Pursuing a Diplomate

By Lori A. Burkhart

You’ve earned your doctor of chiropractic degree, but is that enough? You’ve put in the long hours of study and most likely accumulated student-loan debt, and there are only so many hours in a day. The economy is difficult now, too. Yet, for people who like to learn, and doctors of chiropractic (DCs) tend to be in that group, the idea of pursuing further education is often tantalizing.

Pursuing a diplomate is a major undertaking, and it isn’t easy. The American Chiropractic Association (ACA) offers 11 programs leading to diplomate certification for those who complete postdoctoral training in clinical specialties (see Figure 1). A diplomate is a DC who has made significant achievement beyond the mandatory educational requirements and who is certified by an examining board.

To bring to life the process of pursuing a diplomate, ACA News discussed what is involved with four experts, all of whom have successfully earned diplomates and put them into practice.

Why Earn a Diplomate?
The reasons given are as varied as the specialties in which they can be earned. The personal satisfaction and feeling of accomplishment of being able to merit a board certification in a specialty are priceless, according to Jeffrey Ware, DC, DABCI, ACA’s president of the Council on Diagnosis and Internal Disorders (CDID) and a faculty member and clinic director at Logan College of Chiropractic.

Gary Longmuir, DC, immediate past president of ACA’s Council on Diagnostic Imaging and owner of Diagnostic X-Ray Consultation Services,® says DCs should earn a diplomate “because it’s the yardstick by which competency is measured.” He explains that chiropractic needs to catch up with the rest of the professional communities as to their inference of credential. He asks, “As insurance dollars are doled out, what are you credentialed to do?”

“To be honest, the reason I pursued my first diplomate in orthopedics is because when I got out of school I realized I didn’t know as much as I needed to know—now that was 30 years ago,” says Kelli Pearson, DC, DABCO, who runs Pearson & Weary Pain Relief Center in Spokane Valley, Wash., and is ACA governor of District 1 and board liaison to the Council on Physiological Therapeutics and Rehabilitation. “Today the DCs that come out of school know much more—I just felt insufficient.”

Dr. Pearson believes pursuing a diplomate would stimulate an older practitioner. She says the opportunity to learn from diplomate courses is even more important for someone who has been out of school awhile.

Dr. Pearson adds there is another reason she furthered her education in orthopedics. ”I did learn a lot in school, and I got straight As, but there is something about learning material concomitant to treating a patient that makes the material more useful,” she explains. Dr. Pearson earned her diplomate in orthopedics in 1987 and more recently completed classes to be board eligible for one in occupational health, but has not taken the certification test yet.

From a practical standpoint, many DCs want to pursue sports, Dr. Pearson observes, pointing out that she is the DC for the Spokane Shock, a men’s arena football team, but she notes that with sports you do a lot of volunteer work. “Occupational health is such a huge opportunity for DCs to go in-house and provide care on-site for large industries,” she explains.

“The diplomate coursework enabled me to say, ‘Oh, that is how you do that,’ and these people have done it, so I didn’t have to reinvent the wheel,” she says. Dr. Pearson adds that pursuing a diplomate “gets you connected to the source. You know who is who and what is what, and I strongly recommend pursuing one. It makes work fun too.”

Dale Huntington, DC, DABCO, secretary of ACA’s Council on Orthopedics, owns Huntington Clinic of Chiropractic in the Arkansas town of Springdale, with three Fortune 500 companies based within a 30-mile radius, including Wal-Mart. “As I look back, the diplomate has improved my clinical skills and it has improved my presence in the community in which I practice,” he says.

The Coursework
The diplomate is a board-certified credential earned by a DC, typically with post-graduate study encompassing 300 to 400 hours of coursework, earned one weekend a month over three years; although, for example, radiology is unique and requires a full-time commitment of three to four years. These classes usually are administered through the post-graduate department of an accredited chiropractic college or by a college holding status with an accrediting agency recognized by the U.S. Department of Education or with similar reciprocity. The pediatric certification program, for instance, is a 30-module, 360-plus classroom-hour course, administered through various chiropractic institutions in the United States, Canada and New Zealand.

Dr. Ware cautions that while most diplomates are gained with a 300-some hour course of lectures and hands-on workshops, each council offers diplomates differently. CDID requires its own certification program be taken to earn the diplomate in Diagnosis and Internal Disorders (DABCI); some councils (like acupuncture) do not have a set curriculum, but you must have taken 300 hours in a certain level of courses prior to sitting for the test (see May 2012 ACA News, p. 12).

To obtain a DABCI, the cities where the courses will be offered change but remain in place for the three years required for program completion. The DABCI program, for example, consists of nine modules covered over many weekends. Dr. Ware notes that generally each weekend seminar is stand-alone and you can take just one class. ”You can actually take the whole diplomate program and never take the diplomate test; that happens often because it can be costly and time-consuming to study for a very difficult test,” he says.

There is hope for bringing overall program costs down, at least in some areas of study. Dr. Pearson, who five years ago became interested in occupational health, attended Dr. Joe Sweere’s three-year course at Northwestern Health Sciences University (NWHSU). The course is now available on DVD, so instead of Dr. Pearson having to fly once a month to Minnesota and spend some $3,000 including airfare, the cost of the course and food and lodging, candidates who live far away can take the course for $179 in the comfort of their homes.

She explains that the DVD was made by NWHSU, so the college is giving the continuing education credits. The courses were videoed: Students watch the DVD and sit for examinations at the end of each course module; candidates then prepare for the diplomate exam at the end of the three years.

“Occupational health is not a hands-on technique. It’s mostly didactic, so you don’t need to touch people to learn that work,” Dr. Pearson explains. “I would think that is also true for nutrition— but not for acupuncture, not sports, not rehab, not pediatrics. There are specialties where you can learn without being in a specific building, because you don’t have to work with patients.”

Dr. Huntington, who holds a DABCO, or Diplomate of the American Board of Chiropractic Orthopedics, notes that any of the chiropractic colleges can offer diplomate programs. The program offerings are in the hands of the colleges, he explains, and the Council on Orthopedics is the keeper of the core curriculum of that program. “That is what we are here to do, is to make sure the program information stays current from year to year,” he says. He explains that the council reviews the content after every exam; if a question is missed by more than 50 percent of the candidates, the committee will re-evaluate it. Also, the council is a contributor to that question pool.

Earning a diplomate in chiropractic diagnostic imaging, called the DACBR, or Diplomate of the American Chiropractic Board of Radiology, however, requires a full-time commitment. Dr. Longmuir explains that the DC starts by doing a residency program that is three or four years in length, depending on the institution, and it is a full-time endeavor. “You can’t practice or see patients while you are doing it,” he says.” You are there in the unit, and you live, breathe, eat and sleep radiology.” He adds that to earn the DACBR, you will be working in the radiology patient department of the chiropractic college for about 2,500 hours.

Boards and Certifying Agencies
ACA’s 11 councils have programs that usually are administered by a board. Dr. Ware points out the difference between the CDID council and board. CDID’s education board is called the American Board of Chiropractic Internists (ABCI). “We as the council have total control over the course material, including providing the lectures,” he says. “The board has total control over administering the national certification test. The council and the board stand completely autonomous, even though we are kind of part of the same group. We don’t want any look of impropriety and so have two autonomous entities.” But Dr. Ware notes that the two do communicate, as CDID has to give the board materials so it knows what it can test, but CDID has no influence whatsoever upon the board.

Two boards, neurology and nutrition, have gone further to raise their profiles by becoming accredited by the National Commission for Certifying Agencies (NCCA), which is a branch of the National Organization for Competency Assurance (NOCA). NOCA strives to ensure the competency of specialists by setting quality standards for their credentialing agencies.

The Test
Earning a diplomate is a big undertaking. Dr. Pearson stresses that the testing bodies within ACA’s councils exist to give credence to DCs’ work. “You need to have a certifying body that is committed to rigorously testing your knowledge, so that when you get that degree behind your name it means something,” she says. “It wasn’t something you can buy; you had to earn it.”

Dr. Longmuir explains that earning the DACBR requires taking a two-part test (see Figure 2). The total radiology exam usually takes four or five days. But when he took the exam, it wasn’t offered in two parts, and it comprised ten exams over four days. “It was exhausting, and every one of us by the time we were done was sick and throwing up,” he says.

Because there is so much material covered in the diplomate exam, Dr. Huntington attended a review class at Texas Chiropractic College. Dr. Pearson, who has yet to sit for her occupational health test, says the diplomate test is difficult because you have to know aspects of the subject you might not use. She recommends taking three months to study.

The Diplomate in Practice
According to Dr. Ware, the diplomate is a clinical certification that enables you to practice a specialty to provide the best patient management possible. “The DABCI allowed me to put together all of the ‘ologies’ from chiropractic school,” explains Dr. Ware. He says he suffered a disconnect among cardiology, dermatology and endocrinology and how to apply that to chiropractic practice.

Avoiding professional burnout is another reason to earn a diplomate, according to Dr. Pearson. “If you know more, you are never frustrated,” she says. “It is like being in practice: If you are not growing, you are dying,” she cautions. “Because you are not adding to your clinical tool box and your enthusiasm for seeing patients is going to dwindle.”

The diplomate gives the practitioner a place to turn for help. According to Dr. Ware, a council serves as a support group for the DC to ask questions and to meet with like-minded members. “For example, let’s say a DC is doing a technique that a state board has a slight problem with. The DC can contact the specialty council with which the DC holds the diplomate for help with the information to educate the state board as to why it is within their state scope of practice,” he explains. “We have that come up every once in awhile.”

Scope of Practice
It is important to note that certification via the diplomate represents professional recognition. It does not authorize or license an individual to practice, which is a state regulatory function.

“In Arizona, our board of examiners recognizes only the subspecialties that they examine on like acupuncture and physical therapy; they don’t consider me a specialist despite my three-year residency, my examination and all my post-doctoral fellowships,” explains Dr. Longmuir. He is held to the same standard as someone who is in patient practice, although he doesn’t see any patients in his radiology consulting practice.

The diplomate does not change a state scope of practice, agrees Dr. Ware, but it does allow the DC to practice that specialty to its fullest within the state scope of practice. “If you want to practice nutrition and the state scope says you can, then you want to be able to practice it as broadly as possible to help as many of your patients as you can, and the diplomate enables you to do that,” he says.

Beyond the Profession
Having a diplomate makes you stand out for other reasons. An important motivation to earn one is that patients respect board certifications. “The patients go to a board-certified cardiologist; they identify with that nowadays, so if you are board-certified in acupuncture or in internal disorders, I think that does make a difference with patients,” Dr. Ware explains.

Dr. Longmuir agrees and says it is important for chiropractic specialists to be credentialed. “Credentialing is the only way to build credibility and access the true competency of our examining board (ACBR) and trade union (American Chiropractic College of Radiology (ACCR)), and the best way to bring us into line with the other professional healing arts,” he says.

Another reason concerns integration. Dr. Longmuir points out that many chiropractic radiologist diplomates work in hospitals or full time with medical radiologists as part of their groups. “I did my rotation when I was in residency at the Truman Medical Center in Kansas City; I read for three MRI centers, and I read and interpret cases for DCs, DOs and MDs,” he says.

It is also a survival strategy. Because there are reduced insurance reimbursements to all professions for just about everything they do, Dr. Longmuir explains it has forced DCs to explore new directions. “I think collaborating in multi-specialty offices or promoting inter-professional referral understanding is a way to enhance that,” he says.


ACA News Extra...

Chiropractic Specialty Programs Approved by ACA

  1. Diagnosis and Management of Internal Disorders
  2. Occupational Health and Applied Ergonomics
  3. Rehabilitation
  4. Diagnostic Imaging
  5. Acupuncture
  6. Nutrition
  7. Orthopedics
  8. Forensic Sciences
  9. Clinical Neurology
  10. Sports
  11. Pediatrics

For the complete list, go to www.acatoday.org/UserFiles/ SpecialtyPrograms.pdf.

Inside Radiology Diplomate Testing
The test for certification as a DACBR, Diplomate of the American Chiropractic Board of Radiology, as explained by Dr. Gary Longmuir, immediate past president, Council on Diagnostic Imaging, is tough, but the full-time, three- to four-year residency requires recognition. In his words:

The board exam consists of two parts. There is a Part 1 and Part 2, and you have to pass Part 1 before taking Part 2. Each one is offered once a year: Part 1 in the spring, Part 2 in the fall.

Part 1 consists of a series of five written exams: (1) Bone and joint imaging—41/2 hours; (2) Thorax imaging—1 1/2 hours; (3) Neuro imaging—2 hours; (4) Abdominal imaging—one hour; and (5) Radiation health, safety and physics—one hour.

Part 2 consists of more practical-oriented tests. There is an oral interview, and you must bring four complete imaging studies of your own with reports. From those cases—and they can’t all be spine cases—of three musculoskeletal cases, two must be conventional radiographs, and one a chest/abdomen or a neuro-radiology case. One case can be submitted in a digital self-extracting DICOM format. So we keep candidates on top of digital imaging as well. Self-extracting DICOM format, as opposed to just DICOM images, means that a disk can be dropped into a computer right in an examining room and the case is accessed by the examiners.

The oral exam is conducted in front of the full membership of the ACBR Board of Radiology. The board chooses two of the four imaging cases brought by the candidate, who gives an extemporaneous presentation. It goes further; the board also has the candidate comment on contraindications, such as how the patient will be cared for and what follow-up imaging is required. Then the candidate chooses two cases brought by the examiners, and reads films he or she has never seen before. The examiners can ask anything on any kind of case.

The second exam within this Part 2 series is narrative report writing. Each candidate has 30 minutes to complete two reports in longhand. Perhaps the candidate is given an E-series, and that may consist of plain films along with CT or MRI and maybe a previous film for comparison and must describe what he or she finds and give impressions and a differential diagnosis. Then the candidate might even give a recommendation for an extraprofessional referral.

There is still another exam on film interpretation. It consists of five stations of 30 minutes duration with six diagnostic cases at each station. There are usually 15 musculoskeletal—bone and joint, six neuro cases, five chest and thorax and four abdomens; the candidate must come up with a diagnosis or a differential. That concludes an exam.

But it is worth it in the end. I don’t see patients and only review plain CTs and MRIs in my practice. I catch an average of one missed tumor and two missed fractures a week.

Diplomate vs. Master’s
According to Dr. Huntington, there is soon to be offered a master’s degree program in clinical chiropractic orthopedics that has been in the making for six to seven years and is going through the accreditation process. It will be taught in chiropractic colleges to further the development of orthopedic specialists and also to train them as instructors.

Dr. Huntington explains that a master’s degree rises to a higher level of education and is more research oriented. “Some of these really bright people that might not have a great interest in clinical practice can be involved with research instead,” he says. “A diplomate makes more sense for me in my clinical practice,” Dr. Huntington adds. Also, a master’s allows options for scholarships.

“It is important for the profession too, according to Dr. Huntington. “Look at the MDs, the DOs, the PTs, even nursing, and they all have master’s programs in place. In the chiropractic profession, if we were doing it for no other reason than to try and keep up with them, it looks better in the health care field if you have more master’s programs that are directly connected to your profession,” he says.

Published in the August 2012 ACA News.