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Dept. of Education to Council on Chiropractic Education: “Straighten Up!”

Our last look at the Council on Chiropractic Education (CCE), about 18 months ago, found the CCE deeply embroiled in a heated dispute among various chiropractic factions over new accreditation standards for chiropractic colleges. Today we offer an update on that situation.

Update: the CCE is deeply embroiled in a heated dispute among various chiropractic factions over new accreditation standards for chiropractic colleges.

As you may recall, the CCE, which accredits chiropractic colleges in the U.S., stood accused of removing the subluxation from its standards for accreditation, so that chiropractic students would no longer be required to learn how to “detect” and “correct” the putative vertebral subluxation. Of course, the chiropractic subluxation doesn’t exist, but we’ll get to that in a minute. This brouhaha was raised by the more traditional wing of the chiropractic community, called “straights,” whose practice (and livelihood) is based on convincing patients that their spines need “adjustments” to remove these subluxations under the threat of ill health should they be left unattended. The straights were also upset at the move by another faction of chiropractic seeking to rebrand chiropractors as primary care physicians who diagnose and treat a wide variety of diseases and conditions.

By way of background, the CCE’s standards for admission to chiropractic colleges are, to my knowledge, the lowest of any program awarding a doctoral degree. (See Policy No. 6 in link.) As you likely know, a student can’t get into graduate school in the standard American college or university (even to pursue a master’s degree, much less a Ph.D) without first obtaining an undergraduate degree and attaining an acceptable score on the Graduate Record Exam. Other graduate programs — such as law, veterinary and medical schools — have their own rigorous entrance exams. (You can find an outline of the topics covered by the Medical School Admissions Test here.) Not chiropractic college. A student need not have an acceptable exam score because there is no entrance exam for chiropractic college. In fact, the student doesn’t even need a college degree – only 90 undergraduate hours, including 24 hours of basic science courses, and a 2.5 (“C”) average. In other words, the entrance requirements for a D.C. degree are less selective than those for a master’s degree in one of the sciences.

Straighten up!

To redress their grievances, the straights organized a campaign to attack the CCE during its review by the U.S. Department of Education (DOE), which was required to retain its status as the sole national accrediting agency for American chiropractic colleges. Instead of evaluating higher education institutions itself, the DOE parcels this job out to private accreditation agencies but makes these agencies meet certain standards. Each accrediting agency is reviewed by the DOE every 5 years and it was CCE’s turn at bat. Reviews are conducted for the DOE by the National Committee on Institutional Quality and Integrity (NACIQI).

Accreditation is key to colleges and universities because it opens the door to taxpayer-funded loans for their students. States also use CCE accreditation in determining whether to accept a degree from a particular chiropractic college in licensing decisions.

A DOE staff analysis found that the CCE was not in compliance with 44 of the criteria for accrediting agencies outlined in the Code of Federal Regulations. This included failure to comply with regulations governing conflicts of interest, record keeping, processing of student complaints and the adequacy of its site review of accredited chiropractic colleges. (The DOE staff’s full report covers a number of accrediting agencies and is not numbered sequentially. You can find the section on CCE by scrolling down to page 61 of the PDF.)

The staff report noted that one chief concern of the dissenters was the elimination of the term “subluxation” from the CCE’s standards. In a response clearly demonstrating that a science-based education is of no concern to the DOE, the staff report stated:

This is a professional issue within the chiropractic community. Staff concludes that it is beyond the purview of the Department to dictate to any [accrediting] agency what its curriculum requirements and accreditation standards should be.

In other words, feel free to teach implausible and unproven concepts of human anatomy and physiology to students who will become licensed health care providers. That is not our job.

One particularly glaring omission in the CCE’s oversight of chiropractic education was in determining how many credit hours a college assigned to its courses. The DOE requires all accrediting agencies

to conduct an effective review and evaluation of the reliability and accuracy of the institution’s assignment of credit hours. . . . The agency is required to make a determination whether the institution’s assignment of credit hours conforms to commonly accepted practices.

It wasn’t that the CCE’s policies and procedures were insufficient. Rather, the CCE totally failed to address this criterion at all. This, it seems to me, is a crucial gap in the record, for it goes to the very heart of the quality of an institution’s education. Without this information we can’t know if schools are inflating the number of hours credited to coursework. Credit hours assigned to courses becomes a virtually meaningless figure.

The straight’s attack on the CCE was prolific, if ultimately only partially successful. The NACIQI received approximately 4,000 comments regarding the CCE during its review, only 30 of which were supportive. Although many of the negative comments were simply copies of the same complaint, it does indicate some level of dissatisfaction among the approximately 50,000 practicing chiropractors in the U.S.

The NACIQI voted 12-0 to accept the DOE staff’s report on the CCE’s noncompliance. In light of the many complaints, the NACIQI told the CCE to demonstrate wide acceptance by chiropractors of its standards, policies, procedures and decisions “and to address how its standards advance quality in chiropractic education.” This, as well as the 44 shortcomings found by staff, must be remedied in 12 months.

The DOE’s final decision, in a letter to the CCE dated March 15th, accepted the NACIQI’s recommendation on all points except the added requirement that the CCE demonstrate wide acceptance. The recognition of CCE was continued provisionally for 12 months in order for the CCE to bring itself into compliance. It has 30 days after that to submit a full report on compliance, at which time the DOE will make a final decision regarding recognition. The DOE reminded the CCE that granting extensions of time to come into compliance were rare, and failure to achieve compliance in the additional time allotted would, in accordance with federal law, result in refusal to recognize CCE as an accrediting agency.

Interestingly, the Chair of CCE failed to mention the full extent of the DOE’s ruling in a March 20th memo to “Interested Parties and Stakeholders.” Rather, he opted to describe the DOE’s decision this way:

We would like to publicly acknowledge the U.S. Department of Education’s recent decision to renew its recognition of CCE. On March 15, 2012 CCE received written notification that the Secretary of Education, after performing a thorough review of our evidence, and following comprehensive and careful analysis of recommendations made by the Department Staff and National Advisory Committee on Institutional Quality and Integrity (NACIQI), decided to ‘continue CCE’s recognition as a nationally recognized accrediting agency.’

Looks like he left out a few important details.

The International Chiropractors Association, an organization representing straight chiropractors, was obviously unsatisfied with the DOE’s decision, as potentially devastating as it was. It is asking chiropractors to get in touch with their Congressmen to straighten this situation out. (I’m not sure what Congress can do, given that this decision is within the jurisdiction of the DOE.)

The subluxation stays

Right before its appearance before the NACIQI, the beleaguered CCE wrote “An open letter to the profession” trying to quell the controversy over its accreditation standards. It labeled a “myth” the assertion that it was trying to remove all mention of the subluxation from the standards and that students no longer have to know how to assess for subluxation. Not true, says the CCE: We didn’t eliminate it, we just moved it to the “meta-competencies” section of our policies, which describes what students of accredited programs must be able to do. And, true to the CCE’s claim, there it is, under “Meta-Competency 1 – Assessment and Diagnosis.”

C. Performing case-appropriate physical examinations that include evaluations of body regions and organ systems, including the spine and any subluxation/neuro-biomechanical dysfunction that assist the clinician in developing the clinical diagnosis(es).

Neuro-biomechnical dysfunction? What’s that? As the CCE explains in its letter,

Between the three drafts and the final 2012 Standards, subluxation received considerable attention by the Task Force and the Council. Despite its historical legacy in the profession, a number of educational programs and practitioners have opted to use other terms, such as joint fixation or joint dysfunction. [And, I might add, manipulable lesion, spinal lesion, etc., etc.] Even the Association of Chiropractic Colleges (ACC) has not reached a unified definition or specific criteria for subluxation, despite its own task force addressing this issue. The 2012 Standards opted to use a combination phrase, ‘subluxation/neuro-biomechnical dysfunction.’

So, in summary, although chiropractic’s two leading educational organizations devoted considerable attention to the issue, we don’t know what a subluxation is or how to define it. Nevertheless, we chiropractors give it a bunch of different names so, to add to the confusion, we invented another one. And, even though we don’t know what they are, we are going to make chiropractic students learn to detect and correct these subluxations/neuro-biomechanical dysfunctions or whatever you want to call them.

Another “myth” busted by the CCE was the contention that the standards no longer require students to learn to “adjust.” Again, not true. It’s right there in the meta-competencies that the student must “provide appropriate chiropractic adjustments and/or manipulation procedures.” But, the dissenters protested, that means that the college could teach only manipulation and not adjustments. What’s the difference, you ask? Well, manipulation is a plausible non-CAM manual therapy with some evidence of effectiveness employed by physical therapists, physiatrists, osteopaths, and chiropractors. It’s purpose is to reduce pain, increase joint range of motion, and address other physical manifestations of joint impairment. An adjustment is a means of correcting the non-existent subluxation. But, as the CCE notes, “many in our profession use the terms adjustment and manipulation interchangeably” so manipulation, to a chiropractor (but no one else), is also a “therapy” used to correct the subluxation. Got that?

The CCE also labeled as a “myth” the allegation that it was “forcing colleges to teach students how to prescribe. CCE is changing the profession into Medicine.”Once again, not true, says the CCE — there is no requirement that the DC curriculum include “prescriptive medications or pharmacology,” although it could if the college wanted it to. However, there is a requirement that the DC curriculum include “toxicology.” According to the CCE “many DCPs [Doctor of Chiropractic programs] see this as an opportunity to include instruction on the adverse health effects of medications.” So, although they need not have any training in pharmacology, DCs are presumably sufficiently educated by a course in “toxicology” to understand “the adverse health effect of medications.”

Bad Press

As if all this weren’t enough, a series of articles in The Chronicle of Higher Education appeared over the last few months which hung some dirty chiropractic laundry out to dry in plain sight of all of academia. First, not one, but two, articles in the Chronicle detailed the CCE’s fight with the straights as well as the drubbing it got from the DOE. The Chronicle summarized the DOE’s message to the CCE as a demand to “clean up its act within a year.”

Then came two more Chronicle articles exposing the high salaries and nepotism among chiropractic college presidents and their administrations. One article detailed how, in spite of declining chiropractic college enrollment, “the presidents of chiropractic colleges are taking in some of the biggest paychecks in higher education.” One example: In 2009, the president of Logan College of Chiropractic earned $791,418, an amount equal to 3 % of the college’s entire budget. This is about the same compensation paid to the president of the California Institute of Technology (yes, Cal Tech!) which has a $2.3 billion budget, or, as the Chronicle reporter calculated, 90 times the budget of Logan. The president of Parker University (formerly Parker Chiropractic College) earned about the same as the president of Brown University and the salary of Cleveland Chiropractic College’s president was comparable to that of Vassar’s. All of this raised eyebrows among several experts consulted by the Chronicle, who cited potential problems with the IRS and “governance weaknesses” indicated by the unusually high salaries.

Most recently, a piece appeared in Forbes questioning the use of taxpayer funds to subsidize chiropractic education through student loans. Author Steven Salzberg specifically noted chiropractic belief in subluxations, which, as he correctly points out, “have not even been shown to exist.” Referencing the recent controversy over college student loans, Salzberg asked:

But what about institutions that provide a substandard education? Or worse, what about institutions that educate people in quackery and pseudoscience? Subsidies to these institutions are worse than useless. These so-called colleges spread misinformation that will require much more investment to correct, if it is even possible. Why, to be specific, is the U.S. government subsidizing students to attend chiropractic colleges?

The answer: we shouldn’t.

Perhaps the CCE’s poor showing in front of the DOE and this spate of bad publicity will awaken policy makers to the deficiencies of an educational system that tolerates “CAM” education. At the least, the DOE should refuse to recognize credentialing agencies which fail to require science-based education for health care providers. This would stop the flow of student loans to these schools and eliminate wasting even more taxpayer dollars on pseudoscience. Without student loans these schools could not survive. That would go a long way in eliminating quackery in our health care system.

Posted in: Chiropractic, Legal, Politics and Regulation

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