance to most chiropractors and strongly influence their attitude and approach towards health care. A majority of practitioners within the profession would maintain that the philosophy of chiropractic includes, but is not limited to, concepts of holism, vitalism, naturalism, conservatism, critical rationalism, humanism and ethics. (p. 5)
Regarding “Full chiropractic education,” Section 4.4.5 includes
“history, principles and health care philosophy pertinent to chiropractic” and “ethics and jurisprudence pertaining to the practice of chiropractic.” (p. 12)
Annex 3: A sample full (conversion) programme, and Annex 4: A sample limited (conversion) programme, includes courses in Chiropractic History and Principles and Philosophy of Chiropractic. (p. 35, 37)
Guidance as to What Would be Required in this Area
A review of the above documents indicates that there should be no difficulty in providing guidance as to what exactly would be required in this area.
The Foundation for Vertebral Subluxation urges all chiropractic education programs to comply with these standards by including the following course work in the philosophy of chiropractic at a minimum:
· Chiropractic History
· Chiropractic Principles and Health Care Philosophy
· Branches of Philosophy
· Epistemology and Evidence-Based Practice
· Philosophy and Clinical Decision Making
· The Chiropractic Paradigm
· Professional Ethics
Graduates of any chiropractic program which fail to include such minimum instruction in philosophy should be ineligible for licensure or registration until they complete such course work through another accredited chiropractic institution.
[i]http://www.importanceofphilosophy.com/FiveBranchesMain.html Accessed 5/20/10. [ii]http://www.cceintl.org Accessed 5/20/10. [iii]http://www.worldchiropracticalliance.org/acc/acc.htm Accessed 5/20/10. [iv]http://www.cceintl.org Accessed 5/20/10. [v]http://www.cce-usa.org/uploads/2007_January_STANDARDS.pdf Accessed 5/20/10. [vi]http://apps.who.int/medicinedocs/documents/s14076e/s14076e.pdf Accessed 5/20/10.
We propose fundamental and far reaching reforms of the educational and accreditation system within the chiropractic profession. This reform begins with substantial structural and personnel changes to be made within the CCE in order to create two autonomous accreditation Councils.
These Councils will enable curricular freedom for those who desire primary care status and those who wish to provide a conservative, traditional chiropractic education. This will require substantial changes in the bylaws, operating structure and the function of the CCE.
The key for this model to be successful is the ability for both Councils to work autonomously. Separate Councils will need to be created along with separate Site Team panels and there will need to be coordination of each of them.
This restructuring of the CCE will then offer accreditation of two programs leading to chiropractic degrees that will be offered by institutions. One program, focused on vertebral subluxation, will lead to the already existing Doctor of Chiropractic and the other will lead to an as yet unnamed degree. Governance changes will need to be made to the overall structure of CCE to ensure a workable level of trust from stakeholders.
Once established, these autonomous Councils will develop appropriateStandards and competencies including those for subluxation-centered chiropractors and programs. Institutions could offer the program they desired. This proposal will have to include the development of similar autonomous bodies and testing programs within the National Board of Chiropractic Examiners or the establishment of an additional testing arm.
This proposal involves parallel tracks and does not include the concept of tiering or a hierarchy in any way as it is detrimental to both factions. More so, it suggests that the subluxation centered chiropractor is inferior. Under no circumstances would this proposal move forward under such concepts.
This proposal is not made without significant and serious review of the history of accreditation, the political landscape within chiropractic and an analysis of the various possible scenarios in regards to reform. This proposal also embraces a restructuring of the current delivery and pedagogical models utilized in the chiropractic educational system.
For a detailed review of these analyses please see the following document: