According to U.S. and Canadian chiropractic school accrediting authorities, chiropractic students are required to have only 1,000 hours of clinical training before graduating and going into practice. The Canadian Federation of Chiropractic Regulatory and Educational Accrediting Boards requires that chiropractic students develop a diagnosis, formulate a treatment regiment, and manage the case for only 35 different patients under faculty supervision. The U.S. Council on Chiropractic Education doesn’t even specify a minimum number of patients the student must evaluate. It is left to the chiropractic school’s “discretion.”

Because chiropractors do not have internship or residency requirements (although, confusingly, the article discussed in this post refers to undergraduate chiropractic students in clinical training as “interns”), they go straight into practice without further supervised clinical training. Yet, as noted by the authors of a new study in the Journal of Chiropractic Education:

very few recent studies have examined chiropractic students’ clinical education.

And:

there is an absence of current literature that actually quantifies the clinical experiences of chiropractic interns.

So, they set out to:

describe the case mix experienced by chiropractic students during their clinical internship at the Canadian Memorial Chiropractic College.

Amazingly, the authors say that, to their knowledge, this is the first study ever to describe the average caseloads of chiropractic students in clinical training. While their sample of students was small (only 24 to start, reduced to 23), some startling facts were revealed: Only two students had any clinical experience with children or infants. In addition, very few saw grade-school or teenage patients (12 of 23). According to the authors, preclinical chiropractic students do complete “a 22-hour course in pediatric topics.” So, if this study holds true for chiropractors as a whole, the vast majority go into practice without any clinical experience with infants and children, armed with only 22 hours of classroom instruction in “pediatric topics.” This is frightening when, as the authors note, according to a retrospective study, “17% of [chiropractic private practice] patients represent pediatric populations,” although a prospective, practice-based study reported a much lower percentage of pediatric patients (2%-4%).

The figures weren’t much better for senior citizens. Perhaps putting the best face on it, the authors say that all students managed “at least one patient over 65 years old.”

Even though the participating students examined only 36 patients on average (thereby beating the requirements by all of one), the students had to chum up their own patients to practice on. Almost a quarter of the patients were either fellow students or friends or family members of students. This is consistent with another study which found that about a fourth of new patients at a chiropractic teaching clinic were family members of students. This has become such a problem that Canadian standards now specify that no more than 20% of the minimum clinical requirements can be performed on other students or their families and services to one’s immediate family are prohibited.

On the other hand, patient complaints seen by the students were pretty much as one would expect.

  • 93% were for pain-based complaints
  • 65% included a complaint in the cervical, thoracic or lumbar spine or pelvis

What the authors call “yellow flag” complaints (a term they do not further define) were present in only 16% of patients and “red flags” in 7%, leading the authors to conclude that:

some interns are not exposed to many situations beyond noncomplicated musculoskeletal (MSK) pain with regard to these specific measures

such as clinical flags, the necessity of medical referral, and suspicion of underlying pathology.

Normally, one would not think to compare chiropractic clinical training to that of family practice doctors. However, since it is the chiropractors themselves who are pushing the notion that they are “primary care physicians,” (including yet another bill to allow chiropractors to perform sports physicals for student athletes), let’s see how their clinical training compares to that of real primary care physicians. During a 3-year family practice residency, a resident must (among many other requirements), log in at least:

  • 200 hours (or 2 months) and 250 patient encounters in the care of ill children in the hospital or emergency room.
  • 200 hours (or 2 months) and 250 patient encounters in the care of children in an ambulatory setting, including acute and chronic conditions and well care.
  • 40 newborn patient encounters, including well and ill newborns.
  • 100 hours (or 1 month) or 125 patient encounters dedicated to the care of the older patient, including functional assessment, disease prevention and health promotion, and management of patients with multiple chronic diseases.
  • 1,650 in-person patient encounters in a family medical practice setting.

It is small wonder, then, that only 20% of surveyed North American orthopedic surgeons thought that chiropractors have sufficient clinical training. This opinion, these authors note:

may contribute to low rates of MD to DC referrals.

Personally, I imagine it’s a combination of factors, not wanting to subject their patients to rank quackery being one of them.

Policy makers and the public know little about chiropractic education and training, which takes place in small, independent schools not connected to the mainstream American university system. Their educational system, including the examinations that allow one to become licensed, are completely controlled by chiropractors themselves and there has been never been an independent investigation of the adequacy of their education and training. The authors of this small study are not independent of that system – they are themselves chiropractors. However, they are to be congratulated for providing some illuminating statistics highlighting the inadequacy of chiropractic clinical education. This includes the disturbing fact that a chiropractor, who has no legal limitation on the age of the patients he sees and few on the conditions he can claim he treats, can go into practice having seen only uncomplicated MSK conditions in his entire clinical training and not a single pediatric patient.

Posted by Jann Bellamy

Jann J. Bellamy is a Florida attorney and lives in Tallahassee. She is one of the founders and Board members of the Society for Science-Based Medicine (SfSBM) dedicated to providing accurate information about CAM and advocating for state and federal laws that incorporate a science-based standard for all health care practitioners. She tracks state and federal bills that would allow pseudoscience in health care for the SfSBM website.  Her posts are archived here.