Chiropractors obtain a first professional degree in the field of chiropractic.[77] Chiropractors often argue that this education is as good as or better than medical physicians', but most chiropractic training is confined to classrooms with much time spent learning theory, adjustment, and marketing.[61] The curriculum content of North American chiropractic and medical colleges with regard to basic and clinical sciences has been more similar than not, both in the kinds of subjects offered and in the time assigned to each subject.[78] Accredited chiropractic programs in the U.S. require that applicants have 90 semester hours of undergraduate education with a grade point average of at least 3.0 on a 4.0 scale; many programs require at least three years of undergraduate education, and more are requiring a bachelor's degree.[79] Canada requires a minimum three years of undergraduate education for applicants, and at least 4200 instructional hours (or the equivalent) of full‐time chiropractic education for matriculation through an accredited chiropractic program.[80] Graduates of the Canadian Memorial Chiropractic College (CMCC) are formally recognized to have at least 7–8 years of university level education.[81][82] The World Health Organization (WHO) guidelines suggest three major full-time educational paths culminating in either a DC, DCM, BSc, or MSc degree. Besides the full-time paths, they also suggest a conversion program for people with other health care education and limited training programs for regions where no legislation governs chiropractic.[34]
Upon graduation, there may be a requirement to pass national, state, or provincial board examinations before being licensed to practice in a particular jurisdiction.[83][84] Depending on the location, continuing education may be required to renew these licenses.[85][86] Specialty training is available through part-time postgraduate education programs such as chiropractic orthopedics and sports chiropractic, and through full-time residency programs such as radiology or orthopedics.[87]
Chiropractic is established in the U.S., Canada, and Australia, and is present to a lesser extent in many other countries.[10] In the U.S., chiropractic schools are accredited through the Council on Chiropractic Education (CCE) while the General Chiropractic Council (GCC) is the statutory governmental body responsible for the regulation of chiropractic in the UK.[88][89] The U.S. CCE requires a mixing curriculum, which means a straight-educated chiropractor may not be eligible for licensing in states requiring CCE accreditation.[61] CCEs in the U.S., Canada, Australia and Europe have joined to form CCE-International (CCE-I) as a model of accreditation standards with the goal of having credentials portable internationally.[90] Today, there are 18 accredited Doctor of Chiropractic programs in the U.S.,[91] 2 in Canada,[92] 6 in Australasia,[93] and 5 in Europe.[94] All but one of the chiropractic colleges in the U.S. are privately funded, but in several other countries they are in government-sponsored universities and colleges.[15] Of the two chiropractic colleges in Canada, one is publicly funded (UQTR) and one is privately funded (CMCC). In 2005, CMCC was granted the privilege of offering a professional health care degree under the Post-secondary Education Choice and Excellence Act, which sets the program within the hierarchy of education in Canada as comparable to that of other primary contact health care professions such as medicine, dentistry and optometry.[81][82] Chiropractic curricula in the U.S. have been criticized for failing to meet generally accepted standards of evidence-based medicine.[95]
Regulatory colleges and chiropractic boards in the U.S., Canada, Mexico, and Australia are responsible for protecting the public, standards of practice, disciplinary issues, quality assurance and maintenance of competency.[96][97] There are an estimated 49,000 chiropractors in the U.S. (2008),[98] 6,500 in Canada (2010),[99] 2,500 in Australia (2000),[19] and 1,500 in the UK (2000).[100]
A 2008 commentary proposed that the chiropractic profession actively regulate itself to combat abuse, fraud, and quackery, which are more prevalent in chiropractic than in other health care professions, violating the social contract between patients and physicians.[40] A study of California disciplinary statistics during 1997–2000 reported 4.5 disciplinary actions per 1000 chiropractors per year, compared to 2.27 for MDs; the incident rate for fraud was 9 times greater among chiropractors (1.99 per 1000 chiropractors per year) than among MDs (0.20).[101]
Utilization, satisfaction rates, and third party coverage
In the U.S., chiropractic is the largest alternative medical profession,[8] and is the third largest doctored profession, behind medicine and dentistry.[11] In the U.S., chiropractors perform over 90% of all manipulative treatments.[102] The percentage of the population that utilizes chiropractic care at any given time generally falls into a range from 6% to 12% in the U.S. and Canada,[13] with a global high of 20% in Alberta.[103] Chiropractors are the most common CAM providers for children and adolescents, who consume up to 14% of all visits to chiropractors.[104] The vast majority who seek chiropractic care do so for relief from back and neck pain and other neuromusculoskeletal complaints;[105] most do so specifically for low back pain. Practitioners such as chiropractors are often used as a complementary form of care to primary medical intervention.[13] Satisfaction rates are typically higher for chiropractic care compared to medical care, with a 1998 U.S. survey reporting 83% of respondents satisfied or very satisfied with their care; quality of communication seems to be a consistent predictor of patient satisfaction with chiropractors.[106] A 2011 consumer report survey found that the public considered chiropractic to outperform all other available back and neck pain treatments.[107]
Chiropractic does not have the same level of mainstream credibility as other healthcare professions. Public perception of chiropractic compares unfavorably with mainstream medicine with regard to ethics and honesty: in a 2006 Gallup Poll of U.S. adults, chiropractors rated last among seven health care professions for being very high or high in honesty and ethical standards, with 36% of poll respondents rating chiropractors very high or high; the corresponding ratings for the other professions ranged from 62% for dentists to 84% for nurses.[40][108][109] The 2008 book Trick or Treatment states chiropractors, especially in America, have a reputation for unnecessarily treating patients, and in many circumstances the focus seems to be put on economics instead of health care.[51] Many chiropractors have sought to address their minor status within the U.S. medical community by attending practice-building seminars to assist chiropractors to persuade their patients of the efficacy of their treatments, increase their revenue, and boost their morale as unorthodox medical practitioners.[110] Unsubstantiated claims about the efficacy of chiropractic have continued to be made by individual chiropractors and chiropractic associations.[17] The largest chiropractic associations in the U.S. and Canada distributed patient brochures which contained unsubstantiated claims.[111] Sustained chiropractic care is promoted as a preventative tool, but unnecessary manipulation could present a risk to patients. Some chiropractors are concerned by the routine unjustified claims chiropractors have made.[17] A 2010 questionnaire presented to UK chiropractors indicated only 45% of chiropractors disclosed with patients the serious risk associated with manipulation of the cervical spine as a direct consequence of the fear that the patient would refuse treatment despite knowing the moral responsibility.[112]
Utilization of chiropractic care is sensitive to the costs incurred by the co-payment by the patient.[1] The use of chiropractic declined from 9.9% of U.S. adults in 1997 to 7.4% in 2002; this was the largest relative decrease among CAM professions, which overall had a stable use rate.[113] As of 2007 only 7% of the U.S. population is being reached by chiropractic.[114] Employment of U.S. chiropractors is expected to increase 14% between 2006 and 2016, faster than the average for all occupations.[98]
In the U.S., most states require insurers to cover chiropractic care, and most HMOs cover these services.[104] In Canada, there is lack of coverage under the universal public health insurance system.[115] In Australia, most private health insurance funds cover chiropractic care, and the federal government funds chiropractic care when the patient is referred by a medical practitioner
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