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Chiropractic Specialties on the Rise
Mirroring the trend toward specialization in other areas of health care, chiropractors are returning to the classroom for diplomate certification, master’s degrees
By Gina Shaw, Contributing Writer
In the beginning, there is the DC degree. Chiropractic physicians share one common path to practice—years of study at one of the 16 schools of chiropractic accredited by the Council on Chiropractic Education (CCE). But after making the leap into the professional world of the practicing doctor, many chiropractic physicians recognize that, just as in allopathic medicine, more and more patients are looking for specialty-trained clinicians with advanced training and experience.
There are no overall statistics on the percentage of doctors of chiropractic who eventually find their way back into the classroom to earn a diplomate, a master’s degree or other specialized training. But most experts in the field say that specialization is a growing trend within chiropractic, as it is in traditional medicine.
“Completing chiropractic college shares a similarity with becoming certified to scuba dive. In diving, you learn the basics and can perform at a basic level under normal circumstances, and you know enough to be safe. You aren’t considered an expert until you have at least 100 hours of bottom time,” says Robert E. Dubro, DC, DACBOH, DABCO, president of the American Board of Chiropractic Specialties and past president of the Occupational Health Council. “After graduating from chiropractic college, you have the basic skill set to treat patients presenting with average, everyday complaints and injuries. In general, you do not yet have the expertise to treat highly chronic illnesses and injuries or specific, complex occupational, sports or traumatic injuries. Specialty training is an important path to that kind of expertise.”
“Everything that you learn in college when you graduate is certainly not enough to stay in practice,” agrees Harold Tondera, DC, FACO, president of the ACA’s Council on Orthopedics. “It only gives you the foundation. That’s why there are postgraduate courses and specialty councils. And more and more, patients expect certification and specialization. Certification demands respect—they know that you have established expertise in that area.”
For many years, the path to specialization in chiropractic has been the diplomate—a specialty certification that requires some 300 to 400 hours of advanced study, concluding with rigorous written, oral and/or practical examinations. This training is usually offered through chiropractic colleges or associations.
So what do all those hours of diplomate study get you, other than permission from the appropriate specialty board to use a few more letters after your name (DACBN, DABCO, DACBR, and so on)? You can’t actually charge more for your services as, say, a chiropractic sports physician, than you could if you didn’t have the diplomate.
“The No. 1 reason has to be the goal of making the patient better,” says Ted Forcum, DC, DACBSP, vice president of ACA’s Council on Sports Injuries and Physical Fitness. “Otherwise, it doesn’t work. You should be pursuing a specialty you’re interested in because you want your training to help you better serve your patients. Second, if you can do that, it’s likely to generate more referrals from patients. And if you can speak the language of other professionals thanks to certification in a specialty, you’re also more likely to get professional referrals.”
Dr. Forcum notes that a significant part of his practice is referrals not only from other DCs but other health care providers in general. “Having advanced education dramatically helps that. It also aids in justifying to patients why they’re seeing you, specifically, rather than someone else in the phone book. It qualifies you as an expert, which is extremely important in the competitive age of [health care].”
Spotlight on Specialties
So how do you choose a specialty? Ultimately, says Dr. Dubro, it has to come from the heart. If you’ve always had a passion for caring for children, consider chiropractic pediatrics. If you were an avid tennis player in college and coach your son’s Little League team or your daughter’s soccer team, the sports physician diplomate might be for you.
“Don’t pursue a specialty just to do it—you should be drawn to it for some reason,” he says. “Maybe it’s an interest you’ve had for a long time, or maybe it’s an important need you see in your community.”
Dr. Dubro, who holds joint diplomates in occupational health and orthopedics, spent 17 years working for Safeway, having joined the grocery chain while still in high school. Working at Safeway put him through chiropractic school, and he had originally planned to stay with the company to put his degree to use there. “I wanted to apply biomechanical, ergonomic and chiropractic principles to the workplace, so that we could avoid injuries, decrease the losses from workers’ compensation and maximize the company’s profits,” he said.
The Safeway plan didn’t work out, but his passion for the issue drew him into occupational health specialty training. “All people have an occupation that could injure them, whether employed or not,” Dr. Dubro says. “Whether it’s something like taking care of the home or maintaining your car, everyone has something that they do regularly that could hurt them, simply because of the way they do it. Occupational health is ‘Every Body’s Business.’”
The ACA has nine councils, which offer 10 different diplomate programs:
- Chiropractic Pediatrics
- Chiropractic Physiological Therapeutics and Rehabilitation
- Chiropractic Acupuncture
- Diagnosis and Internal Disorders
- Diagnostic Imaging (Radiology)
- Occupational Health
- Sports Physician
Here’s a quick spotlight on two:
Diagnosis and Internal Disorders
This specialty, says its council president, Cindy Howard, DC, DABCI, FIAMA, is essentially the chiropractic version of primary care. “We look at primary care a little bit differently,” she says. “A lot of people look at it in terms of being the first doctor someone comes to. We look at it from the perspective that we want to handle everything: work up the problem, diagnose you, and treat you. Instead of referring you to the ‘proper person,’ we want to be that person.”
Dr. Howard acknowledges that not all cases can be treated by a chiropractic physician, but thanks to the extensive training provided by the DABCI (Diplomate—American Board of Chiropractic Internists) certification, there are many that can. The 26 sessions of 12-hour weekends take three years to complete, followed by a three-part board exam—two written segments and one clinical competency examination.
“We do laboratory workups, blood chemistries, adrenal and hormone testing, GI function studies, EKGs,” says Dr. Howard. “We treat everything from allergies to thyroid problems to fatigue. It makes us more of a family doctor—not in the sense that we always take care of the whole family, but we can take care of all that ails them. I have people come into my office not for neck and back pain, people who don’t get adjusted, because we have other capabilities to treat naturally. If I’m adjusting somebody and not getting them better, [my training] gives me a broader range of things to look at as to what it might be.”
(The scope of chiropractic practice varies in accordance with the laws of each state; in some states, doctors of chiropractic are not permitted to conduct certain tests or procedures. All chiropractic specialties confirm to these scope-of-practice laws.)
“Chiropractic is orthopedics,” says Dr. Tondera. “All chiropractors should consider an orthopedic specialty due to the very nature of our profession.” Essentially, he says, a diplomate in orthopedics is much the same as acquiring a postgraduate degree in chiropractic itself.”
“A chiropractic orthopedist,” he continues, “should be able to talk with an orthopedic surgeon, or someone else in a totally different area of health care, and be speaking the same language about orthopedics: equipment, procedures, exercise regimen and so on.”
He notes that the trend in this curriculum, as in all of chiropractic—and indeed, all of health care—is toward evidence-based practice. “This is the wave of the future. No insurance company is going to pay for any type of procedure that does not have a good evidence-based track record. There are many procedures, both in medicine and in chiropractic, that don’t have that evidence base—and we need a definite plan to get there in a scientific way, with peer review.”
New Specialty Trends
Although the diplomate programs command great respect within the chiropractic profession, most doctors of chiropractic will concede that the majority of them are little known and little understood among other health care professionals.
“Other than radiology, it’s largely true that diplomate programs don’t get the same acknowledgement outside chiropractic that they do within the field,” says Dana Lawrence, DC, MMEd, an associate professor at Palmer College of Chiropractic, in the Palmer Center for Chiropractic Research. “Several years ago, the Council on Diagnostic Imaging altered the way that radiology would award its diplomate. They now require a comprehensive residency, which is a level of comprehensiveness and thoroughness that medical professionals outside of chiropractic recognize.”
“Others, including the public, don’t have an understanding of what a diplomate is,” says Dr. Forcum. “They think it’s a correspondence course, so it often doesn’t get the recognition it deserves. If we had more of our specialties look toward a master’s program—a standard, recognizable degree that’s known anywhere you go in the world—I think that would really help us in a competitive global marketplace.”
To address the lack of familiarity with diplomates—and raise the profile and acceptance of their programs among outside groups—two specialty boards, Neurology and Nutrition, have sought and earned accreditation by the National Commission for Certifying Agencies (NCCA)—an arm of the National Organization for Competency Assurance (NOCA), which strives to ensure the competency of specialists by setting quality standards for their credentialing agencies.
“With full accreditation from NOCA/NCCA, the chiropractic neurologist has and maintains parity with other health care professionals,” says Frederick Carrick, DC, PhD, FACCN, FICC, president of the ACA Council on Neurology.
Other chiropractic specialty boards are considering converting their diplomates to master’s degrees; at the same time, more and more chiropractic colleges have begun offering master’s degree programs.
One such program, the master’s degree in chiropractic research offered by Palmer, is now in its fourth year. The two-year, full-time graduate program comprises six trimesters of coursework, and as an experiential program, can’t be done through distance learning. About half of the program’s degree candidates come straight from chiropractic college, while the other half have returned for further education after some years in practice.
Although some—probably most—of the program’s students are interested in careers in clinical research, others are not aiming for academia or a health care research setting. “Some of our students really want to go back into private practice but would like to increase their ability to participate in research from private practice, which is very important to advancing the field,” says Dr. Lawrence. “There’s a real need in chiropractic to have more research infrastructure. It’s a specialized field with specialized skill sets.”
Palmer also offers a master’s degree in clinical anatomy, while both New York Chiropractic College and National University of Health Sciences offer MS degrees in diagnostic imaging, and in acupuncture and oriental medicine.
Eight years ago, Southern California University of Health Sciences added a master’s degree in applied and musculoskeletal sciences to its curriculum. Although it’s primarily composed of distance learning, the two-year program does require periodic three-day intensive work sessions on campus.
Unlike Palmer’s clinical research master’s, this program is recommended only for practicing doctors of chiropractic, not new graduates. “Students should have some real-world experience to draw from,” says program administrator Cindy Skoren. “The emphasis is on current concepts: headache, the cervical spine, the lumbar spine. Our students pursue the master’s degree for a number of reasons—some for teaching, some to advance with a program like the International Olympic Committee, and some just to advance their knowledge for patients.”
Among the councils now considering the establishment of a master’s program are those on orthopedics and sports medicine. “We’re looking at a program that we could bring the average practitioner into,” says Dr. Forcum. “It’s not practical for most doctors to leave their practice and then step into an institutional role and come back out and regroup again, so we would like to be able to have a master’s program give credit for experience to people who have already received their diplomate. There’s enough material to make such a program happen, so it’s just a matter of finding an educational institution that will take on the project, which we’re working on now.”
This could be just the beginning of a new move toward chiropractic specialization, says Dr. Lawrence. “We’d hope to ultimately see specialization toward PhD training, with more and more doctors of chiropractic leaving college and following their interests toward advanced training.”