There has been much discussion about the new CCE standards.  Will they improve chiropractic education?  Will they allow the further dilution of chiropractic education?  Has the chiropractic adjustment now become optional?  Is there a real cause for concern ... or is it just  "Much Ado About Nothing"?  This column focuses on CCE claims at the NACIQI hearing ( referring to the NACIQI transcripts ) , what is actually in the 2012 Standards document ( and what is not ) and what is in Policy #3 ( referred to by the Standards ). 

During the testimony before the NACIQI the CCE representative, Dr. Wickes, made the following assertion in describing the new standards and related policies:  "the student is required to be able to demonstrate competency in actually adjusting the spinal area for which they found the spinal subluxation."

He also stated, that  " ... the standards require that the students learn how to evaluate, understand the concepts of subluxation, how to assess for the presence of subluxation, and how to perform the vertebral adjustment to correct subluxation. That's a part of our accreditation requirement. You cannot get accredited unless you show that your students are competent in those areas."

Dr. Wickes also explained in his testimony that:

"In terms of subluxation, there  was no real change. The 2007 standards had a section  on competency evaluation for assessment of spinal function, spinal subluxation, and the 2012 section has  it as well."

The accuracy of the above statements are in the eye of the beholder. Although it is correct to state that there is a reference to the assessment of the subluxation in Policy #3, it is actually also correct to state that the reference to subluxation is not part of the standards.  Policy #3 is not actually part of the standards, but rather exists in a separate and distinct policy document.  The 2007 Standards devoted 25 pages to section J, the "Clinical Requirements".  The  2012 reduced the clinical requirements to less than one page of Meta-Competencies and moved detailed statements of mandatory and optional requirements out of the standards document and placed them into a CCE Policy Statement ( Policy #3).  One might ask what clinical Meta-Compentencies are actually required by the standards themselves?  Let's take a look at what the standards actually require at the global level:

Mandatory meta-competencies have been identified regarding the skills, attitudes, and knowledge that a DCP provides so that graduates will be prepared to serve as primary care chiropractic physicians.* These competencies require a DCP graduate to demonstrate that she/he can:  

* perform an initial assessment and diagnosis;

* create and execute an appropriate case management/treatment/intervention plan;

* promote health, wellness, safety and disease prevention;

* communicate effectively with patients, doctors of chiropractic and other health care professionals, regulatory agencies, third party payers, and others as appropriate;

* produce and maintain accurate patient records and documentation;

* be proficient in neuromusculoskeletal evaluation, treatment and management;

* access and use health related information;

* demonstrate critical thinking and decision making skills, and sound clinical reasoning and judgment;

* understand and practice the ethical conduct and legal responsibilities of a health care provider;

* critically appraise and apply scientific literature and other information resources to provide effective patient care; and

* understand the basic, clinical, and social sciences and seek new knowledge in a manner that promotes intellectual and professional development.

The mandatory meta-competencies and their required components and outcomes, plus recommended sources and types of evidence used to demonstrate student achievement of the meta-competencies and evidentiary guidelines for assessment, are cited in CCE

Policy 3.      

* ED: Please note that the definition of a Primary Care Chiropractic Physician that existed in the 2007 Standards was removed and does not exist in the 2012 Standards.

 As you can see, the broad requirements as outlined in the standards do not reference either the subluxation or the chiropractic adjustment.  By removing all language that uniquely identifies chiropractic as it is defined in most state laws, the new standards would be satisfied if a student demonstrated the ability to perform a diagnosis, execute an appropriate treatment plan, and be proficient in neuromuscular evaluation, treatment and management.  Since there are a number of different "treatments" for "neuromuscular conditions", many of which are pharmaceutical based, it appears that these "meta-competencies" could be satisfied without ever demonstrating proficiency in delivering a proper chiropractic adjustment.

The next underlying question is:   Do the detailed requirements in Policy #3 actually REQUIRE demonstration of proficiency in performing a chiropractic adjustment to correct a subluxation?   

Many would argue that they DON'T.  Here is why:

The requirement in META-COMPETENCY 2 - MANAGEMENT PLAN is clearly stated as:

E. Determining the need for chiropractic adjustment and/or manipulation procedures, or other forms of passive care.

The adjustment for the correction of a subluxation, a non-therapeutic, chiropractic specific procedure has just become optional in the new standards.  The required outcomes reinforce the optional nature of the adjustment by stating that:

4)Deliverance and documentation of appropriate chiropractic adjustments/manipulations, and/or other forms of passive care as identified in the management plan.

Yet, CCE proclaims that there have been no changes!   And to add insult to injury, the new meta-competencies now require that the student demonstrate the following outcome:   

Formulation and documentation of an evidence-informed management plan appropriate to the diagnosis, inclusive of measureable therapeutic goals and prognoses in consideration of bio-psychosocial factors, natural history and alternatives to care.

It should be noted that the requirement does not say inclusive of measureable clinical goals, but rather uses the specific term "therapeutic" goals.  It appears that the non-therpeutic adjustment to correct a subluxation is now optional, and the provision of other "therapeutic" services are now mandatory.  Once again, I guess it all depends on what the meaning of "and/or" is!

Yet the CCE proclaims that there have been no changes in this aspect of the standards.  They also claim that they do not support any particular approach to chiropractic. They also claim that proficiency in delivering a chiropractic adjustment to correct a subluxation is an absolute requirement for accreditation.  The obvious question becomes:  If it was the intent of the CCE to require " ... that the students learn how to evaluate, understand the concepts of subluxation,how to assess for the presence of subluxation, and how to perform the vertebral adjustment to correct subluxation.",  then why wasn't it clearly included in the Standards as a key component of the global statements of required Meta-Competencies, or at least clearly stated as a requirement in the details defined in Policy #3?  A close examination of both the Standards themselves and the related Policy #3 fail to uncover any reference to the requirement as outlined in the testimony to the NACIQI committee.

Here are the links to the 2007 Standards, the 2012 Standards, and the 2012 Policies.  Here is a link to the NACIQI transcripts.  Please do the homework.  Read them yourself.  You be the judge ...  just don't take my word for it!  "The devil is in the details"

Another controversial issue is the removal of the phrase "without drugs and surgery" from the standards.  Once again, CCE stated to the NACIQI committee that:

"Now, one of the questions came up on relating to the phrase "without the use of drugs and surgery."  And that obviously was an area of considerable discussion. However, I think it's important to note that that phrase only appeared only in a prefatory part of the previous standards. It was not actually in the requirements for accreditation itself."

Dr. Wickes also testified that:

"In terms of the drugs and surgery part, much of the thinking on that had to do with not wanting an institution to feel that it could not teach those things ...  we don't want to put that institution in the position where it is in violation of the standards,... we don't want them to  feel as if they're violating the standards.   And the other part of the discussion had to do with this particular phrase that was in there was not one upon which we were routinely doing a site team evaluation and making an accreditation decision on. So it wasn't serving an evaluative purpose for the agency."

One has to ask the next obvious question:  If the reference was not actually in the requirements itself, and it was not an issue in site team evaluations then why was it removed ?  ...  if not for "political" purposes?  Would it had not been more acceptable to just leave the phrase in the standards because they were in a section that was not part of "... the requirements for accreditation" ?  Why does an organization that continues to define Chiropractic as the application of science that "... focuses on the inherent ability of the body to heal without the use of drugs or surgery" and then insist on removing that same terminology from the educational standards, particularly after admitting that the phrase was in the prefatory part and " ... not actually in the requirements for accreditation itself." Could it be that there was more concern for how the liberal schools would feel than how the conservative schools would feel? 

E-mail me at icainaction@mindspring.com with your comments, concerns and/or questions.