Doctors of chiropractic must learn how to use new technologies and ensure the most accurate diagnosis to realize the most favorable outcomes our patients expect and deserve.
The sophistication of X-ray use and the advent of MRI and CAT scan technologies have added to so many of today’s successful practices and to the direct benefit of the patients we care for.
The evidence in the literature offers so much for a practitioner to learn that directly affects patient care. There is also emerging technology to diagnose biomechanical pathology more accurately, which is the core of what we treat. When considering an accurate clinical evaluation, motion palpation is a clinically sound starting point; however, static and motion palpation have poor intra- and inter-rater reliability outcomes.1-4 Once concluded in a thorough clinical evaluation, imaging should be considered to validate a dysfunctional vertebral motion segment. X-ray is a reliable tool to diagnose dysfunctional segments conclusively.5-9
Back in the 1970s, when I started taking continuing education (CE) courses, the choices were technique, based on the instructor’s experience or philosophy. In the late 1980s and early 1990s, nutrition, kinesiology taping and rehabilitation crept into CE and were a good alternative, as much was evidence-based but not centered on the most common denominator in chiropractic: adjusting. From an instructor’s perspective, it took more time to create those courses based on having to present the evidence, and fewer were teaching as a result.
Today, there is so much evidence and more to learn to be better doctors and diagnosticians based on the science and chiropractic’s access to the entire healthcare system. That access has led us to be primary spine care providers (PSC) or the first referral for spine if we choose. As a result of being a PSC provider, there are an 1,856,918 patients (according to the Academy of Chiropractic and validated by U.S. Digital Sciences) who have been referred to DCs nationally over the last decade, validating how being a better diagnostician adds managing cases and increased utilization.
In today’s marketplace, bringing a course for CE that is not based on a doctor’s experience or belief takes time, resources, a lot of research and often collaboration with he medical community. Being a CE provider for more than two decades has given me a front-row seat in the process. Similar to medicine, to educating doctors on being more accurate diagnostician requires those who are best at teaching. Those typically are in academia. When considering teaching stroke analysis and early diagnosis, we have no one in our profession with the knowledge or experience of a double-boarded vascular neurologist from a medical teaching institution. When teaching MRI spine interpretation, our DACBRs are incredibly smart, but do not have the same in-depth knowledge or experience as a neuroradiologist from Harvard who worked with Dr. Paul Lauterbur. (The Nobel Laureate who invented MRI and has been published more than 200 times, interpreted 1,000,000s of spinal MRIs and taught clinical rotations, residency programs, mini-fellowship and fellowship programs in medical and chiropractic academia.)
This is a small sampling of the type of expertise our doctors and patients deserve from those teaching contemporary chiropractic CE. This does not make us medical doctors (nor do I want to be one), but it gives us the same education being taught to MDs and is in the public best interest, especially if you strive to be a PSC provider, which every DC should because it will save lives by diagnosing co-morbidities early and helping people get better more quickly.
Years ago, bringing a CE course to the marketplace required an idea, some images or PowerPoint slides and a live platform. Today, this level of expertise competes with hospital on-call schedules, teaching responsibilities, direct patient care, and limited time off. As a result, it has become an expensive process of teaching fees, recording technology fees, and a huge amount of time researching and documenting the evidence so these providers will work with us. In the past, it took a few days to bring a course to market; now, on average, it takes six months to a year of work and coordination.
Once the course is ready for the marketplace in continuing medical education (CME), you must meet the requirements of the Accreditation Council for Continuing Medical Education (ACCME), a national umbrella for all 50 states with approximately 1,600 members, including medical schools, state and national organizations and specialty boards. Once a course is approved by any of the 1,600 entities, CME credits are accepted nationally. There is also joint accreditation for interprofessional CE to allow “world-class education” to providers other than MDs and DOs. The CME provider pays one fee under one set of rules, and the credits are accepted nationally and territorially.
Not in chiropractic
We are akin to the “Wild West” for chiropractic CE approvals. A chiropractic provider of CE must apply in multiple places to get courses approved. Thankfully, the Federation of Chiropractic Licensing Boards (FCLB) covers 32 states with one set of rules and one consistent, fair fee. However, the other 18 states (mostly the larger populated states for DCs) do not and require separate applications with separate rules and separate fees. For most providers, it has become a cost-prohibitive process to accredit all or some courses in every state, to the detriment of the doctors and the patients. An example is California, which just changed its rules and charges exorbitant fees for accreditation. In this apparent “money grab,” many chiropractic colleges will no longer do CE business in California, and neither will many CE providers, leaving the most populated state for DCs void of life-saving education by limiting the scope of courses available in the 49 other states. This also forces doctors to often sit through less-than-desired coursework because their license requires it, which is all they have.
Louisiana still does not allow online courses. How will that Harvard-trained neuroradiologist or double-boarded vascular neurologist show up in Louisiana to teach with on-call schedules, etc.? Florida and North Carolina use CE Broker, an intermediary with an entirely different set of rules and fees, and Oklahoma, a state which charges $300 per course for accreditation, even if one credit. Accrediting numerous courses under the constructs created by many states has become prohibitive, as you must factor in the labor of completing lengthy applications in many states for filing course approvals. Other states charge $15-$25 per course, but again, you must factor in the lengthy application process with different rules for each state.
It is time to change the system, work under one umbrella and learn from others, such as ACCME; one of the best systems in the world for providing healthcare graduate-level (postdoctoral) education or the FCLB, which already has an infrastructure in place. It is time every state organization and every patient demands from their legislators the best education possible for DCs to protect the public and work under one system. They also must consider the CE providers because, without them, too many critical courses will be not be available.
Final thoughts
It is hard to be the best of the best through clinical excellence when the system is stacked against you. In the end, the patients pay the price.
MARK STUDIN, DC, FPSC, FASBE(C), DAAPM, is an adjunct assistant professor at the University of Bridgeport, School of Chiropractic and an adjunct postdoctoral professor at Cleveland University-Kansas City, College of Chiropractic. He is a clinical instructor at The State University of New York at Buffalo, Jacobs School of Medicine and Biomedical Sciences, Office of Continuing Medical Education. He also earned his Fellowship in Primary Spine Care certified in joint providership from The State University of New York at Buffalo, Jacobs School of Medicine and Biomedical Sciences, Office of Continuing Medical Education, and Cleveland University Kansas City, College of Chiropractic. He also runs the Academy of Chiropractic’s Personal Injury Program. He can be reached at 631-786-4253 or DrMark@AcademyOfChiropractic.com.
References
- Jonsson A and Rasmussen-Barr E. Intra-and inter-rater reliability of movement and palpation tests in patients with neck pain: A systematic review. Physiotherapy theory and practice. 2018;34(3):165-180. PubMed. https://pubmed.ncbi.nlm.nih.gov/29111857. Accessed Jan. 28, 2024.
- Kawchuk GN, et al. Clinicians’ ability to detect a palpable difference in spinal stiffness compared with a mechanical device. Journal of Manipulative and Physiological Therapeutics. 2019;42(2):89-95. PubMed. https://pubmed.ncbi.nlm.nih.gov/31000343. Accessed Jan. 28, 2024.
- Nolet PS, et al. Reliability and validity of manual palpation for the assessment of patients with low back pain: a systematic and critical review. Chiropractic and manual therapies. 2021;29(1):33. PubMed. https://pubmed.ncbi.nlm.nih.gov/34446040. Accessed Jan. 28, 2024.
- Cooperstein R, et al. Interexaminer reliability of cervical motion palpation using continuous measures and rater confidence levels. The Journal of the Canadian Chiropractic Association. 2013;57(2):156. PubMed. https://pubmed.ncbi.nlm.nih.gov/23754861. Accessed Jan. 28, 2024.
- Fedorak C, et al. Reliability of the visual assessment of cervical and lumbar lordosis: How good are we? Spine, 2003;28(16):1857-1859. PubMed. https://pubmed.ncbi.nlm.nih.gov/12923476. Accessed Jan. 28, 2024.
- Marques C, et al. Accuracy and reliability of X-ray measurements in the cervical spine. Asian Spine Journal. 2020;14(2):169-176. PubMed. https://pubmed.ncbi.nlm.nih.gov/31668048. Accessed Jan. 28, 2024.
- Jang JS, et al. Reliability Analysis of Vertebral Landmark Labelling on Lumbar Spine X-ray Images. Diagnostics. 2023;13(8):1411. PubMed. https://pubmed.ncbi.nlm.nih.gov/37189512. Accessed Jan. 28, 2024.
- Yeager MS, et al. Reliability of computer-assisted lumbar intervertebral measurements using a novel vertebral motion analysis system. Spine journal. 2014;14(2):274-281. PubMed. https://pubmed.ncbi.nlm.nih.gov/24239805. Accessed Jan. 24, 2024.
- Yi YS, et al. Reliability and validity of rasterstereography measurement for spinal alignment in healthy subjects. Physical therapy rehabilitation science. 2016;5(1):22-28. Korean Academy of Physical Therapy Rehabilitation Science. https://www.jptrs.org/journal/view.html?doi=10.14474/ptrs.2016.5.1.22. Accessed Jan. 28, 2024.