A Unified Direction

Discussions surrounding education within the chiropractic profession
are not new, but have certainly been taking on compelling dimensions,
particularly vis-a-vis the expanding global chiropractic community.

Discussions surrounding education within the chiropractic profession are not new, but have certainly been taking on compelling dimensions, particularly vis-a-vis the expanding global chiropractic community. Woven into the tapestry of fundamental issues that face the profession, education is significant because training is the point at which directions for each practitioner are forged and, thus, where the public, other health-care practices and governments may look to understand what a chiropractor should be and what levels of excellence can be expected from the discipline. Although much is – indeed, should be – learned after graduation, it is an education system’s job to lay foundations for best practices, clinically and in practice management, further learning and discovery, respectful vigilance, interaction within and outside of the profession, and more – all of which must reflect the unique and distinct features of the discipline of chiropractic. 

Worldwide, training in chiropractic has taken on many forms, sometimes to the general consternation – and detriment – of the profession. From weekend courses aimed at tacking “chiropractic manipulations” on to the roster of practitioners from other disciplines to fully accredited university-based programs, this scattered situation has resulted in a hodgepodge of graduates that range from astute clinicians and researchers to those who are far from qualified to perform chiropractic work. Furthermore, even among accredited institutions, great differences can be found in focus – differences that perpetuate the diversifications (and concomitant claims of supremacy) that have threatened the survival of chiropractic by compromising clarity in identity.  Not only does this situation put patients and the public at risk – particularly in countries where non-accredited programs are offering chiropractic education that falls far short of international standards – but it also clouds the persona of chiropractic as it is understood by patients, others in heath care, and government regulating or legislating bodies. Although this lack of understanding from the outside world serves to prevent the profession from moving forward on many levels, chiropractic leaders are quite clear in pointing out that the problem stems from within the profession – and, also, that it can be remedied from within the profession. 

In his recent address at the 84th Federation of Chiropractic Licensing Boards (FCLB) Educational Congress, president of the Ordre des chiropraticiens du Québec and distinguished 20th annual Joseph Janse lecturer, Dr. Andre-Marie Gonthier, touched on this concept. 

Dr. Gonthier noted, “We do not live in an ivory tower or on an island and we are, more than ever, in the history of mankind, all interlinked, on a “www.worldwide scale”. The whole world is really looking at us. We are in Cybermonitoring. They can look in our backyard . . . . We have to come together, with all our members, to help each other to unite, in a strong way, and this, more than ever.”

STANDARDIZING CURRICULA – A DEBATE
It begins to become evident that the education system training chiropractic practitioners is a good place to root urgently needed minimum standards in a way that instils a unified chiropractic purpose, or paradigm, while recognizing the potential that intraprofessional diversity has to stretch boundaries of excellence. Standardizing chiropractic education internationally, and thereby unifying the stream through which DCs are matriculated into their careers as practitioners, educators, researchers and so forth, says Dr. Gonthier, will serve to increase the profession’s clinical, academic and cultural authority, thereby ensuring its survival as a unique and distinct entity. 

The case for standardizing chiropractic education is countered by concerns about excessive uniformity imposed by a minority’s interpretation of chiropractic scope, loss of true chiropractic identity through conformity to requirements that might be more suited to other health-care disciplines, cultural relevance (in some areas), and others.

Two prominent Canadian members of the international chiropractic community who support and/or are working for the standardization of chiropractic education – Dr. Andre-Marie Gonthier, mentioned above, and Dr. Daniel Saint-Germain, president of the Federation of Chiropractic Licensing Boards (FCLB) – join Canadian Chiropractor in a discussion that addresses these reservations while considering the reasons for and advantages of standardizing curricula.

DR. DANIEL SAINT-GERMAIN
Dr. Saint-Germain prefaces his comments as follows:

“My responses to these questions will be from the regulatory perspective. As president of the Federation of Chiropractic Licensing Boards, I have the unique opportunity to consider education from the viewpoint of promoting what is best for the public.”

Canadian Chiropractor:  What exactly does standardizing chiropractic education entail?  Which components need to be standardized and where might colleges retain some flexibility within their curricula? 

Standardizing education stems from establishing minimum acceptable standards through the accreditation process. Accreditation, like regulation, must draw the line below which an educational standard is unacceptable, while simultaneously encouraging programs to stretch for excellence. It is my belief that the standardization of education starts with the establishment of similar, measurable standards, below which programs should not be accredited. These standards should focus on developing doctors of chiropractic who can diagnose broadly, treat competently, refer specifically, and function ethically.

Standardizing of chiropractic education has also come about via testing. Both the Canadian Chiropractic Examining Board and the National Board of Chiropractic Examiners base their independent tests on a careful combination of what is taught in the accredited programs and practised in the field, all in accordance with the legal scopes of practice in the various jurisdictions. Regulation’s reliance on examination has gone far to standardize education.

I believe the accredited chiropractic educational programs worldwide are much more similar than they are different. There will always be room for flexibility in the methods of educational delivery and the philosophical emphasis, provided there is a uniform commitment to the best interests of the patient.

CC: Why is the standardization of chiropractic education necessary in North America?  Globally?

There are two primary reasons standardization is necessary in North America and throughout the rest of the world.
Most importantly, the public should have a clear idea of what chiropractors can do to help them achieve maximum levels of health and flexibility. As the scopes of practice blend more to reflect what is taught at accredited colleges and assessed by independent examinations, chiropractic will have a clearer identity and patients won’t be confused.

The second reason is that practitioner mobility depends on standardization. Chiropractors no longer simply get just one licence and practice in the same location for a lifetime. We move to be near aging parents or warmer climates, or to take advantage of new business opportunities. We travel with athletic events both as volunteers and paid staff.

Standardization in education, testing and regulation breaks down unnecessary bureaucratic barriers while assuring the public that its doctors are appropriately qualified. Legislation such as Canada’s Agreement on Internal Trade and Australia’s national health professional licensure are moving us in the right direction. I am a strong advocate of national, and indeed international, standards with local (state or provincial) control.

CC: In standardizing the curricula of chiropractic training programs, which components must be retained across the colleges to ensure the identity of chiropractic and its status as a distinct and unique practice are not compromised?

From the first day we become involved with the profession as patients and students, we begin to build our understanding of this unique profession. We should never forget our history, our roots, our philosophy. We cannot change our past nor deny it, even the sad parts, where we have failed to work as a team to unite the profession.

The key components that must be retained centre on diagnosis, treatment skills, referral and ethics. By putting the patient ahead of the dollar, we keep our vision focused, and decisions are clear.

The basic science of chiropractic will remain the same. Its unique emphasis is on the patient as a whole, integrated person – not just a collection of independent symptoms. The value of our core tool, spinal manipulation, has been validated by research and outcomes to the point where other professions want to use it. As a regulator, my concern is that many of them do not have the depth of training and understanding of spinal manipulation to safely use it without endangering the
public.

I believe there are three key strategies that can help us retain our chiropractic identity:

• We must review our postgraduate credentials. Rather than small groups of specialty certifications, postgraduate education should embrace the rigours of university-level credentials. Academic masters and doctoral degrees must become the norm, and we need to support our chiropractic colleges in adding these advanced degrees.
• Research will improve and refine the basic science underlying chiropractic, and the effectiveness of various techniques and therapies. Each practising doctor of chiropractic should either be involved in a research project or contributing financially to research. Research creates our future.
• Teamwork is essential. Competition within teams and among teams refines each endeavour but, in the end, the joy and the accomplishment of working together creates limitless energy and blurs boundaries.

DR. ANDRE-MARIE GONTHIER
CC: What are the reasons for standardizing chiropractic education? 

In my discussions with federal and provincial government officials, I have received the comment that one of the biggest advantages, or strengths, of our profession is its standardization in terms of education, and, in particular, the presence of the CCEI and its affiliated national Councils of Chiropractic Education organizations. But, in my opinion, this is not enough. We have to do more at the college or program level, all around the world.

For instance, we must set uniform entrance level requirements, in order to admit the best students. We must work harder not to limit the number of applicants, but to attract the best candidates for chiropractic studies. It is not by lowering entrance standards, in order to fill up our programs, that we will have strong student bodies.

As well, we must work toward a more unified core curriculum in all chiropractic colleges and programs. 

One of the reasons for this is so that our accreditation agencies, along with the World Federation of Chiropractic, would then be able to refer governments wishing to establish new chiropractic programs in a specific country to these programs. In my opinion, this should greatly facilitate and harmonize the international growth and development of our profession, and will greatly reduce the creation of new laws or regulations, that might not be appropriate to our profession, in other countries.

The direct consequence of all this will be more academic and clinical authority and will then produce more cultural authority.

CC: Which aspects of chiropractic education do you feel need to be standardized and where might individual colleges be allowed some autonomy? 

All aspects of chiropractic education must be looked at. A great deal of this has already been done, with the help of the CCEI and the Association of Chiropractic Colleges (ACC). We could easily form an international forum for this, comprising not only the presidents of the institutions or programs, but also the academic and research deans of all CCEI-accredited institutions or programs. The end product would be a uniform template, a uniform core curriculum.  

From there, specific additions could be accommodated, reflecting the uniqueness of each institution or program, along with the qualities and credentials of the academic and research staff.

CC: How does standardizing chiropractic education achieve common goals and promote unity even in the face of opposing groups within the profession?

It is only by being strongly united that we will succeed as a profession. The major problem that we struggle with is how we manage our internal divisions. We must join together, as a professional community. We must continue to internally debate, discuss, even oppose, but always constructively, never negatively, and this is crucial – especially in this time of our history – to demonstrate to the external world a strong united image.

I believe that the colloidal substance that will unite us is our chiropractic paradigm, as put forward by the leaders of the Association of Chiropractic Colleges in 1995. Some aspects of this statement need to be adapted, but its core is very strong. Furthermore, the vast majority of our profession is actually adhering to it. This adhesion to a paradigm, according to the philosophy of scientist Thomas S. Kuhn, is vital. In this sense, I am optimistic.

This paradigm can be reflected in education programs that are standardized to include the necessary and fundamental elements of practice as a doctor of chiropractic.

But I know that some in my profession will not share those ideas – this brings us back to the internal battle, or struggle, surrounding identity. We are very young, as a profession – I would say we are like a young adult. In order to grow and to reach our full destiny, we need to unite very strongly.  In this, standardized chiropractic education – that incorporates high entrance standards and a strong clinical, philosophical and scientific/research core curriculum – can help by providing a common ground from which other dialogues can proceed. Diversities can then be navigated with respect, but firm adherence to fundamental chiropractic principles.  

FINAL COMMENTS
When asked for some final comments, Drs. Saint-Germain and Gonthier had the following to offer:
Dr. Saint-Germain:  Let us set aside old thinking. Together, let us embrace the best standards in education, testing and clinical practice, and continually move the line of minimal performance ever higher. Our patients deserve this.

Dr. Gonthier: I am convinced, more than ever, at this moment of our history, of the importance of unity within the profession. As regulators, as educators, as researchers, as association leaders, as public members on chiropractic boards, as presidents of chiropractic academic institutions, as doctors of chiropractic, we still have indeed a great deal of work to do. We will succeed but only with unity, and with a common goal for chiropractic in mind.