Ruth Sandefur, DC, PhD, Theresa A. Febbo, DC, Ronald L. Rupert, MS, DCc
Cleveland Chiropractic College,
Kansas City, MO 64131, USA.
OBJECTIVE: To examine the influence of chiropractic education on knowledge of primary care tasks. Scores received on a test of knowledge of primary care tasks were compared between 3 samples of chiropractic students and 1 small sample of medical students.
DATA SOURCES: The taxonomy of primary care tasks that was previously published provided the basis for test items used in this study. A team of test writers prepared an evaluation instrument that was administered to final-term chiropractic students at 3 colleges and to a small sample of medical students as they were entering their residency programs.
RESULTS: The chiropractic students scored below the medical students on the primary care examination in every area except musculoskeletal conditions. Chiropractic students scored higher than medical students on the musculoskeletal portion of the examination.
CONCLUSIONS: In this sample, chiropractic students performed almost as well as medical students on a test that was designed to measure knowledge of primary care tasks. If the premise is accepted that medical school is the gold standard of primary care instruction, that chiropractic students fared almost as well as medical students is noteworthy.
From the Full-Text Article:
There is a spirited and often passionate debate within the chiropractic profession regarding the ability, or even the appropriateness, of chiropractors to fill the role of primary care providers. From a practical standpoint, being a primary care provider opens doors to systems of reimbursement that otherwise are not approachable. This may help explain the passion often associated with the “to be or not to be” a primary care provider question. There is the view that doctors of chiropractic (DCs) fail to qualify as primary care physicians, especially when applying the Institute of Medicine’s definition of primary care that includes “accessible, comprehensive, coordinated and continuous.” [1-3] Conversely, many chiropractors consider themselves to be primary care providers, [4-6] but this does not provide the necessary documentation that they indeed fill that role.
Perhaps one problem surrounding this issue is the elusiveness of the concept and the fact that primary care is difficult to define in absolute terms. [7, 8] According to Kranz,  the difficulty in establishing a widely accepted definition of primary care has made the accumulation of data that can be used to measure primary care challenging. The establishment of a taxonomy of primary care tasks reported in a previous study  may be a first step in providing tools for this purpose.
9, 10Historically, chiropractors have devoted a good deal of their internal resources to survival.  Antitrust litigation, college accreditation, and practitioner autonomy have mitigated resources and the focus of professional efforts. Major strides were made when the chiropractic college accrediting agency, the Council on Chiropractic Education, was officially recognized in 1974 by the US Office of Education.  This recognition was the culmination of years of work involving chiropractic organizations. Because of the accreditation of chiropractic institutions by the Council on Chiropractic Education, educational rigor and faculty credentials have been elevated. Professional efforts became focused when members of the profession involved in developing a research infrastructure had the foresight to see a need for future preparedness. As a result, a cadre of highly trained scientific researchers has emerged.  On many levels, chiropractors have assumed regulatory responsibility. The Mercy Guidelines document is a notable example. 
Questions have been raised about the role of chiropractic in health care, acknowledging the established benefits of spinal manipulation for low-back and neck pain, but conceding few other areas of potential health benefits.  Appeals have been made that chiropractors are qualified to offer certain aspects of primary care. [15-17] Proponents of chiropractors serving as primary care providers usually offer caveats, such as
(1) improve the education of chiropractic students to better prepare them for primary care practice;
(2) serve as a member of a primary care team in a multidisciplinary setting; and
(3) offer primary care in the context of prevention and wellness care. [15-19]
On the issue of state laws and their impact upon the practice of chiropractic, there are no data on the effect of scope of practice restrictions and the ability of chiropractors to deliver primary care services. 
With regard to practicing chiropractors, a discrepancy exists between how most chiropractors see themselves and how they actually practice. As pointed out in a survey of the practitioners listed in the National Directory of Chiropractic 1993-1994 edition,  90.4% answered “yes” to the question, “Do you consider yourself a primary care practitioner?” Evidence to support this contention is sparse. In a survey of North American chiropractors with 687 respondents conducted by McDonald et al,  data were collected on various aspects of chiropractic practice. Although the specific question addressing attitudes about primary care was not asked in this survey, it is not unreasonable to make inferences based on survey responses. The question “Should the adjustment be limited to musculoskeletal conditions?” was answered “no” by (89.8%) of those surveyed. Respondents clearly do not want to be limited to treating only musculoskeletal conditions. Another related finding of this survey is that 93.6% reported that they offer “wellness” care in their practices. 
Although chiropractors continue to debate the pros and cons of being primary care providers, and although chiropractic educators are striving to meet the challenge of training primary care physicians, patients tend to seek chiropractic care largely for neuromusculoskeletal conditions.  A survey of chiropractic practice patterns from 1985 through 1991 at 5 US sites and 1 Canadian site showed that 68% of the care provided by chiropractors was for low-back pain.  A later report stated that 70% of patients who visited chiropractors had consulted the chiropractor for back or neck pain. Of this sample, only 6% of the visits were for conditions that were not musculoskeletal in nature. 
With regard to primary care, the public has little to help them determine whether the chiropractor they plan to visit for back pain can also diagnose and treat their reflux disease. [15, 24] For chiropractors to enjoy a wider traditional covenant, the competence of graduates in primary care activities must be established. It is also useful to determine how well chiropractic graduates score on tests that compare them to medical counterparts on knowledge about primary care activities. This research was undertaken with that aim in mind.
In a previous study, the curricula of selected medical schools and chiropractic schools were compared.  The authors concluded that in the basic sciences, chiropractic and medical curricula are quite similar. The biggest difference existed in the clinical practice portion of the curriculum where medical school exceeded chiropractic institutions in the number of hours offered. Among other recommendations advanced was that the quality of educational programs be explored. In a study addressing physician’s perceptions of their ability to provide high-quality care in a managed care system, it was notable that in each category polled, the primary care providers scored themselves higher than specialists in being able to offer quality services to their patients.  This study takes a small, first step by evaluating knowledge of chiropractic students compared with medical students on knowledge of primary care activities.
The debate over the role chiropractic will play in primary care will no doubt continue for a long while and, in the meantime, the Council on Chiropractic Education  has mandated that chiropractic institutions “educate and train a competent doctor of chiropractic who will provide quality patient care and serve as a primary care physician” as a requirement for accreditation. Chiropractic institutions, coveting accreditation, strive to meet these standards and, despite philosophical objections that some academic leaders may have, include in their curricula requisite numbers of courses in pathology and diagnosis. This study, rather than engaging in the ongoing primary care debate that previously has been extensively reviewed, [16-18] approached the subject from a pragmatic standpoint and simply asked the question, “How well do our institutions train students in knowledge of primary care activities?”
In 2001, a publication reported on a study that asked 2 panels of experts to identify tasks performed by health-care providers that were considered to be “primary care activities.”  In addition, these panels considered the potential role of chiropractors to provide primary care services. This report is a follow-up and expansion on previously published work that established a taxonomy of primary care activities and examined the potential role for chiropractors to provide primary care services. The purpose of the present study was to evaluate the ability of chiropractic students to correctly respond to questions formulated around the identified primary care tasks.
Despite the limitations imposed by study design, sampling methods, sample size, and test format, which all have been addressed elsewhere, the results obtained have provided some interesting information. These data will be provided to the administrators of the colleges participating in this project. Chiropractic educators may wish to provide feedback to those who supervise the instruction in the areas identified as weak. Claims about the usefulness of these data for chiropractic educators, however, must be tempered in light of the small number of questions addressing each subject area. The problem associated with attempting to address  identified tasks with a 50-item evaluation instrument is obvious. For the medical students and their performance on the musculoskeletal questions, medical educators have previously acknowledged the need to better prepare graduates in this area of study. 
An additional caveat with regard to these data is that neither the study design nor the subject population met parametric assumptions considered necessary for the proper application of statistical tests. The student sample was a nonrandomized convenience sample. It cannot be claimed that the groups were obtained from the same population because of the differences in their educational programs. The statistical results were presented only to provide an additional way to view the results.
There are factors that may have affected the performance of chiropractic students on a test of primary care tasks. One of those factors is that of personal bias. If the student does not value primary care, they may not score well on a test designed to assess that knowledge. In addition, there is a vocal segment of the chiropractic profession that embraces the subluxation complex, the sine quo non of chiropractic, to the exclusion of all other considerations. This faction seems to deplore traditional diagnostic methods. They are able to exert influence on chiropractic students through on-campus organizations and outside-of-campus seminars. They often disparage the study of subjects not directly related to the subluxation complex. Students thus influenced may score poorly on tests designed to evaluate primary care knowledge.
Because the range of average scores for all of the students tested was between 56% and 73%, the difficulty level of the examination is called into question. As previously stated, the examination was found to be reliable upon split-half reliability testing. The issue of validity was addressed by sending copies of the test to members of the original expert panels soliciting their opinions as to the appropriateness of the test questions in addressing primary care tasks. Although the results of this inquiry were not unanimous, and several panel members expressed concerns about some of the test items, most responders agreed that the test adequately covered the primary care tasks. The majority attested to the appropriateness of the examination. The results obtained in this study suggest, however, that the test may be difficult. That consideration aside, the medical students scored higher than the 3 chiropractic groups. At this point, it should be explained that the medical student sample was obtained just as they entered their residency programs. These students most likely would have fared better on the examination had it been administered after their residency training. The timing of evaluation selected for this study was to provide a more logical comparison with the chiropractic students who were completing a 4-year program of study.
Although this study used a standard testing format to examine the issue of how well students performed on an evaluation of knowledge of primary care tasks, it is acknowledged that, “primary care is a way of delivering health care,” and not a body of knowledge.  The World Health Organization has long advocated the coordinator aspect of primary care, wherein the physician takes into account the patients’ cultural, social, and economic circumstances.  The National Academy of Sciences has developed a definition of primary care that describes accessibility and coordination of services as important components to that practice.  Obviously, as some have pointed out, chiropractors have significant deterrents to being primary care practitioners in the usual sense of the term. [2, 20, 32] Chiropractors do not manage infectious diseases nor are they in a position to “manage 90% of the problems arising in the served population without referral.” [2, 24] According to data published in the Job Analysis of Chiropractic, 2000, only 5.2% of chiropractors have staff privileges at a medical or osteopathic facility, indicating that it may be difficult to meet the “continuous” aspect of primary care as defined by the Institute of Medicine. 
Nevertheless, many chiropractors consider themselves to be primary care providers. [4, 15] To be relegated to the role of neuromusculoskeletal practitioner is offensive to some chiropractors, who suggest that to accept that role would deprive the public of the potential benefits chiropractic may be able to offer patients with nonneuromusculoskeletal conditions. Those with a more pragmatic approach [2, 24] suggest that the benefits to be gained through chiropractic will occur even if treatment is provided for a neuromusculoskeletal complaint. Pragmatists say that the acceptance of chiropractic into the health-care system will be met with fewer objections if that entry is as a neuromusculoskeletal specialist. 
Previous data suggest that chiropractors do well with regard to patient satisfaction and perceived patient participation. [23, 34] Patients seek alternative therapies and are looking for practitioners well versed in wellness and prevention. [18, 35] Indeed, a burgeoning class of entrepreneurial physicians (eg, Drs Andrew Weil and Deepak Chopra) has capitalized on the momentum. People want options or “alternatives.”  Chiropractic care positively correlates with a lower number of hospital stays, fewer nursing home days, and fewer visits to physicians in a population of geriatric patients.  The geriatric population is particularly challenging because many of their problems are longstanding. Therefore, it is not unreasonable to hypothesize that younger people might expect even higher positive health indicators with regular chiropractic care. According to a survey by Hawk and Dusio,  a large segment of practicing chiropractors consider themselves to be wellness care practitioners. A number of chiropractors have expressed the view that chiropractic is positioned favorably to fill the wellness care model. [17, 18, 19, 37]
Flexibility in maintaining a focus different than that of the typical medical primary care provider would, as many have argued, [17, 19] be more in keeping with the social milieu and the public’s interest in health and wellness. In the 21st century, the focus will be on prevention and maintenance of function rather than cure.  The bandwagon of alternative care, however, may not offer a smooth ride. One author  warns that the desire of the public to seek alternative care may result in the medical profession seeking to be the sole provider of these services. “Notice,” Jusino  warns, “that it is the therapies and not the practitioners that they intend to incorporate into their system.”
Medical educators have reported strategies used to bolster the number of medical students entering a primary care specialty.  With the goal of increasing generalist practitioners, adequate interaction between medical students and role models among faculty well versed in generalist specialties became a priority.  Furthermore, recommendations were made,  whereby faculty members were to “cease deprecating careers in primary care specialties.” Studies show that attitudes of faculty members have significant influence on institutional reform and on increasing the numbers of generalist graduates. 
The physician workforce has shifted dramatically in terms of specialty composition over the past few decades. For example, between 1965 and 1992, the total number of physicians increased 65%. During this time, the number of specialists per 100,000 rose 121%, whereas the numbers of primary care physicians increased by only 13%.  By 1998, more than two thirds of the practicing physicians in the United States were specialists.  As a result of the demand for primary care by managed care organizations and the disproportionate growth of the specialty workforce, policymakers began to focus on a goal to have 50% of all medical school graduates choose primary care careers.  The Council on Graduate Medical Education established the objective and medical schools targeted increases in the selection of primary care residencies by postgraduates. The targeted selection process was apparently successful, and there was a shift in the other direction. From 1992 to 1997, the percentage of medical school graduates who chose primary care residencies rose from 14.6% to 39.6%. 
As society became more complex and the uninsured and underserved segment increased, trust in the health-care professions declined.  In the United States, this situation has become progressively worse and is complicated by perhaps the most confusing system of health-care reimbursement in the world. As Hawk  states, “The U.S. system of health care is characterized by the highest costs and lowest consumer satisfaction of any developed country.” Although our per-capita spending dwarfs any other nation, our performance with regard to health care is modest. 
At the end of the 20th century, the United States ranked 37th among nations by measures of health-care quality, relevance, and cost-effectiveness.  Furthermore, more than 22 million US citizens have inadequate access to primary care. [3, 40] This situation has made it difficult, if not impossible, for American medical educators to live up to the social contract. Having acknowledged this, many medical educators maintain that the training of the generalist as opposed to the specialist physician is crucial to the evolving health-care system. [31, 44-46] Equal access of patients to health care has been further compromised by increased numbers of specialists.  Perhaps if chiropractors were prepared to offer primary care services, this would contribute to balancing the distribution of health-care providers. [15, 18]
As was made clear in the October 1993-1994 joint meeting of the World Health Organization and the Educational Commission for Foreign Medical Graduates in Geneva Switzerland, self-assessment of medical schools is a good beginning step toward ensuring quality in medical education.  It is proposed that the test used in this study might serve as a tool for self-assessment in chiropractic colleges. There are, however, limits to the information to be gained from this tool. Clearly, this test takes into consideration the assertion of Greenlick  that, “little or no accounting for the preexisting characteristics, interests, and career plans of students and residents across schools and programs.”
Career choices have been studied in medical education. Factors affecting medical students’ choices of a career in primary care over medical specialties were examined. [41, 49] Often the individual decides long before he or she matriculates in medical school how they are going to practice.  Indeed, these preconceived practice preferences actually preempt any specific training that is later encountered.  The importance of interest in family medicine versus durability of that interest throughout the educational period has been studied. When this predictor variable was examined, initial interest was more highly related to practice patterns than the content of the medical education.  If this example holds for chiropractic students, one could speculate that students who enter chiropractic college, having already decided to relegate primary care activities to a secondary position, are not likely to alter their eventual practice patterns regardless of what they are exposed to during their professional education.
Many groups are stakeholders in the quality of health-care education. Students, licensing boards, local health organizations, third-party pay groups, and patients are all concerned with provider education and how limited or general is their scope of knowledge. In this social accountability, Retchin et al  have stated, “for any learned profession there are but two alternatives for establishing standards of practice and education. Responsibility can be assumed by the organized profession through a voluntarily accepted self discipline, or by society as a whole, operating through government.” If the profession does not take responsibility, society will demand the vacuum be filled and government will provide outside regulation. [43, 52] Acceptance of this responsibility both reassures the public that the profession warrants trust and obviates a subordinate relationship likely to develop because of outside regulation.3, 
In the future, it may be determined that the best role for chiropractors is that of portal of entry providers with the ability to differentially diagnose, but with a focus on structural and functional wellness not addressed by the typical primary care provider. As Seater  has suggested, “both chiropractors and consumers might prefer that chiropractors not be primary care providers in the usual sense of the term.” Gatterman  has called for a patient-centered paradigm for chiropractic education, research, and practice. The proposed patient-centered approach includes wellness concepts embedded within a broader framework encompassing social, environmental, and individual concerns.
The challenge for the chiropractic profession is to take on the issue of primary care with a sophistication that allows a clear perception of the complexities involved. Declarations by chiropractors that they “are primary care providers” must be balanced with supporting data.  Surveys by chiropractors and leaders in the profession  will not suffice without data on the readiness of graduates to provide these services. The determination regarding whether DCs are qualified to provide primary care should be predicated upon data indicating that students performed well on examinations such as the one used in this study. The social contract and the accountability aspect of the practice of primary care depend upon grass roots efforts by chiropractic educators to both widen the practice covenant and to expand the collective consciousness regarding primary care without individual or professional bias.  This project is an example of an educational assessment that was funded by a professional organization. In other venues, the profession is providing the accountability that the public demands and deserves.
Because the test instrument used in this study showed reliability, educational institutions could implement the test to evaluate internal effectiveness of their programs. It could be argued that a pen-and-paper, multiple-choice examination is not adequate to evaluate knowledge about primary care tasks. Admittedly, this type of test is not the best evaluation tool. It has been suggested that evaluation methods in medical education have not kept up with progress made on the delivery side of the equation.  It should be pointed out, however, that a major portion of the examinations used to determine whether a chiropractor will receive licensure remains this type of test.
The test designed for this study assessed how a sample of chiropractic students compare with medical students in knowledge about primary care activities. The chiropractic test takers scored below their medical counterparts, but not by much. Considering the emphasis on primary care within medical education over the past few decades and the ambiguity with which the chiropractic profession has approached primary care, the fact that chiropractic students scored almost as well as medical students is noteworthy. A follow-up to this study using a clinical competency practical examination constructed around the identified primary care tasks should be undertaken.