I would like to offer an opinion that I hope will generate discussion and perhaps solutions from readers. I believe there is a rather large disconnect between chiropractic education and the practice of chiropractic.
I suggest there are many reasons for the alleged disconnect, and I'm certain the faculty and administrators of chiropractic colleges wish it wasn't so. It is of utmost importance to the colleges that our graduates easily transition into practice and quickly become successful. That scenario ensures referrals back to our institutions, which are dependent upon their student population to survive.
I'm sure some are tempted to say that the colleges function mostly to generate income, but that view demonstrates a profound lack of understanding of the expenses associated with running a chiropractic college. Without our colleges graduating students who can pass national boards and state examinations, this profession will soon only be a memory. It could happen in only a few decades if college populations continue to shrink as they have over the past 17 years.
The March 2013 issue of The Chiropractic Report states that there are 75,000 chiropractors in the U.S. When I was in college, 45 years ago, we were told there were about 50,000 chiropractors. That doesn't seem like much growth for 45 years; however, with the current combined college populations, it may be difficult to maintain the number of current practitioners, let alone continue slow growth. Sadly, chiropractors do retire, and even die.
Chiropractic colleges report their fall enrollment totals to the Association of Chiropractic Colleges, and a chart is prepared and distributed to colleges annually. These data show that overall college enrollments peaked in 1996 at 15,398 total students. The lowest total enrollment since 1996 occurred in 2011 at 9,619. It has been practically a downhill trend since 1996, with just an occasional upturn that invariably doesn't last.
Data are presented providing the percent increase or decrease from year-to-year. The highest downturns occurred in 2000, 2001 and 2002 with double-digit percentage decreases for each of those years. Overall, all-college enrollment has declined by almost 38 percent over this timespan. It doesn't take a genius to realize that if this trend continues, we could fail to replace our existing population of chiropractors in only a few decades.
Reasons for Alumni Apathy
It is my contention that our colleges have lost much of the loyalty and the support of their alumni, who are such an important factor in college well-being. This loss, I believe, has occurred for reasons that cannot be ameliorated by the institutions. I have no hard data to support this conclusion, but allow me to speculate. I have identified five main reasons for loss of alumni (and professional) support of colleges: 1) the cost of education; 2) lack of infrastructure; 3) insurance company "blues"; 4) ill-advised counsel; and 5) disconnect between teaching and practice. There are probably more factors, but these stand out for me. Allow me to elaborate.
1. Cost of Chiropractic Education
The profession most likely would have died out years ago were it not for the CCE, which pulled chiropractic from the unscientific and poorly educated profession of the early years to a profession with a real future in the health care system. The changes necessary to obtain and maintain accreditation were extremely expensive for chiropractic institutions.
CCE mandates much of the chiropractic curriculum, the research personnel and productivity, requirements for libraries, facilities, clinics and even the operating capital necessary to graduate enrolled students. It is enormously expensive to comply with these mandates. Another example is the requirement for PhD's to teach basic sciences. Colleges had to compete with traditional colleges and medical schools for PhD faculty, and as the PhD's were hired, DC faculty demanded parity.
Meeting CCE requirements is necessary and extremely beneficial to the profession, but the costs are staggering. A beneficial outcome was that with accreditation came student loans. The institutions probably would have folded attempting to maintain accreditation without the benefit of student loans.
Student loans, however, represent a two-edged sword. Students graduate today with a lot of debt and tend to blame the institution for that debt. True, a good portion of their student-loan money goes for tuition, books, etc., but students have little knowledge of the expenses incurred by the institutions. There is a tendency to compare chiropractic education to traditional colleges and medical schools who get the bulk of their operating dollars from their state of residency, the federal government and grants. This is like comparing apples to oranges, as chiropractic colleges enjoy few of these benefits. College administrators are poorly compensated when compared to the potential of practicing chiropractic or to salaries that would be enjoyed in the corporate world.
I believe the bottom line is that graduates tend not to recommend or recruit students to their alma mater because they don't want to be a party to another person having such a large student-loan debt.
2. Lack of Infrastructure
There is nothing original here, but the lack of professional infrastructure cannot be ignored when attempting to identify problems incurred by chiropractic graduates. To repeat a previously stated conjecture – institutions are largely dependent upon alumni referrals for students. When graduates learn how difficult it is to begin a chiropractic practice and when they realize that compared to medicine, which has an enormous infrastructure, they are pretty much on their own to become established. Graduates tend to blame the chiropractic institution for not properly preparing them for the realities of practice.
The institution with which I am most familiar has instituted programs to assist the transition from student to practitioner. It has engaged full-time positions to work with students throughout their educational program and on into their first months after graduating, preparing them for the realities of practice, assisting with business plans, loan acquisitions, and even helping to negotiate practice partnerships and leases.
Even so, because the program is voluntary, many students are so engrossed in their education and upcoming board examinations they fail to take advantage of the program. I trust that many institutions offer similar programs; however, the number of students enrolling in our institutions would suggest these measures are not yet increasing alumni referrals.
3. Insurance "Blues"
This subject doesn't need much elaboration. Anyone in practice knows of "insurance blues." When I began practice 47 years ago, chiropractic was not covered under any (that I know of) insurance reimbursement programs. Every practice (that I knew of) was a cash practice. Fees were rather low and patients just assumed they would pay for their care.
In the early '70s, reimbursement for chiropractic services gradually increased to include Medicare and Medicaid, worker's compensation and insurance reimbursement for MVAs. Soon an explosion of benefits occurred and chiropractic entered the years of "insurance heaven."
All good things must come to an end, and by the mid to late '90s (oddly, the peak in chiropractic college enrollments) insurance reimbursement began to be threatened. Insurance companies placed limitations on numbers of treatments and a few states lost their worker's compensation chiropractic benefits. Medicare and Medicaid put restrictions on numbers of adjustments, as well as imposing other extreme regulations.
Insurance companies hired chiropractors to review and sometimes deny coverage for chiropractic claims. These "reviewers" often were vilified by the practitioners whose insurance reimbursements were diminished; but for most reviewers, the motivation was to prevent the abuses by a few practitioners that potentially would (and eventually did) result in almost total shut-out of chiropractors within a few insurance markets.
I believe lack of insurance reimbursement may be another reason for a practitioner to want their son / daughter, friend, patient or acquaintance to pursue a profession other than chiropractic.
4. Practice Management
I am confident that practice-management groups provide considerable help for graduates and probably have good intentions. However, whether there is misinterpretation or misapplication of their advice, or whether the advice is simply bad, the effects of practice-management organizations frequently have damaged the reputation of the profession.
I especially dislike the rumors I hear that some PM groups encourage DCs to demand large fees in advance of services. It is said (again, rumor only) that about one-third of patients will engage services under these circumstances. It may be that the patients who adopt this plan will continue with care and receive benefits, but it is probable that the two-thirds of patients who refuse the offer never again will seek care from a chiropractor.
I suggest that while some practices benefit from practice-management consultations, it is doubtful that PM advice has increased student population, nor has it increased the percentage of the public seeking chiropractic health care.
5. Disconnect Between Teaching and Practice
The final thesis I present is that our institutions, mostly for reasons outside their control, aren't suitably connected to the "outside" world of chiropractic practice. Recent practitioners who have chosen to teach most likely are close to practice; however, for each year spent in chiropractic education, that knowledge diminishes.
A few might claim that because they teach part-time and practice part-time, they are "in touch," but I doubt their awareness matches those in full-time practice. The institutions need close connection to local (and distant) practitioners to remain grounded in the realities of practice.
Practicing chiropractors who remain involved in their colleges are one of the greatest assets to an institution. It is especially beneficial when the doctor is motivated by a desire to promote chiropractic, rather than to promote their own practice or "pet" technique, or sell something to students.
Students especially want to hear of current successes with patients. Students need to be reminded what their future will be like if they continue to endure the long hours of study and countless examinations necessary to graduate. It is important for students to observe a healthy number of alums who are constantly engaged with the institution, raising money for scholarships, offering free programs for students, donating, referring students and otherwise participating with their alma mater.
If alumni will continue to be involved in their chiropractic institution, the gap between education and practice is likely to narrow. This would be of immeasurable benefit to the continued growth of the profession.
Dr. Ruth Sandefur spent 28 years in chiropractic education with Cleveland Chiropractic College - Kansas City, where she graduated in 1967, including serving as vice president of academic services, chief academic officer and director of research for the college at various stages of her career. She can be contacted with questions or comments regarding this article via e-mail:
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