What kind of chiropractor are you? Part II

I am a firm believer in the idea that a full discussion of any issue includes not only identification and clear explanation of the concern, itself, but the subsequent suggestion of one or more potential solutions together with delineation of the necessary action steps to implement them. This should include recognition of the individuals and / or organizations responsible for enacting each step. Therefore, I spent a few hours on the long train ride back to Geneva from Vienna outlining a “suggested solution” to the problem of inconsistency in chiropractic education. I outlined processes for incorporating all of the stakeholders, coming to consensus on standards and methods for addressing outliers, producing an acceptable and prudent outcome, and the follow-up to support continued success of the solution.

When I completed this, however, I took a deep breath and passed it across to intern colleague Mr Daniel Bronstein (www.danielbronstein.wordpress.com) for review and critique. After appraising the assessment and suggested “solution” work plan, the future Dr Bronstein raised the point that, while my ideas were not inherently controversial in the abstract, I did identify existing chiropractic organizations, and by extension, individuals, who I suggested should be responsible for each of the many steps in the process. He observed that this might not yet be ready for posting, as I had not yet discussed my ideas directly with the organizations / individuals. Although I understand that this is only a blog and the posts here are only my opinions and observations based on the experiences that I have had, I acknowledged the validity of Mr Bronstein’s remark, and have therefore archived the post in question for now, and it will hopefully be revived in the future when I can have the many necessary conversations.

I do want to offer something, however, as an intermediary step as we begin to discuss the standardization of chiropractic education and prepare the global academic whitepaper on the subject, and so I would like to draw attention to the less-specific, minimum standards of education for chiropractic practitioners (whether at the Bachelor’s, Master’s, or Doctoral Degree level) as outlined in the WHO guidelines for basic training and safety in chiropractic (2005). These standards were agreed upon by representatives of schools, organizations, accrediting institutions, licensing and examination agencies, experts in education, government and NGO representatives, and just about every identifiable stakeholder. These included all the chiropractic expertise, of course, but also experts in educational standards, general health care, and representatives from other TM/CAM fields, such as osteopathy, tuina, and manual medicine. These guidelines were a consensus coordinated by WHO, an organization without political motivation or bias in the field, and they were written, edited, commented on, and edited again over the course of several years. When completed, they were unanimously accepted as a global representation of the necessary standardization of the professional education of chiropractic practitioners. As a reference, I have also posted links to this document in many languages. You can find them under “Recommended Reading” in the sidebar to the right.

To clarify, these guidelines are not the pinnacle of educational standards; they are, as they are titled, the absolute minimum standards deemed necessary to train practitioners to an acceptable level of knowledge and safety.

Many chiropractic academic programs already far exceed these standards, and this should always be our goal: to continually raise the standards of excellence such that each successive graduating class of chiropractic practitioners has not only the skills and knowledge of the cohort that passed before them, but also the additional insight garnered from learning from the mistakes of those who passed before us and taking advantage of newly available resources.

In any case. . .

When first considering the creation of a new academic programme, there are several generic academic and administrative considerations which WHO recommends be considered. These are independent of the techniques being taught, and they include:
- minimum competencies required for qualified practice;
- oversight of training programmes and practitioners to ensure adequate competency;
- methods by which training and education are accomplished;
- the need for part-time or transitional programmes, and their relationship to the development of full-time programmes;
- minimum standards for conversion training programmes for health care practitioners;
- the most appropriate training for persons with no prior health care training and the prerequisites for entry into such training programmes;
- guidelines for an individual practitioner’s scope of practice;
- development of appropriately trained and accredited teaching staff;
- facilities required for training;
- role of continuing professional development;
- creation of a framework for registration and/or licensing;
- training in research skills.

The WHO guidelines outline 4 models of education in two categories; I(A), I(B), II(A), and II(B).

I(A) and I(B) are where I will focus. These are full chiropractic education for individuals who have no prior healthcare practitioner education or for existing medical or other health practitioners who want to go back to school to also legitimately practice chiropractic in addition to their existing skill, but who may be able to “test out” of some of the chiropractic programme coursework because they will have already completed the subject, i.e. anatomy, physiology, biochemistry, etc.

For education at Category I(A) and I(B) levels, the objective is to provide and education in which chiropractors will practice as primary-contact, health care providers either independently or as members of health care teams within health care centers or hospitals. This will include a minimum of 4200 student / teacher contact hours with 1000 of these hours being devoted to supervised clinical training. Obviously, some programs may choose to require a greater number of lecture or clinical training hours, and all programs will require the students to engage in self-directed learning / review studying at home to support their progression through the course.

I will not really discuss II(A) and II(B) at all, as these are “limited chiropractic education” courses which do “not lead to full qualification” as a chiropractic practitioner. These programs were initially intended to be “intermediate” steps to assist countries as they tried to start from scratch to build academic programmes, accrediting institutions, licensure, examinations, and all the necessary accoutrements. These programs did not, to my knowledge, actually exist anywhere in the world at the time of drafting the guidelines, but were rather invented in the abstract. They have not been seen as very successful, however, and such programs have been eliminated from more recent parallel educational standard normative guidelines produced by WHO.

According to WHO recommendations, all chiropractic academic programs must, either during the course of study or as a prerequisite to admission, complete basic science components. During the chiropractic program, students must also complete pre-clinical science, clinical science, and chiropractic science components, as well as patient management interventions, documentation and clinical record keeping, research, and some additional topics. In abridged summary, these include:

Basic Science – Chemistry, physics, and biology

Pre-Clinical Science – Anatomy, physiology, biochemistry, pathology, microbiology, pharmacology, toxicology, psychology, dietetics and nutrition, and public health

Clinical Science – History-taking skills, general physical examination, laboratory, diagnosis, differential diagnosis, radiology, neurology, rheumatology, EENT, orthopaedics, basic paediatrics, basic geriatrics, basic gynaecology & obstetrics, and basic dermatology

Chiropractic Sciences and Additional Subjects – Applied neurology, applied orthopaedics, clinical biomechanics, history, principles and health care philosophy pertinent to chiropractic, ethics and jurisprudence, and a background on traditional medicine and complementary/alternative healthcare

Patient Management Interventions – Manual procedures, exercise, rehabilitative programmes and other forms of active care, psychosocial aspects of patient management, emergency treatment and acute pain management procedures, and recognition of contraindications and risk management procedures, and the limitations of chiropractic care.

Documentation and Clinical Record Keeping – Accurately recording all aspects of every patient encounter and an appreciation of confidentiality and privacy issues, consent obligations, insurance and legal reporting.

Research – Basic research methodology and bio statistics, interpretation of evidence based procedures/protocols and best practice principles, an epidemiological approach to clinical record keeping, encouragement to document particular case studies and participate in field research projects, development of a critical thinking approach in clinical decision making, the consideration of published papers and relevant clinical guidelines, and development of the necessary skills to keep abreast of the relevant current research and literature.

These partner with the list of competencies deemed necessary in graduates that are also outlined in the guidelines.

These things are the essentials, the basics, the minimum agreed upon by representatives of all sections of the profession and endorsed by WHO, the most influential and widely accepted purveyor of health care information and standards in the world. We, as a profession, agreed to these standards not even 5 years ago, and so I propose that a good place to start is to make sure that, at a minimum, every one of our chiropractic educational programs meets these standards. If a program is unable or unwilling to meet these minimum standards, then we must be able to stand together and acknowledge that we, as a profession, are only as strong as our weakest colleagues, our “weakest link”, and take the necessary action to rectify the situation. This is the only way forward.

And so I ask us to spend some time in careful self-reflection. Does every single chiropractic practitioner graduate in full possession of the necessary skills and competencies to meet these standards? Does every single chiropractic academic program provide the necessary academic information, with appropriately qualified instructors and adequate teaching facilities, to meet the obligatory standards? Does every single accrediting body or agency demand that the academic programs meet these standards and take the necessary action to continually ensure that they do so? Does every jurisdiction have an independent system of examination to serve as a check to the balance of the educational system? Do our licensing agencies take responsibility for ensuring that all of the previous requirements have been completed satisfactorily? It does not matter if 50%, or even 90%, of the programs voluntarily pursue excellence in education, we are judged by our minimum requirements, by the least of us, not by the best we produce. Unless these standards are mandatory and universally enforced, we really don’t have any base to stand on. I suggest that if each of us can set aside our bias, and our “school pride”, and really critique ourselves, we will all come to the conclusion that, as a global profession, we have some serious work to do.

What kind of chiropractor are you?

I find it curious that this is a question that is asked so frequently, and almost always by individuals inside of the profession.  Naturally, there are some patients who have had multiple doctors for some reason or the other, and they may be asking about the doctor’s technique, but these are the minority.  Although there are multiple ways to answer this question, including on the basis of technique, philosophy, or other criteria, we most commonly identify ourselves by our Alma Mater.  I do this, of course, proudly identifying myself as a recent Northwestern graduate.  I have only recently realized that this might be a problem.

Let me stress first, however, that I have absolutely no problem with school pride.  I loved attending Northwestern and although I will admit that no school is perfect, I am happy to say that after visiting more than a dozen different campuses around the world, I am still glad I chose Northwestern and I would choose it all over again.  I am sure there are other students who feel the same way about their own programs.  This is natural, and to be expected.

Where I see it being a potential problem, however, is when where you completed your coursework actually means you are a different “kind of chiropractor”.  What is a “chiropractor”?  Does the word actually mean anything?  If patients cannot open a phone book and know that whoever they go see will at least offer them the same basic standards of care, no matter which school they attended, how can we legitimately call ourselves a profession?

Among the first things on our list to do as a group of committed individuals is to standardize our education at a international level.  Before you throw up your defenses with regard to the sanctity of the sovereignty of each individual school, hear me out.  I think we need to boil everything down into what actually makes us what we are, and ensure that all chiropractic students are taught this foundation and that they all reach the defined level of competency.  Then, of course, there are a lot of “extras”, and each school can mix and match these electives as they see fit to expand on the curriculum and add their own particular “flavor”.

For example, I think we can all agree that if you will get a slightly different medical education if you go to Harvard compared to attending Iowa State.  At one school you might have more focus on clinical research or the inclusion of information about Acupunture, while at the other they might have extra classes in public health.  My point is that both schools will require their students to take anatomy, physiology, pathology, pharmacology, etc. and both schools demand a certain level of competency which is subsequently independently verified.  This results in two different, but credible and strong academic programs.  It means that when a mother brings in her child to one of these two MDs, she can be sure that she will have a similar experience, even if the treatment eventually selected by the specific doctor might be different.  Basically what I am trying to say, is when you make an appointment to go see your local MD, even if you have never met them, you kind of know what they do and you can, with notable exception, reasonably predict what you’re going to go through when you get there.

Can we make this same claim?  Do we have a well-defined and accepted cultural identity?  If you walk up and down the street and ask people what a chiropractor does, how many different answers do you think you will get?  Can we begin to see that having nearly 40 global schools each doing their own thing, training dozens of different “kinds of chiropractors”, might actually be a problem?

The reason why this point is especially pressing for me is because of the work I am doing and the experiences I am having here in Geneva.  As the only chiropractor to have ever been in my position, I am constantly having to define who I am and what I do to people who have little to no understanding of the practice of chiropractic.  I do not mean in the slightest to underplay the amazing work that the World Federation of Chiropractic (WFC) has done, both within the Secretariat and among national policy-makers at events such as the Executive Board meetings and World Health Assemblies.  To make the point plain, without the work that WFC has done and continues to do, without the foundation they have built, and without their status as the only chiropractic-related NGO in official relations with WHO, I would not be here.  However, nearly every day I have someone ask me about chiropractic.  It is only very rarely that they have absolutely no idea, rather it is more common that they have heard something, but do not really understand.  Depending upon their level of existing knowledge, and any preconceived notions they may have developed along the way, I have to explain in a different way.

As an example, I might have to explain to the Minister of the Permanent Mission of XXXXX that although he has believed that as a “chiropractor” I am some sort of massage therapist, I actually completed a doctoral level program of education in the United States which covered all the basic science areas such as anatomy, histology, and biochemistry, and the clinical science areas of radiology, clinical pathology, neurodiagnosis, EENT, etc.  as well as having spent considerable time focusing on the techniques of manual medicine and the diagnosis and treatment of neuromusculoskeletal conditions.  Next, however, when speaking to the German representative of XXXXX I need to explain that the “chiropractor” she visited with whom she had a very bad experience may or may not actually have been trained as such, as there is no regulation on the practice or protection of the title “chiropractor” in her home country.  I need to explain to a WHO Coordinator why chiropractic interventions should be considered when writing “best practice” protocols for some non-communicable diseases, when she is from a North African country but knows “chiropractic” in terms of what she saw when working in New Zealand.  I must be aware that the University of Southern Denmark and the University of Zurich are fully integrated into the health care programs in their countries, with Switzerland admitting chiropractic and medical school students together as a joint class for the initial stages, but that the United States schools are generally entirely privately funded and independent.  My point is that to know how to explain chiropractic to an international audience, you must explain each school independently, as every one is a special case!

So what is the actual solution?

Welcome to the blog

Before I say anything else, I want to express my appreciation to the two individuals who unknowingly prompted me to begin this blog.  The first individual is Daniel Bronstein, current intern at the World Health Organization and soon-to-be Doctor of Chiropractic, who has already created a blog to share his experiences forging the way for the profession into the global public health arena.  The other individual is Dr M. Navarro of Minnesota, a private practice clinician for whom I have a great deal of respect.   In speaking to Dan about his blog, Dr Navarro asked if I had one, too, thus allowing more individuals to learn about the experiences I have had and the opportunities which exist within WHO.

When I heard about this, I realized that this was a lapse on my part.  I have spent my time here sharing my experiences with a fairly select group of individuals who have expressed interest in being “in the know”, but direct e-mail is far too inefficient for mass communication, even when supplemented with a number of personal phone calls as necessary.    Thus, I have taken the plunge and joined in.  I will attempt to keep up with things as they happen, while also providing some historical perspective, as time permits

As long as I am here, I may as well begin!

I was initially accepted into the WHO Internship Program last year while attending Northwestern Health Sciences University in Bloomington, Minnesota.  Approximately 12 weeks after submitting my application, I heard back that I had been accepted.  Fifteen weeks later, I left for Geneva, Switzerland, making me the first ever Doctor of Chiropractic Student to be accepted to the World Health Organization in their entire 60 year history.  It was amazing, and something which would not have been possible without the support of many organizations and individuals.

The internship learning curve was steep, and I am exceedingly grateful to my prior education which provided me with a strong foundation in both basic and clinical sciences on which I could build.  I learned an exceptional amount in a very short time, and was able to integrate into the Organization as well as learning the fundamentals required to operate within a world of “WHO speak”.

In an interview I gave just before leaving for Geneva in early 2008, I was asked what my primary objective was for my time at WHO as related to the chiropractic profession.  Forced to only choose one, I said “If I can make it so that when I am done, they say ‘Wow, if all chiropractors are like Molly Meri, we need to bring more of them over,’ then I’ll be satisfied.”

Well, I don’t know if I can comment on that, but I have been very fortunate, and following my internship in Traditional Medicine and graduation as a Doctor of Chiropractic, I was invited to return on a one-year contract as a Technical Officer in the same area.  I began back here at the start of the year, but this is a marathon compared to last year’s sprint.  Additionally, there have been other Doctor of Chiropractic Students who have correctly and successfully negotiated the rigorous Internship Program application process and also come to WHO.  Earlier this year, Dr Jennifer Nash, of the Canadian Memorial Chiropractic College, spent three months in Geneva.  As previously mentioned, future Dr Daniel Bronstein, of Southern California University of Health Sciences, joined WHO at the start of last week.   As a graduated doctor and WHO staff member, I have done what I can to assist these new interns with the necessary preparations and the complex internship period, as one of the hardest things I had dealt with was having no guidance within the Organization.

If forced again to choose one primary objective, I would have to say my goal this year is to help bring a genuine public health perspective to chiropractic, and to bring chiropractic into public health.

This is more complicated then it initially may appear. 

First, even the colleges and universities with the strongest academic programs are aware that the vast majority of graduates will be practicing clinicians, and therefore the curricula are designed to support this objective.  Public Health is included in the coursework to varying degrees, of course, but I do not believe that all students, everywhere in the world are truly qualified upon graduation to integrate public health concepts into the treatment of their patients and to support the advancement of public health objectives.  Many Doctors of Chiropractic focus on the individual patients, as well they should, but sometimes may fail to consider community health at the population level.

Second, chiropractic students do not always learn to work together with other health care professionals, whether within the realm of TM/CAM or without.  The fundamentals of this involve finding and focusing on common ground, and speaking a common language.  We are not exactly like any other health care provider, but neither are we all exactly like each other.  All of us, however, have the best interests of the patients at heart.  Let us respect our individualities but still focus on the points of convergence in our efforts to work together for the benefit of the patients we serve. Let us also not let historical or traditional language prevent us from moving forward.  To put it into perspective, I do not wander around Geneva demanding that everyone understand my English.  I may not speak French well, but in an attempt to get along, I am learning, and I make the effort.  We have a common meaning; let us work in common terminology.  After all, anyone can talk a good game, but it is through our actions that we will be defined.

The road we must follow is simple enough to explain, even if difficult to navigate, and it centers on the three pillars of safety, efficacy, and quality.  These concepts are absolutely necessary in any health care system, and although equally important, they must be addressed in order.

First, we must be able to prove that the practice of chiropractic is safe.  This seems like an obvious statement to those of us who have had a considerable amount of experience and training in the field, but anecdotal evidence and clinical experience, no matter how voluminous, is not sufficient.  We must prove this to a commonly accepted standard, as it does not matter if we are effective if we cannot legitimately and accurately judge the risks and the benefits.  The fortunate thing is that much of this evidence already exists, we need only to start to collect it, organize it, identify what we have and where the holes may be, and format the findings.

After we handle the issue of safety, we can begin on the issue of effectiveness, and lastly, issues of quality control in training, interventions, etc.

This is not a quick project, and it is not something any one of us can do alone.  It is a feasible project, however, and a necessary one.