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Relationship Between Chiropractic Teaching Institutions and Practice Characteristics Among Canadian Doctors of Chiropractic: A Random Sample Survey
RELATIONSHIP BETWEEN CHIROPRACTIC TEACHING INSTITUTIONS AND PRACTICE CHARACTERISTICS AMONG CANADIAN DOCTORS OF CHIROPRACTIC: A RANDOM SAMPLE SURVEY Aaron A. Puhl, MSc, DC, a Christine J. Reinhart, PhD, DC, a Jon B. Doan, PhD, b
Marion McGregor, DC, PhD, FCCS(C), c and H. Stephen Injeyan, PhD, DC d ABSTRACT Objective: The objectives of this study were to determine if faction membership among Canadian doctors of chiropractic (DCs) is associated with differences in educational program characteristics among English-speaking Canadian and United States chiropractic colleges and to determine if those differences are expressed in terms of surveyed attitudes and behaviors regarding treatment efficacy, radiographic imaging, vaccinations, and interprofessional referrals. This study also aims to identify if educational programs may be a potential source of multiple professional identities. Methods: A randomly selected sample of Canadian DCs, stratified across the English-speaking provinces, was surveyed by mail. Survey items included school of graduation, self-categorization by chiropractic subgroup, perceptions of conditionspecific treatment efficacy, use of plain film radiographic imaging, vaccination attitudes/behaviors, and patient referral patterns. Self-categorization by chiropractic subgroup included: the unorthodox faction (associates the chiropractic subluxation as an encumbrance to the expression of health) and the orthodox perspective (associates with musculoskeletal joint dysfunction, public health, and lifestyle concerns). For data analysis, chiropractic schools were divided into 2 groups according to location: English-speaking Canada and the US. The US was further clustered into liberal (“interested in mixing elements of modern and alternative therapies into the practice of chiropractic") and conservative categories (“chiropractors who believe in continuing the traditions of chiropractic"). Results: Of 740 deliverable questionnaires, 503 were returned for a response rate of 68%. χ2 Testing revealed significant differences in self-categorized faction membership associated with the clustering of colleges based on ideological viewpoints (χ 2 = 27.06; P = .000). Descriptive results revealed a relationship between school of origin and perceived treatment efficacy, use of radiographic imaging, and vaccination attitudes. No significant differences were found relative to interprofessional referral patterns. Conclusion: Chiropractic program attended is a significant predictor of orthodox vs unorthodox faction membership and professional practice characteristics for Canadian DCs. This suggests that the current chiropractic education system may contribute to multiple professional identities. (J Manipulative Physiol Ther 2014;37:709-718) Key Indexing Terms: Chiropractic; Interprofessional Relations; Attitude of Health Personnel; Professional Education
D
octors of chiropractic (DCs) are commonly sought health care professionals in Canada. 1 People seek out DCs almost exclusively for musculoskeletal
a Chiropractor (Private Practice), Able Body Health Clinic, Lethbridge, AB, Canada. b Associate Professor, Department of Kinesiology and Physical Education, University of Lethbridge, Lethbridge, AB, Canada. c Director of Education, Year II, Professor, Canadian Memorial Chiropractic College, Toronto, ON, Canada. d Chair, Department of Pathology and Microbiology, Professor, Canadian Memorial Chiropractic College, Toronto, ON, Canada. Submit requests for reprints to: H. Stephen Injeyan, MSc, PhD, DC, Chair, Canadian Memorial Chiropractic College, 6100 Leslie St, Toronto, ON, Canada, M2H 3J1. (e-mail: [email protected]). Paper submitted March 12, 2014; in revised form August 3, 2014; accepted August 28, 2014. 0161-4754 Copyright © 2014 by National University of Health Sciences. http://dx.doi.org/10.1016/j.jmpt.2014.09.005
conditions, primarily back and neck pain, 2 and are usually treated with a wide range of manual and manipulative therapies, active rehabilitation, and health promotion information. 3,4 Chiropractic is an evolving health care profession; originally based on principles that served to distinguish and isolate the profession from mainstream medicine, research has gradually redefined the nature of the discipline and its educational system. As a result of these changes, chiropractic now sits poised to enter mainstream care. 5 Although still controversial, chiropractic is increasingly viewed as an effective musculoskeletal specialty by those in the medical profession, with 25% to 50% of medical doctors (MDs) claiming to have referred patients to a DC. 6,7 The establishment of direct, formalized referral relationships between MDs and DCs ultimately improves efficiency, quality, and patient safety in the health care system. 8,9 Interprofessional communication, however, may be hampered by profession-specific identities, 10 and professional
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Fig 1. Survey item for self-categorization by chiropractic subgroup. education has been viewed as a means of creating a uniprofessional identity. 11 Associated with social identity theory, 12,13 Khalili et al 11 suggest that the cognitive maps created or maintained during profession-specific education may result in sufficient cohesiveness to result in discrimination against outside groups. It is well understood that every profession contains factions, 14–19 subgroups within the whole that have different ideas and opinions than the rest of the group. Factions have also been found to exist within the chiropractic profession. 20 Historically, most practitioners were thought of as “straights”; they were educated consistent with Langworthy's original premise of the supremacy of the nerves in maintaining health and perceived subluxation as an impediment to general health, with its only remedy being manipulation/adjustment. 21 However, recent work has shown that DCs in Canada who continue to define themselves in accordance with this more traditional premise currently represent a minority faction. 20 Moreover, Canadian DCs who self-identify with this group can be predicted based on specific professional characteristics related to perceived treatment efficacy, use of radiographic imaging, and vaccinations, which would be seen as unorthodox by those in mainstream health care professions. 20 Amplification of the unorthodox practice attributes that are associated with this minority chiropractic faction have been observed to impede patientcentered communication between chiropractic and medicine. 7 A recent examination of chiropractic education programs has suggested that there may exist significant differences between them, based on philosophical underpinnings that lie along a spectrum of “conservative” (maintaining historically “straight” traditions, such as those of Langworthy's notion of the supremacy of the nerves in maintaining health) 21 to “liberal” (more inclined toward current scientific models). 22 Based on this previous work, questions regarding the impact of chiropractic education on factions and, therefore, on interprofessional dynamics can now be asked. A nationwide survey in 1997 found that 99.7% of DCs in Canada graduated from either the Canadian Memorial Chiropractic College (CMCC; 74.8%) or a chiropractic school in the United States (US; 24.9%). 4 The CMCC currently represents Canada's only English-language chiropractic program and declares an evidence-based approach to the role of chiropractic in health care and a focus on treatment of neuromusculoskeletal disorders, differential diagnosis,
patient-centered care, and research. 23 The US currently has 15 chiropractic colleges that span the ideological spectrum 24; as of 2005, two-thirds of schools were associated with a liberal focus and one-third of schools with a conservative focus. 22 Professional education is one means of creating a uniprofessional identity, but different factions exist within chiropractic, and this has been suggested to interfere with interprofessional relationships. To understand the potential impact of differing factions in chiropractic on interprofessional dynamics, it is important to understand the extent to which chiropractic institutions might be inspiriting unorthodox attitudes and behaviors and thus facilitating multiple professional identities. The purpose of this analysis was 2-fold: (1) to determine if previously defined 20 intraprofessional factions in chiropractic are associated with differences in educational program characteristics among English-speaking US and Canadian chiropractic colleges and (2) to determine if these differences are also expressed in terms of surveyed attitudes toward treatment efficacy, use of radiographic imaging, vaccinations, and interprofessional referral patterns.
METHODS Survey development and administration have been detailed in previous work. 20 A survey instrument was developed by the authors that contained 16 items, both qualitative and quantitative in nature, ranging in topics from professional behaviors to practice philosophy. The survey instrument was tested by 10 practicing DCs. A list of all currently licensed DCs for each of the 9 English-speaking Canadian provinces was developed from the online directories of the provincial chiropractic licensing bodies. A random sample was then selected from each provincial list, 749 DCs (12%), stratified proportionally across the English-speaking Canadian provinces. The survey was administered by mail from August 2010 to December 2010. The CMCC Research Ethics Board approved the study protocol (REB approval no. 1006X02), and the CMCC Research Division provided all funding. Survey items pertinent to this investigation included school of graduation, self-categorization by chiropractic subgroup, perceptions of condition-specific treatment efficacy, use of plain film radiographic imaging, vaccination attitudes/behaviors, and patient referral patterns. The self-categorization by chiropractic subgroup question (Fig 1) has been detailed in
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Fig 2. Survey item for perceptions of condition-specific treatment efficacy. ADHD, attention deficit hyperactivity disorder; TMJ, temporomandibular joint.
Fig 3. Survey item for use of plain film radiographic imaging.
previous work. 20,25 It was used to subgroup practitioners with an unorthodox perspective of patient care (unorthodox faction), as compared with those holding a relatively more orthodox perspective (orthodox faction). Consistent with earlier work, 20 the unorthodox view was defined by the subgroup who identified themselves with the notion that the chiropractic subluxation (lesion treated) was an “encumbrance to the expression of health.” In contrast, all other chiropractic subgroups are identified with musculoskeletal joint dysfunction, with some also including public health and lifestyle concerns. To evaluate perceptions of condition-specific treatment efficacy, respondents were asked to indicate, from an alphabetized list of 27 complaints and diagnoses, which disorders they believed they could address the underlying causes (Fig 2). The list of conditions was divided into disorders for which the authors could find some peer-reviewed research evidence that exists to suggest manual treatment may positively affect the condition (although treatment studies may have disputed the suggestions), 26–42 and disorders for which no such evidence-associated basis in treatment could be determined. The conditions for which no peer-reviewed, evidence-associated basis for treatment could be found were allergies, attention deficit/hyperactivity disorder, cancer, cystic fibrosis, diabetes, and multiple sclerosis. A strong relationship between perceived efficacy of treatment for disorders wherein no research evidence currently exists and a self-categorization of unorthodoxy was shown previously 20; participants were characterized as having unorthodox perceptions of efficacy if they indicated that they could affect the underlying cause of any one, or more, of the 6 disorders for which no scientific literature could be found.
To evaluate DCs use of plain film radiographic imaging, the survey included a question to document whether practitioner use of this imaging modality is consistent with current, evidence-based guidelines (Fig 3). 43 Consistent with previous literature, 20 participants were categorized as unorthodox in their use of radiography if they indicated that they used radiographic imaging to “identify subluxations (or equivalent),” which is not recommended in current guidelines. 43 With respect to vaccination attitudes, respondents were asked to indicate the extent to which they agreed or disagreed with each of 2 vaccination statements and 1 statement reflecting an understanding of the germ theory, based on a 5-point Likert scale for each (Fig 4A). The responses to these 3 questions were combined to provide a “vaccination consistency score” of between 3 and 15, with a lower score reflecting a more positive attitude toward vaccination. Positive/orthodox attitudes toward vaccination were considered those responses consistent with current medical science and the official statement of the Canadian Chiropractic Association. 44,45 Participants were also asked to indicate, from a list of 6 possible responses, how they would respond to questions from patients regarding childhood vaccinations (Fig 4B). Referral patterns of Canadian DCs were assessed by asking what percentage of their patients, in the previous year, was formally referred to an MD and what percentage was informally referred (Fig 5).
Data Analysis Chiropractic schools were divided into 2 groups according to location, that is, English-speaking Canada
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a)
b)
Fig 4. a, Survey items for vaccination attitudes. b, Survey item for vaccination behaviors. MD, medical doctor.
Fig 5. Survey item for patient referral patterns. MD, medical doctor. and the US. Programs located in the US were then further clustered into liberal and conservative categories (conservative = “chiropractors who believe in continuing the traditions of chiropractic" and liberal = “interested in mixing elements of modern and alternative therapies into the practice of chiropractic"). 22 Descriptive statistics (percentages, means, and SDs) were used to report the proportion of respondents answering questions evaluating school of graduation, location of graduate, perceived efficacy of treatment, use of radiographic imaging, referral patterns, and vaccination attitudes, relative to school cluster. χ 2 Tests were used to examine observed vs expected frequency of self-categorization into an orthodox/unorthodox chiropractic subgroup associated with chiropractic program. χ 2 Tests were also used to examine these frequencies with respect to orthodox/unorthodox professional attitudes/behaviors, as determined by responses to questions about perceived efficacy, use of plain film radiography, and referral to MDs, within school clusters. For these tests, an expectancy of 80% concordance with orthodox practice (20% unorthodox) was used in the χ 2 testing, based on previous examinations of chiropractic orthodoxy and dissidence, and previous research on the appropriateness of health care. 20,46 A Kruskal-Wallis test was used to compare mean ranks between school groups for the vaccination consistency score, with follow-up Mann-Whitney U tests used to elucidate the significance of any difference between school clusters.
RESULTS Demographic Characteristics of Respondents Of the 749 surveys mailed to DCs practicing in Canada, 740 were deliverable, and 503 were returned, for a response rate of 68%. Seven respondents returned the cover page only, indicating they did not wish to participate. Most respondents attended chiropractic college at CMCC (n = 315; 62.6%), whereas nearly 36% (35.9%) attended a professional program in the US. Table 1 provides a breakdown of respondents by school cluster and Table 2 shows the distribution of respondents by Canadian provinces.
Professional Factions Table 3 provides a breakdown of self-categorized, orthodox vs unorthodox chiropractic factions, relative to school of graduation cluster. Self-categorization from both the liberal US school cluster and from CMCC indicated 80% or greater identification with the orthodox chiropractic subgroups. However, self-categorization to the orthodox subgroups from the conservative school cluster was only approximately 59%. χ 2 Testing indicated that this difference associated with school cluster was statistically significant (χ 2 = 27.06; P = .000).
Professional Practice Characteristics The prevalence of unorthodox practice characteristics among Canadian DCs, with regard to perceived efficacy, use of plain
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Table 1. The Clustering of Chiropractic Schools a and the Proportion of Respondents Represented Within Each Cluster Chiropractic School Cluster
Respondents, Chiropractic Schools Included a % (n)
English-Canadian schools
Canadian Memorial Chiropractic College
“Liberal" US schools Logan; National; New York; Northwestern; Texas; Western States “Conservative" Cleveland KC; Cleveland LA; US schools Life; Life West; Palmer; Palmer-West; Palmer-Florida; Parker; Sherman Other schools Anglo-European; Université du Québec à Trois-Rivières Not provided
62.6 (315) 20.0 (101)
15.9 (80)
clusters showed a high frequency of informal patient referrals to MDs (CMCC: χ 2 = 75.270; P = .000; liberal: χ 2 = 15.960; P = .000; conservative: χ 2 = 14.821; P = .000), there was a trend toward a lower number of DCs educated at conservative US schools who reported making any formal referrals (CMCC: χ 2 = 1.351; P = .245; liberal: χ 2 = 0.561; P = .454; conservative: χ 2 = 2.813; P = .094). This conservative school group also had significantly discordant vaccination consistency scores compared with either Canadian or liberal school graduate groups (U = 8918.000, Z = − 4.842, P = .000; U = 2901.500, Z = − 2.888, P = .004, respectively).
0.8 (4)
DISCUSSION 0.6 (3)
a
Includes only those schools that were attended by respondents of this survey; does not represent a complete list of international chiropractic schools.
film imaging, and MD communication, is summarized in Table 4. Most respondents (76.3%) perceived the efficacy of their treatment techniques in a manner that was considered orthodox. Similarly, a majority of respondents reported use of plain film radiography in a manner that was considered orthodox (78.5%). Almost 80% of Canadian DCs report formally referring some of their patients to an MD or other medical specialist by way of a letter or telephone call, and nearly every respondent (98.6%) claimed to have informally suggested that some of their patients see an MD. Table 5 summarizes the percentage of patients referred by respondents to their MDs each year. Table 6 summarizes the response of participants to queries about childhood vaccination and provides the vaccination consistency scores. The most common responses were to advise that parents talk to an MD or public health nurse for information about childhood vaccines (39.0%) or provide information on both the pros and cons of childhood vaccinations (38.4%). A large majority of respondents expressed agreement with the idea that microorganisms can play a role in disease and usually result in specific signs and symptoms (71.1% agreed or strongly agreed; 8.8% disagreed or strongly disagreed); a smaller majority was in agreement with the statements expressing that vaccinations have improved public health (56.2% agreed or strongly agreed; 21.6% disagreed or strongly disagreed) or have a strong evidence base (55.8% agreed or strongly agreed; 20.7% disagreed or strongly disagreed). Many of the professional practice characteristics examined in this analysis were significantly associated with the school cluster. Doctors of chiropractic in both US-educated groups had significantly discordant perceptions of treatment efficacy (CMCC: χ 2 = 0.081; P = .776; liberal: χ 2 = 4.232; P = .040; conservative: χ 2 = 12.571; P = .000). Graduates of US schools with conservative ideology also had significantly discordant perceptions on the use of radiographic imaging (CMCC: χ 2 = 3.791; P = .062; liberal: χ 2 = 3.055; P = .080; conservative: χ 2 = 17.578; P = .000). Although all school
Professional Factions Data from this investigation show that a significantly greater proportion of DCs from the conservative US school cluster categorized themselves as “unorthodox.” Unorthodox is defined by McGregor et al 20 as corresponding to the chiropractic subgroup believing “subluxation as an encumbrance to the expression of health”; χ 2 = 27.06; P = .000. As determined by previous investigation, practitioners who identify with this unorthodox chiropractic subgroup can be strongly predicted by unorthodox practice characteristics associated with treatment efficacy beliefs, use of plain film radiographic imaging, and attitudes about vaccination. That significantly more practitioners from schools self-defined as conservative are associated with this group suggests that the current chiropractic education system may be encouraging multiple professional identities. Through social identity theory, 12,13 it is to be expected that multiple identities will create strong within-group trust, leading to bias and strife directed at those out of group, even when those out of group are members of the same profession. Certainly, this has been observed among subgroups within the chiropractic profession. 21,47 Chiropractic factions, encouraged by chiropractic college affiliation, places stress on interprofessional communication, and ultimately, patient care may become compromised. Although all professions have factions, 14–19 a profession like medicine, with a strong overall, perceived, uniprofessional focus, is likely to find communication difficult when trying to relate to the multiple identity phenomenon in chiropractic. Unfortunately, poor interprofessional communication has been suggested to manifest as hesitation in the appropriate referral of patients between professions. 7 It is clear that the problem of college-engendered factionalism must be resolved for the benefit of patient care. We suggest that multiple professional identities in chiropractic may be expected to have an adverse impact on interprofessional relations, which may be already challenged by the attributes associated with social identity theory. 12,13 Knowledge from this study may inform the development and assessment of strategies to encourage a re-evaluation of chiropractic's multiple professional identities and their impact on interprofessional relationships, for the sake of improving the efficiency, quality, and safety of patient care. The findings of this study suggest that
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Table 2. Response Rates and Respondent Demographics by Province Province
Other, a Response Rate, % (n) CMCC Graduates, % (n) Liberal US Graduates, % (n) Conservative US Graduates, % (n) % (n)
British Columbia Alberta Saskatchewan Manitoba Ontario New Brunswick Nova Scotia Prince Edward Island b Newfoundland Total
71.3 (72) 68.1 (79) 76.2 (16) 68.8 (22) 66.2 (291) 87.5 (7) 71.4 (10) – 85.7 (6) 68.0 (503)
59.7 (43) 32.1 (25) 68.8 (11) 18.2 (4) 74.7 (216) 42.9 (3) 90.0 (9) – 66.7 (4) 62.6 (315)
29.2 (21) 24.1 (19) 12.5 (2) 36.4 (8) 16.8 (49) 14.3 (1) 10.0 (1) – 0 (0) 20.0 (101)
9.7 (7) 43.0 (34) 18.8 (3) 45.5 (10) 7.2 (21) 42.9 (3) 0 (0) – 33.3 (2) 15.9 (80)
1.4 (1) 1.3 (1) 0 (0) 0 (0) 1.7 (5) 0 (0) 0 (0) – 0 (0) 1.4 (7)
CMCC, Canadian Memorial Chiropractic College. a Reported receiving their formal chiropractic education somewhere other than CMCC or a US school or did not provide place of education. b All mailed surveys (n = 2) were undeliverable
Table 3. Self-Categorization Into Chiropractic Faction Relative to School Cluster School Cluster “Conservative" “Liberal" CMCC Total
Orthodox % (n) 59.15 (42) 80.81 (80) 86.04 (265) 80.96 (387)
Unorthodox
Total
% (n)
% (n)
40.85 (29) 19.19 (19) 13.96 (43) 19.04 (91)
100 (71) 100 (99) 100 (308) 100 (478)
Efficacy of treatment, use of radiographic imaging, and χ . Sample size reflects respondents who provided answers to both questions. CMCC, Canadian Memorial Chiropractic College. χ2 = 27.06; P = .000 2
the development or sustainment of multiple professional identities in chiropractic may be facilitated, at least in part, by an individual's chiropractic college affiliation.
Perceived Efficacy and Interprofessional Communication Although most discussions with regard to the efficacy of chiropractic care are focused on spinal manipulation/ mobilization, most DCs use a wide variety of therapies for their patients (eg, manual and physical therapies, exercise, therapeutic modalities, health and lifestyle advice, etc). 3,4 We found that a majority of respondents perceived the value of these treatments in a manner that is reasonably consistent with current peer-reviewed literature. However, nearly a quarter of the Canadian DCs surveyed (23.7%) expressed the belief that they could effectively treat diseases that have known genetic and/or visceral-related underpinnings and no identified peer-reviewed basis for treatment with manual therapies. Unorthodox perceptions of efficacy were significantly more likely among DCs who matriculated from US schools (liberal: χ 2 = 4.23, P = .04; conservative: χ 2 = 12.57, P = .00). McGregor et al 20 found that those respondents with unorthodox perceptions of efficacy were more likely to perceive subluxation as an encumbrance to the expression of health, suggesting that these respondents continue to espouse a traditional chiropractic treatment model. 21,22 This might help to explain why those
respondents who graduated from conservative US chiropractic schools were also least likely to have made formal patient referrals to an MD, perceiving their treatment model as preferable over the biomedical alternatives offered by their medical colleagues and for a broader range of diseases.
Use of Plain Film Radiographic Imaging Among primary health care providers who can request radiographs, DCs are sometimes thought to have utilization rates that exceed what is recommended by practice guidelines. There is indeed some evidence reported in the chiropractic literature of inappropriate use of imaging services. 48–50 Evidence-based, chiropractic radiography guidelines suggest that plain film imaging be restricted to patients with suspected serious disease because, outside of this use, imaging adds very little value to the diagnostic evaluation of spinal pain. 43 Biomechanical assessments or assessment for chiropractic subluxations is not recommended because of morphologic asymmetries, geometric and positional distortions, measurement errors, poor correlation with symptoms, and lack of convincing clinical usefulness. 43 Our survey suggests that most Canadian DCs are not ordering plain film radiographs for the purpose of identifying subluxations. This finding is consistent with previous studies, which have suggested that most radiology instruction provided by accredited chiropractic programs appears evidence based 51 and that there is a strong adherence to radiography guidelines at chiropractic teaching clinics in Canada. 52 However, our study also suggests that a minority of practitioners continue to use radiography for the identification of subluxations, despite the existence of evidence-based guidelines for DCs that advise against it. The unorthodox use of plain film imaging was significantly more likely to be found among those respondents who matriculated from US schools that were self-described as having a conservative ideological grounding (χ 2 = 17.58; P = .00). This is consistent with findings of a recent examination of spine radiograph utilization by DCs in the US, which found that chiropractic school attended was one of the most influential predictors of spine radiograph utilization among DCs. 53
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Table 4. Perceived Efficacy, Use of Radiographic Imaging, and Interprofessional Communication by Respondents According to Chiropractic School Cluster CMCC
Liberal US Schools Conservative US Schools Total a
Unorthodox perceptions of efficacy, % (n) 19.4 (60/310) 28.0 (28/100) b Unorthodox use of radiographic imaging, % (n) 15.6 (49/314) 26.7 (27/101) No formal communication with an MD in previous year, % (n) 17.4 (54/311) 22.8 (23/101)
37.0 (27/73) b 38.8 (31/80) b 27.5 (22/80)
23.7 (116/490) 21.5 (108/502) 20.3 (101/498)
CMCC, Canadian Memorial Chiropractic College; MD, medical doctor. a “Total n” may be greater than the sum of the other columns because the “Total n” includes those respondents who graduated from schools outside of English Canada and the US. b Significantly (P b .05) greater than the expected 20% unorthodoxy.
Table 5. The Percentage of Patients Referred to an MD in the Previous 1 Year According to Chiropractic School Cluster CMCC
Liberal Conservative US Schools US Schools Total
% Formally 9.7 (14.1) 8.7 (12.8) referred, Ave (SD) % Informally 20.7 (18.6) 17.2 (16.3) referred, Ave (SD)
5.1 (7.3)
8.7 (13.0)
17.8 (16.4)
19.5 (17.8)
CMCC, Canadian Memorial Chiropractic College.
Vaccination Attitudes and Behaviors Concerns have been raised about the beliefs and behaviors of DCs as they relate to immunization. Consistent with a previous survey of Alberta DCs, 54 our study suggests that a majority of Canadian DCs understand the role of microorganisms in infectious disease; they agree that there is good scientific evidence to support vaccination theory and that vaccination has improved public health. The comparison of vaccination consistency scores indicates that attitudes regarding the cause of infectious disease and the role of vaccination in public health are significantly associated with the ideological foundation of the chiropractic schools where DCs received their formal chiropractic education. Unorthodox attitudes were significantly more likely to be found among respondents who matriculated from conservative US schools and least likely from graduates of CMCC. When examining vaccination-related behaviors that could promote interprofessional collaboration (ie, referring patients to an MD or public health nurse for information) or, alternatively, behaviors that could marginalize the profession (ie, advising parents against vaccinating their children), respondents from conservative US schools were approximately 4 times as likely to report giving antivaccination recommendations as respondents from CMCC. Respondents who graduated from CMCC were nearly 4 times as likely to recommend a discussion with an appropriate medical health professional. Although an earlier investigation of Alberta DCs did not find any association between vaccination attitudes or behaviors and country of matriculation from chiropractic school, 54 that
analysis did not account for the ideological differences between US schools. The current study suggests that the largest proportion of DCs in Canada prefer to leave discussions about childhood vaccination to other appropriate health care providers. A previous survey investigation suggested that it was common for Alberta DCs to advise patients on freedom of choice, 54 and similarly, the current study found that discussing the pros and cons of vaccination with parents was an approach preferred by many Canadian DCs. Earlier investigation of Alberta DCs found a much greater proportion of respondents would advise parents against vaccinating their children (27%), 54 than did our study (6.7%). However, upon analyzing only the survey data from respondents practicing in Alberta, 16.2% (12/74) indicated that they would provide information against childhood vaccinations. This is both higher than the national average in our data and lower than previous work. 54 Potential differences between national results and those of Alberta DCs may be explained by regional differences regarding where DCs received their formal chiropractic education. Our data (Table 2) suggest that Alberta and Manitoba may have higher proportions of licensed DCs who matriculated from US schools that have a conservative ideological grounding.
Limitations Our study has a number of limitations. The clustering of US schools was based on a previous analysis of the ideological grounding, as self-reported by school administrations and not all schools were represented. 22 The current study did not confirm the results of the 2005 analysis and does not suggest which of these schools continue to espouse a conservative ideological grounding. The data presented here were self-reported and thus were not subject to independent verification. As such, the responses may have been influenced by a social desirability bias. The response rate (68%) may be considered a strength that increases the validity of the findings 55; however, we do recognize that this was a select sample and that both nonsurveyed and nonresponders may have differed systematically from responders in ways that we are unable to predict.
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Table 6. The Distribution of Responses to the Question: “If a Patient Asked for Information Regarding Childhood Vaccinations, How Would You Usually Respond?” and Average Vaccination Consistency Scores Grouped According to Chiropractic School Cluster Advise to vaccinate, % (n) Advise against vaccination, % (n) Give pros and cons, % (n) Refer to MD or health nurse, % (n) Refer them to specific website, % (n) Suggest they search the internet, % (n) Vaccination consistency scores, Ave (SD) b
CMCC
Liberal US Schools
Conservative US Schools
Total a
3.1 (9) 4.1 (12) 33.6 (99) 47.1 (139) 5.8 (17) 6.4 (19) 6.9 (2.7)
3.2 (3) 6.5 (6) 43.0 (40) 33.3 (31) 4.3 (4) 9.7 (9) 7.4 (3.0)
2.8 (2) 16.9 (12) 52.1 (37) 12.7 (9) 7.0 (5) 8.5 (6) 8.6 (2.8)
3.0 (14) 6.7 (31) 38.4 (178) 39.0 (181) 5.6 (26) 7.3 (34) 7.3 (2.8)
CMCC, Canadian Memorial Chiropractic College; MD, medical doctor. a “Total n” may be greater than the sum of the other columns because the “Total n” includes those respondents who graduated from schools outside of English Canada and the US. b Scores could range from 3 to 15; lower scores reflect a more positive attitude toward vaccination. A significant (P b .05) difference was found between school clusters.
Our survey only sampled from English-speaking Canadian provinces, and it is plausible that the professional characteristics of DCs in the Canadian Territories and Frenchspeaking Canada may be different than those reported here.
Future Research This analysis was not designed to provide evidence of causation; the results only indicate an association between practice characteristics and chiropractic school attended. Although it would be helpful to design longitudinal studies that compare students' attitudes before and after receiving a formalized chiropractic education, it should be noted that the development of professional identity is understood to begin (at least in some cases) before formal education. 11,56 Value judgments and attitudes toward professions—and potentially its subgroups—may come initially from cultural sources, including the media, which may or may not accurately portray reality. 57 In addition, although formal chiropractic education can be expected to nurture professional attitudes and values, 58 there is evidence that additional self-directed, post-graduate education also contributes to changes in practice characteristics. 59 Future studies should examine the contribution of formalized school curricula as well as independent training seminars marketed to students and postgraduate training to the emergence of orthodox and unorthodox professional identities.
CONCLUSIONS The survey results indicate a significant relationship between ideological cluster of chiropractic educational institution and identification with orthodox vs unorthodox professional factions. Perceived treatment efficacy, use of plain film radiographic imaging, and vaccination attitudes were also significantly associated with the school from which DCs received their professional education. Although
most Canadian DCs appear consistent with orthodox practice, with regard to the items investigated, practitioners from conservative colleges in the US are more frequently associated with unorthodox faction membership and practice characteristics that may challenge chiropractic's relationship with mainstream health care. These findings suggest that the current chiropractic education system may contribute to multiple professional identities.
FUNDING SOURCES OF INTEREST
AND
POTENTIAL CONFLICTS
This project was internally funded by the CMCC Research Division. No conflicts of interest were reported for this study.
CONTRIBUTORSHIP INFORMATION Concept development (provided idea for the research): A.P., and C.R. Design (planned the methods to generate the results): A.P., C.R., and S.I. Supervision (provided oversight, responsible for organization and implementation, writing of the manuscript): A.P., M.M., and S.I. Data collection/processing (responsible for experiments, patient management, organization, or reporting data): A.P., and C.R. Analysis/interpretation (responsible for statistical analysis, evaluation, and presentation of the results): A.P., J.D., and M.M. Literature search (performed the literature search): A.P., J.D., and M.M. Writing (responsible for writing a substantive part of the manuscript): A.P., and J.D. Critical review (revised manuscript for intellectual content, this does not relate to spelling and grammar checking): A.P., C.R., J.D., M.M., and S.I.
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Practical Applications • There is a relationship between ideological cluster of chiropractic educational programs in the US and practitioners' identification with orthodox vs unorthodox notions of practice. • Most Canadian DCs appear consistent with orthodox practice. • Canadian DCs that matriculated from conservative programs in the US are more frequently associated with unorthodox practice behaviors.
REFERENCES 1. Metcalfe A, Williams J, McChesney J, Patten SB, Jetté N. Use of complementary and alternative medicine by those with a chronic disease and the general population—results of a national population based survey. BMC Complement Altern Med 2010;10:58. 2. Coulter ID, Hurwitz EL, Adams AH, Genovese BJ, Hays R, Shekelle PG. Patients using chiropractors in North America: who are they, and why are they in chiropractic care? Spine 2002;27:291-6. 3. Coulter ID, Shekelle PG. Chiropractic in North America: a descriptive analysis. J Manipulative Physiol Ther 2005;28:83-9. 4. Kopansky-Giles D, Papadopoulos C. Canadian chiropractic resources databank (CCRD): a profile of Canadian chiropractors. J Can Chiropr Assoc 1997;41:155-91. 5. Meeker WC, Haldeman S. Chiropractic: a profession at the crossroads of mainstream and alternative medicine. Ann Intern Med 2002;136:216-27. 6. Greene BR, Smith M, Allareddy V, Haas M. Referral patterns and attitudes of primary care physicians towards chiropractors. BMC Complement Altern Med 2006;6:5. 7. Busse JW, Jacobs C, Ngo T, et al. Attitudes toward chiropractic: a survey of North American orthopedic surgeons. Spine 2009; 34:2818-25. 8. Lee T, Pappius EM, Goldman L. Impact of inter-physician communication on the effectiveness of medical consultations. Am J Med 1983;74:106-12. 9. Mainous AG, Gill JM, Zoller JS, Wolman MG. Fragmentation of patient care between chiropractors and family physicians. Arch Fam Med 2000;9:446-50. 10. Lloyd JV, Schneider J, Scales K, Bailey S, Jones R. Ingroup identity as an obstacle to effective multiprofessional and interprofessional teamwork: findings from an ethnographic study of healthcare assistants in dementia care. J Interprof Care 2011;25:345-51. 11. Khalili H, Orchard C, Spence Laschinger HK, Farah R. An interprofessional socialization framework for developing interprofessional identity among health professions students. J Interprof Care 2013;27:448-53. 12. Tajfel H, Turner JC. The social identity theory of inter-group behavior. In: Worchel S, Austin LW, editors. Psychology of intergroup relations. Chicago: Nelson-Hall; 1986. p. 7-19. 13. Tajfel H. Experiments in intergroup discrimination. Sci Am 1970;223:96-102. 14. Abbott AA. The system of professions. An essay on the division of expert labor. Chicago: University of Chicago Press; 1988.
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15. Akers RL. Framework for the comparative study of group cohesion: the professions. Pac Sociol Rev 1970;13:73-85. 16. Armor DJ, Klerman GL. Psychiatric treatment orientations and professional ideology. J Health Soc Behav 1968;9:243-55. 17. Eraut M. The many meanings of theory and practice. Learn Health Soc Care 2003;2:61-5. 18. Glaser WA. The politics of paying American physicians. Health Aff 1989;8:129-46. 19. Pels P. Professions of duplexity: a prehistory of ethical codes in anthropology. Curr Anthropol 1999;40:101-36. 20. McGregor M, Puhl AA, Reinhart C, Injeyan HS, Soave D. Differentiating intraprofessional attitudes toward paradigms in health care delivery among chiropractic factions: results from a randomly sampled survey. BMC Complement Altern Med 2014;14:51. 21. Wardwell WI. Chiropractic: history and evolution of a new profession. St Louis: Mosby Year Book; 1992. 22. The future of chiropractic revisited: 2005-2015. Alexandria, Virginia: Institute for Alternative Futures; 2005. Available at: http://www.altfutures.org/future-chiropractic-revisited-20052015 (accessed January 13, 2014). 23. The Canadian Memorial Chiropractic College [Internet] Academic programs overview. Available from, http://www. cmcc.ca/page.aspx?pid=290 Accessed: Jan 11, 2014. 24. The Council on Chiropractic Education [Internet] Accredited doctor of chiropractic programs. Available from, http://cceusa.org/Accredited_Doctor_Chiro.html [Accessed: January 11, 2014]. 25. McGregor-Triano M. Jurisdictional control of conservative spine care: chiropractic versus medicine. Texas at Dallas: University of Texas at Dallas; 2006. 26. Dagenais S, Gay RE, Tricco AC, Freeman MD, Mayer JM. NASS contemporary concepts in spine care: spinal manipulation therapy for acute low back pain. Spine 2010;10: 918-40. 27. Miller J, Gross A, D'Sylva J, et al. Manual therapy and exercise for neck pain: a systematic review. Man Ther 2010;15:334-54. 28. Bronfort G, Nilsson N, Haas M, et al. Non-invasive physical treatments for chronic/recurrent headache. Cochrane Database Syst Rev 2004;3:CD001878. 29. Leininger B, Bronfort G, Evans R, Reiter T. Spinal manipulation or mobilization for radiculopathy: a systematic review. Phys Med Rehabil Clin N Am 2011;22:105-25. 30. Bronfort G, Haas M, Evans R, Leininger B, Triano J. Effectiveness of manual therapies: the UK evidence report. Chiropr Osteopat 2010;18:3. 31. Chaibi A, Tuchin PJ, Russell MB. Manual therapies for migraine: a systematic review. J Headache Pain 2011;12:127-33. 32. French HP, Brennan A, White B, Cusack T. Manual therapy for osteoarthritis of the hip or knee—a systematic review. Man Ther 2011;16:109-17. 33. Fernández-de-Las-Peñas C, Alonso-Blanco C, Cuadrado ML, Miangolarra JC, Barriga FJ, Pareja JA. Are manual therapies effective in reducing pain from tension-type headache?: a systematic review. Clin J Pain 2006;22:278-85. 34. Medlicott MS, Harris SR. A systematic review of the effectiveness of exercise, manual therapy, electrotherapy, relaxation training, and biofeedback in the management of temporomandibular disorder. Phys Ther 2006;86:955-73. 35. O'Connor D, Marshall S, Massy-Westropp N. Non-surgical treatment (other than steroid injection) for carpal tunnel syndrome. Cochrane Database Syst Rev 2003;1:CD003219. 36. Vernon H, Schneider M. Chiropractic management of myofascial trigger points and myofascial pain syndrome: a systematic review of the literature. J Manipulative Physiol Ther 2009;32:14-24.
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37. Hawk C, Khorsan R, Lisi AJ, Ferrance RJ, Evans MW. Chiropractic care for nonmusculoskeletal conditions: a systematic review with implications for whole systems research. J Altern Complement Med 2007;13:491-512. 38. Schneider M, Vernon H, Ko G, Lawson G, Perera J. Chiropractic management of fibromyalgia syndrome: a systematic review of the literature. J Manipulative Physiol Ther 2009;32:25-40. 39. Huang T, Shu X, Huang YS, Cheuk DK. Complementary and miscellaneous interventions for nocturnal enuresis in children. Cochrane Database Syst Rev 2011;12:CD005230. 40. Stevinson C, Ernst E. Complementary/alternative therapies for premenstrual syndrome: a systematic review of randomized controlled trials. Am J Obstet Gynecol 2001;185:227-35. 41. Proctor ML, Hing W, Johnson TC, Murphy PA. Spinal manipulation for primary and secondary dysmenorrhoea. Cochrane Database Syst Rev 2006;3:CD002119. 42. Hondras MA, Linde K, Jones AP. Manual therapy for asthma. Cochrane Database Syst Rev 2005;18:CD001002. 43. Bussières AE, Taylor JA, Peterson C. Diagnostic imaging practice guidelines for musculoskeletal complaints in adults—an evidence-based approach-part 3: spinal disorders. J Manipulative Physiol Ther 2008;31:33-88. 44. Pulendran B, Ahmed R. Immunological mechanisms of vaccination. Nat Immunol 2011;12:509-17. 45. The Canadian Chiropractic Association [Internet] Position Statements: Vaccination and immunization. Available from, http://www.chiropracticcanada.ca/en-us/AboutUs/TheCCA/ PositionStatements/VaccinationandImmunization.aspx [Accessed: November 21, 2013]. 46. Hicks NR. Some observations on attempts to measure appropriateness of care. BMJ 1994;309:730-3. 47. Kaptchuk TJ, Eisenberg DM. Chiropractic: origins, controversies, and contributions. Arch Intern Med 1998;158:2215-24. 48. Ammendolia C, Bombardier C, Hogg-Johnson S, Glazier R. Views on radiography use for patients with acute low back pain among chiropractors in an Ontario community. J Manipulative Physiol Ther 2002;25:511-20.
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49. Scheurmier N, Breen AC. A pilot study of the purchase of manipulation services for acute low back pain in the United Kingdom. J Manipulative Physiol Ther 1998;21:14-8. 50. Carey TS, Garrett J. North Carolina back pain project. Patterns of ordering diagnostic tests for patients with acute low back pain. Ann Intern Med 1996;125:807-13. 51. Ammendolia C, Taylor JA, Pennick V, Côté P, Hogg-Johnson S, Bombardier C. Adherence to radiography guidelines for low back pain: a survey of chiropractic schools worldwide. J Manipulative Physiol Ther 2008;31:412-8. 52. Ammendolia C, Côté P, Hogg-Johnson S, Bombardier C. Do chiropractors adhere to guidelines for back radiographs? A study of chiropractic teaching clinics in Canada. Spine 2007; 32:2509-14. 53. Bussières AE, Sales AE, Ramsay T, Hilles S, Grimshaw JM. Practice patterns in spine radiograph utilization among doctors of chiropractic enrolled in a provider network offering complementary care in the United States. J Manipulative Physiol Ther 2013;36:127-42. 54. Russell ML, Injeyan HS, Verhoef MJ, Eliasziw M. Beliefs and behaviours: understanding chiropractors and immunization. Vaccine 2004;23:372-9. 55. Asch DA, Jedrzwieski MK, Christakis NA. Response rates to mail surveys published in medical journals. J Clin Epidemiol 1997;50:1129-36. 56. Lordly D, MacLellan D. Dietetic students' identity and professional socialization: in preparation for practice. Can J Diet Pract Res 2012;73:7-13. 57. Adams K, Hearn S, Sturgis P, Macleod Clark J. Investigating the factors influencing professional identity of first-year health and social care students. Learn Health Soc Care 2006;5:55-68. 58. Clayton GM, Broome ME, Ellis LA. Relationship between preceptorship experience and roles socialization of graduate nurses. J Nurs Educ 1989;28:72-5. 59. Injeyan HS, Russell ML, Verhoef MJ, Mutasingwa D. Canadian chiropractors' perception of educational preparation to counsel patients on immunization. J Manipulative Physiol Ther 2006;29:643-50.
Marion McGregor, DC, PhD, FCCS(C), c and H. Stephen Injeyan, PhD, DC d ABSTRACT Objective: The objectives of this study were to determine if faction membership among Canadian doctors of chiropractic (DCs) is associated with differences in educational program characteristics among English-speaking Canadian and United States chiropractic colleges and to determine if those differences are expressed in terms of surveyed attitudes and behaviors regarding treatment efficacy, radiographic imaging, vaccinations, and interprofessional referrals. This study also aims to identify if educational programs may be a potential source of multiple professional identities. Methods: A randomly selected sample of Canadian DCs, stratified across the English-speaking provinces, was surveyed by mail. Survey items included school of graduation, self-categorization by chiropractic subgroup, perceptions of conditionspecific treatment efficacy, use of plain film radiographic imaging, vaccination attitudes/behaviors, and patient referral patterns. Self-categorization by chiropractic subgroup included: the unorthodox faction (associates the chiropractic subluxation as an encumbrance to the expression of health) and the orthodox perspective (associates with musculoskeletal joint dysfunction, public health, and lifestyle concerns). For data analysis, chiropractic schools were divided into 2 groups according to location: English-speaking Canada and the US. The US was further clustered into liberal (“interested in mixing elements of modern and alternative therapies into the practice of chiropractic") and conservative categories (“chiropractors who believe in continuing the traditions of chiropractic"). Results: Of 740 deliverable questionnaires, 503 were returned for a response rate of 68%. χ2 Testing revealed significant differences in self-categorized faction membership associated with the clustering of colleges based on ideological viewpoints (χ 2 = 27.06; P = .000). Descriptive results revealed a relationship between school of origin and perceived treatment efficacy, use of radiographic imaging, and vaccination attitudes. No significant differences were found relative to interprofessional referral patterns. Conclusion: Chiropractic program attended is a significant predictor of orthodox vs unorthodox faction membership and professional practice characteristics for Canadian DCs. This suggests that the current chiropractic education system may contribute to multiple professional identities. (J Manipulative Physiol Ther 2014;37:709-718) Key Indexing Terms: Chiropractic; Interprofessional Relations; Attitude of Health Personnel; Professional Education
D
octors of chiropractic (DCs) are commonly sought health care professionals in Canada. 1 People seek out DCs almost exclusively for musculoskeletal
a Chiropractor (Private Practice), Able Body Health Clinic, Lethbridge, AB, Canada. b Associate Professor, Department of Kinesiology and Physical Education, University of Lethbridge, Lethbridge, AB, Canada. c Director of Education, Year II, Professor, Canadian Memorial Chiropractic College, Toronto, ON, Canada. d Chair, Department of Pathology and Microbiology, Professor, Canadian Memorial Chiropractic College, Toronto, ON, Canada. Submit requests for reprints to: H. Stephen Injeyan, MSc, PhD, DC, Chair, Canadian Memorial Chiropractic College, 6100 Leslie St, Toronto, ON, Canada, M2H 3J1. (e-mail: [email protected]). Paper submitted March 12, 2014; in revised form August 3, 2014; accepted August 28, 2014. 0161-4754 Copyright © 2014 by National University of Health Sciences. http://dx.doi.org/10.1016/j.jmpt.2014.09.005
conditions, primarily back and neck pain, 2 and are usually treated with a wide range of manual and manipulative therapies, active rehabilitation, and health promotion information. 3,4 Chiropractic is an evolving health care profession; originally based on principles that served to distinguish and isolate the profession from mainstream medicine, research has gradually redefined the nature of the discipline and its educational system. As a result of these changes, chiropractic now sits poised to enter mainstream care. 5 Although still controversial, chiropractic is increasingly viewed as an effective musculoskeletal specialty by those in the medical profession, with 25% to 50% of medical doctors (MDs) claiming to have referred patients to a DC. 6,7 The establishment of direct, formalized referral relationships between MDs and DCs ultimately improves efficiency, quality, and patient safety in the health care system. 8,9 Interprofessional communication, however, may be hampered by profession-specific identities, 10 and professional
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Fig 1. Survey item for self-categorization by chiropractic subgroup. education has been viewed as a means of creating a uniprofessional identity. 11 Associated with social identity theory, 12,13 Khalili et al 11 suggest that the cognitive maps created or maintained during profession-specific education may result in sufficient cohesiveness to result in discrimination against outside groups. It is well understood that every profession contains factions, 14–19 subgroups within the whole that have different ideas and opinions than the rest of the group. Factions have also been found to exist within the chiropractic profession. 20 Historically, most practitioners were thought of as “straights”; they were educated consistent with Langworthy's original premise of the supremacy of the nerves in maintaining health and perceived subluxation as an impediment to general health, with its only remedy being manipulation/adjustment. 21 However, recent work has shown that DCs in Canada who continue to define themselves in accordance with this more traditional premise currently represent a minority faction. 20 Moreover, Canadian DCs who self-identify with this group can be predicted based on specific professional characteristics related to perceived treatment efficacy, use of radiographic imaging, and vaccinations, which would be seen as unorthodox by those in mainstream health care professions. 20 Amplification of the unorthodox practice attributes that are associated with this minority chiropractic faction have been observed to impede patientcentered communication between chiropractic and medicine. 7 A recent examination of chiropractic education programs has suggested that there may exist significant differences between them, based on philosophical underpinnings that lie along a spectrum of “conservative” (maintaining historically “straight” traditions, such as those of Langworthy's notion of the supremacy of the nerves in maintaining health) 21 to “liberal” (more inclined toward current scientific models). 22 Based on this previous work, questions regarding the impact of chiropractic education on factions and, therefore, on interprofessional dynamics can now be asked. A nationwide survey in 1997 found that 99.7% of DCs in Canada graduated from either the Canadian Memorial Chiropractic College (CMCC; 74.8%) or a chiropractic school in the United States (US; 24.9%). 4 The CMCC currently represents Canada's only English-language chiropractic program and declares an evidence-based approach to the role of chiropractic in health care and a focus on treatment of neuromusculoskeletal disorders, differential diagnosis,
patient-centered care, and research. 23 The US currently has 15 chiropractic colleges that span the ideological spectrum 24; as of 2005, two-thirds of schools were associated with a liberal focus and one-third of schools with a conservative focus. 22 Professional education is one means of creating a uniprofessional identity, but different factions exist within chiropractic, and this has been suggested to interfere with interprofessional relationships. To understand the potential impact of differing factions in chiropractic on interprofessional dynamics, it is important to understand the extent to which chiropractic institutions might be inspiriting unorthodox attitudes and behaviors and thus facilitating multiple professional identities. The purpose of this analysis was 2-fold: (1) to determine if previously defined 20 intraprofessional factions in chiropractic are associated with differences in educational program characteristics among English-speaking US and Canadian chiropractic colleges and (2) to determine if these differences are also expressed in terms of surveyed attitudes toward treatment efficacy, use of radiographic imaging, vaccinations, and interprofessional referral patterns.
METHODS Survey development and administration have been detailed in previous work. 20 A survey instrument was developed by the authors that contained 16 items, both qualitative and quantitative in nature, ranging in topics from professional behaviors to practice philosophy. The survey instrument was tested by 10 practicing DCs. A list of all currently licensed DCs for each of the 9 English-speaking Canadian provinces was developed from the online directories of the provincial chiropractic licensing bodies. A random sample was then selected from each provincial list, 749 DCs (12%), stratified proportionally across the English-speaking Canadian provinces. The survey was administered by mail from August 2010 to December 2010. The CMCC Research Ethics Board approved the study protocol (REB approval no. 1006X02), and the CMCC Research Division provided all funding. Survey items pertinent to this investigation included school of graduation, self-categorization by chiropractic subgroup, perceptions of condition-specific treatment efficacy, use of plain film radiographic imaging, vaccination attitudes/behaviors, and patient referral patterns. The self-categorization by chiropractic subgroup question (Fig 1) has been detailed in
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Fig 2. Survey item for perceptions of condition-specific treatment efficacy. ADHD, attention deficit hyperactivity disorder; TMJ, temporomandibular joint.
Fig 3. Survey item for use of plain film radiographic imaging.
previous work. 20,25 It was used to subgroup practitioners with an unorthodox perspective of patient care (unorthodox faction), as compared with those holding a relatively more orthodox perspective (orthodox faction). Consistent with earlier work, 20 the unorthodox view was defined by the subgroup who identified themselves with the notion that the chiropractic subluxation (lesion treated) was an “encumbrance to the expression of health.” In contrast, all other chiropractic subgroups are identified with musculoskeletal joint dysfunction, with some also including public health and lifestyle concerns. To evaluate perceptions of condition-specific treatment efficacy, respondents were asked to indicate, from an alphabetized list of 27 complaints and diagnoses, which disorders they believed they could address the underlying causes (Fig 2). The list of conditions was divided into disorders for which the authors could find some peer-reviewed research evidence that exists to suggest manual treatment may positively affect the condition (although treatment studies may have disputed the suggestions), 26–42 and disorders for which no such evidence-associated basis in treatment could be determined. The conditions for which no peer-reviewed, evidence-associated basis for treatment could be found were allergies, attention deficit/hyperactivity disorder, cancer, cystic fibrosis, diabetes, and multiple sclerosis. A strong relationship between perceived efficacy of treatment for disorders wherein no research evidence currently exists and a self-categorization of unorthodoxy was shown previously 20; participants were characterized as having unorthodox perceptions of efficacy if they indicated that they could affect the underlying cause of any one, or more, of the 6 disorders for which no scientific literature could be found.
To evaluate DCs use of plain film radiographic imaging, the survey included a question to document whether practitioner use of this imaging modality is consistent with current, evidence-based guidelines (Fig 3). 43 Consistent with previous literature, 20 participants were categorized as unorthodox in their use of radiography if they indicated that they used radiographic imaging to “identify subluxations (or equivalent),” which is not recommended in current guidelines. 43 With respect to vaccination attitudes, respondents were asked to indicate the extent to which they agreed or disagreed with each of 2 vaccination statements and 1 statement reflecting an understanding of the germ theory, based on a 5-point Likert scale for each (Fig 4A). The responses to these 3 questions were combined to provide a “vaccination consistency score” of between 3 and 15, with a lower score reflecting a more positive attitude toward vaccination. Positive/orthodox attitudes toward vaccination were considered those responses consistent with current medical science and the official statement of the Canadian Chiropractic Association. 44,45 Participants were also asked to indicate, from a list of 6 possible responses, how they would respond to questions from patients regarding childhood vaccinations (Fig 4B). Referral patterns of Canadian DCs were assessed by asking what percentage of their patients, in the previous year, was formally referred to an MD and what percentage was informally referred (Fig 5).
Data Analysis Chiropractic schools were divided into 2 groups according to location, that is, English-speaking Canada
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a)
b)
Fig 4. a, Survey items for vaccination attitudes. b, Survey item for vaccination behaviors. MD, medical doctor.
Fig 5. Survey item for patient referral patterns. MD, medical doctor. and the US. Programs located in the US were then further clustered into liberal and conservative categories (conservative = “chiropractors who believe in continuing the traditions of chiropractic" and liberal = “interested in mixing elements of modern and alternative therapies into the practice of chiropractic"). 22 Descriptive statistics (percentages, means, and SDs) were used to report the proportion of respondents answering questions evaluating school of graduation, location of graduate, perceived efficacy of treatment, use of radiographic imaging, referral patterns, and vaccination attitudes, relative to school cluster. χ 2 Tests were used to examine observed vs expected frequency of self-categorization into an orthodox/unorthodox chiropractic subgroup associated with chiropractic program. χ 2 Tests were also used to examine these frequencies with respect to orthodox/unorthodox professional attitudes/behaviors, as determined by responses to questions about perceived efficacy, use of plain film radiography, and referral to MDs, within school clusters. For these tests, an expectancy of 80% concordance with orthodox practice (20% unorthodox) was used in the χ 2 testing, based on previous examinations of chiropractic orthodoxy and dissidence, and previous research on the appropriateness of health care. 20,46 A Kruskal-Wallis test was used to compare mean ranks between school groups for the vaccination consistency score, with follow-up Mann-Whitney U tests used to elucidate the significance of any difference between school clusters.
RESULTS Demographic Characteristics of Respondents Of the 749 surveys mailed to DCs practicing in Canada, 740 were deliverable, and 503 were returned, for a response rate of 68%. Seven respondents returned the cover page only, indicating they did not wish to participate. Most respondents attended chiropractic college at CMCC (n = 315; 62.6%), whereas nearly 36% (35.9%) attended a professional program in the US. Table 1 provides a breakdown of respondents by school cluster and Table 2 shows the distribution of respondents by Canadian provinces.
Professional Factions Table 3 provides a breakdown of self-categorized, orthodox vs unorthodox chiropractic factions, relative to school of graduation cluster. Self-categorization from both the liberal US school cluster and from CMCC indicated 80% or greater identification with the orthodox chiropractic subgroups. However, self-categorization to the orthodox subgroups from the conservative school cluster was only approximately 59%. χ 2 Testing indicated that this difference associated with school cluster was statistically significant (χ 2 = 27.06; P = .000).
Professional Practice Characteristics The prevalence of unorthodox practice characteristics among Canadian DCs, with regard to perceived efficacy, use of plain
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Table 1. The Clustering of Chiropractic Schools a and the Proportion of Respondents Represented Within Each Cluster Chiropractic School Cluster
Respondents, Chiropractic Schools Included a % (n)
English-Canadian schools
Canadian Memorial Chiropractic College
“Liberal" US schools Logan; National; New York; Northwestern; Texas; Western States “Conservative" Cleveland KC; Cleveland LA; US schools Life; Life West; Palmer; Palmer-West; Palmer-Florida; Parker; Sherman Other schools Anglo-European; Université du Québec à Trois-Rivières Not provided
62.6 (315) 20.0 (101)
15.9 (80)
clusters showed a high frequency of informal patient referrals to MDs (CMCC: χ 2 = 75.270; P = .000; liberal: χ 2 = 15.960; P = .000; conservative: χ 2 = 14.821; P = .000), there was a trend toward a lower number of DCs educated at conservative US schools who reported making any formal referrals (CMCC: χ 2 = 1.351; P = .245; liberal: χ 2 = 0.561; P = .454; conservative: χ 2 = 2.813; P = .094). This conservative school group also had significantly discordant vaccination consistency scores compared with either Canadian or liberal school graduate groups (U = 8918.000, Z = − 4.842, P = .000; U = 2901.500, Z = − 2.888, P = .004, respectively).
0.8 (4)
DISCUSSION 0.6 (3)
a
Includes only those schools that were attended by respondents of this survey; does not represent a complete list of international chiropractic schools.
film imaging, and MD communication, is summarized in Table 4. Most respondents (76.3%) perceived the efficacy of their treatment techniques in a manner that was considered orthodox. Similarly, a majority of respondents reported use of plain film radiography in a manner that was considered orthodox (78.5%). Almost 80% of Canadian DCs report formally referring some of their patients to an MD or other medical specialist by way of a letter or telephone call, and nearly every respondent (98.6%) claimed to have informally suggested that some of their patients see an MD. Table 5 summarizes the percentage of patients referred by respondents to their MDs each year. Table 6 summarizes the response of participants to queries about childhood vaccination and provides the vaccination consistency scores. The most common responses were to advise that parents talk to an MD or public health nurse for information about childhood vaccines (39.0%) or provide information on both the pros and cons of childhood vaccinations (38.4%). A large majority of respondents expressed agreement with the idea that microorganisms can play a role in disease and usually result in specific signs and symptoms (71.1% agreed or strongly agreed; 8.8% disagreed or strongly disagreed); a smaller majority was in agreement with the statements expressing that vaccinations have improved public health (56.2% agreed or strongly agreed; 21.6% disagreed or strongly disagreed) or have a strong evidence base (55.8% agreed or strongly agreed; 20.7% disagreed or strongly disagreed). Many of the professional practice characteristics examined in this analysis were significantly associated with the school cluster. Doctors of chiropractic in both US-educated groups had significantly discordant perceptions of treatment efficacy (CMCC: χ 2 = 0.081; P = .776; liberal: χ 2 = 4.232; P = .040; conservative: χ 2 = 12.571; P = .000). Graduates of US schools with conservative ideology also had significantly discordant perceptions on the use of radiographic imaging (CMCC: χ 2 = 3.791; P = .062; liberal: χ 2 = 3.055; P = .080; conservative: χ 2 = 17.578; P = .000). Although all school
Professional Factions Data from this investigation show that a significantly greater proportion of DCs from the conservative US school cluster categorized themselves as “unorthodox.” Unorthodox is defined by McGregor et al 20 as corresponding to the chiropractic subgroup believing “subluxation as an encumbrance to the expression of health”; χ 2 = 27.06; P = .000. As determined by previous investigation, practitioners who identify with this unorthodox chiropractic subgroup can be strongly predicted by unorthodox practice characteristics associated with treatment efficacy beliefs, use of plain film radiographic imaging, and attitudes about vaccination. That significantly more practitioners from schools self-defined as conservative are associated with this group suggests that the current chiropractic education system may be encouraging multiple professional identities. Through social identity theory, 12,13 it is to be expected that multiple identities will create strong within-group trust, leading to bias and strife directed at those out of group, even when those out of group are members of the same profession. Certainly, this has been observed among subgroups within the chiropractic profession. 21,47 Chiropractic factions, encouraged by chiropractic college affiliation, places stress on interprofessional communication, and ultimately, patient care may become compromised. Although all professions have factions, 14–19 a profession like medicine, with a strong overall, perceived, uniprofessional focus, is likely to find communication difficult when trying to relate to the multiple identity phenomenon in chiropractic. Unfortunately, poor interprofessional communication has been suggested to manifest as hesitation in the appropriate referral of patients between professions. 7 It is clear that the problem of college-engendered factionalism must be resolved for the benefit of patient care. We suggest that multiple professional identities in chiropractic may be expected to have an adverse impact on interprofessional relations, which may be already challenged by the attributes associated with social identity theory. 12,13 Knowledge from this study may inform the development and assessment of strategies to encourage a re-evaluation of chiropractic's multiple professional identities and their impact on interprofessional relationships, for the sake of improving the efficiency, quality, and safety of patient care. The findings of this study suggest that
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Table 2. Response Rates and Respondent Demographics by Province Province
Other, a Response Rate, % (n) CMCC Graduates, % (n) Liberal US Graduates, % (n) Conservative US Graduates, % (n) % (n)
British Columbia Alberta Saskatchewan Manitoba Ontario New Brunswick Nova Scotia Prince Edward Island b Newfoundland Total
71.3 (72) 68.1 (79) 76.2 (16) 68.8 (22) 66.2 (291) 87.5 (7) 71.4 (10) – 85.7 (6) 68.0 (503)
59.7 (43) 32.1 (25) 68.8 (11) 18.2 (4) 74.7 (216) 42.9 (3) 90.0 (9) – 66.7 (4) 62.6 (315)
29.2 (21) 24.1 (19) 12.5 (2) 36.4 (8) 16.8 (49) 14.3 (1) 10.0 (1) – 0 (0) 20.0 (101)
9.7 (7) 43.0 (34) 18.8 (3) 45.5 (10) 7.2 (21) 42.9 (3) 0 (0) – 33.3 (2) 15.9 (80)
1.4 (1) 1.3 (1) 0 (0) 0 (0) 1.7 (5) 0 (0) 0 (0) – 0 (0) 1.4 (7)
CMCC, Canadian Memorial Chiropractic College. a Reported receiving their formal chiropractic education somewhere other than CMCC or a US school or did not provide place of education. b All mailed surveys (n = 2) were undeliverable
Table 3. Self-Categorization Into Chiropractic Faction Relative to School Cluster School Cluster “Conservative" “Liberal" CMCC Total
Orthodox % (n) 59.15 (42) 80.81 (80) 86.04 (265) 80.96 (387)
Unorthodox
Total
% (n)
% (n)
40.85 (29) 19.19 (19) 13.96 (43) 19.04 (91)
100 (71) 100 (99) 100 (308) 100 (478)
Efficacy of treatment, use of radiographic imaging, and χ . Sample size reflects respondents who provided answers to both questions. CMCC, Canadian Memorial Chiropractic College. χ2 = 27.06; P = .000 2
the development or sustainment of multiple professional identities in chiropractic may be facilitated, at least in part, by an individual's chiropractic college affiliation.
Perceived Efficacy and Interprofessional Communication Although most discussions with regard to the efficacy of chiropractic care are focused on spinal manipulation/ mobilization, most DCs use a wide variety of therapies for their patients (eg, manual and physical therapies, exercise, therapeutic modalities, health and lifestyle advice, etc). 3,4 We found that a majority of respondents perceived the value of these treatments in a manner that is reasonably consistent with current peer-reviewed literature. However, nearly a quarter of the Canadian DCs surveyed (23.7%) expressed the belief that they could effectively treat diseases that have known genetic and/or visceral-related underpinnings and no identified peer-reviewed basis for treatment with manual therapies. Unorthodox perceptions of efficacy were significantly more likely among DCs who matriculated from US schools (liberal: χ 2 = 4.23, P = .04; conservative: χ 2 = 12.57, P = .00). McGregor et al 20 found that those respondents with unorthodox perceptions of efficacy were more likely to perceive subluxation as an encumbrance to the expression of health, suggesting that these respondents continue to espouse a traditional chiropractic treatment model. 21,22 This might help to explain why those
respondents who graduated from conservative US chiropractic schools were also least likely to have made formal patient referrals to an MD, perceiving their treatment model as preferable over the biomedical alternatives offered by their medical colleagues and for a broader range of diseases.
Use of Plain Film Radiographic Imaging Among primary health care providers who can request radiographs, DCs are sometimes thought to have utilization rates that exceed what is recommended by practice guidelines. There is indeed some evidence reported in the chiropractic literature of inappropriate use of imaging services. 48–50 Evidence-based, chiropractic radiography guidelines suggest that plain film imaging be restricted to patients with suspected serious disease because, outside of this use, imaging adds very little value to the diagnostic evaluation of spinal pain. 43 Biomechanical assessments or assessment for chiropractic subluxations is not recommended because of morphologic asymmetries, geometric and positional distortions, measurement errors, poor correlation with symptoms, and lack of convincing clinical usefulness. 43 Our survey suggests that most Canadian DCs are not ordering plain film radiographs for the purpose of identifying subluxations. This finding is consistent with previous studies, which have suggested that most radiology instruction provided by accredited chiropractic programs appears evidence based 51 and that there is a strong adherence to radiography guidelines at chiropractic teaching clinics in Canada. 52 However, our study also suggests that a minority of practitioners continue to use radiography for the identification of subluxations, despite the existence of evidence-based guidelines for DCs that advise against it. The unorthodox use of plain film imaging was significantly more likely to be found among those respondents who matriculated from US schools that were self-described as having a conservative ideological grounding (χ 2 = 17.58; P = .00). This is consistent with findings of a recent examination of spine radiograph utilization by DCs in the US, which found that chiropractic school attended was one of the most influential predictors of spine radiograph utilization among DCs. 53
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Table 4. Perceived Efficacy, Use of Radiographic Imaging, and Interprofessional Communication by Respondents According to Chiropractic School Cluster CMCC
Liberal US Schools Conservative US Schools Total a
Unorthodox perceptions of efficacy, % (n) 19.4 (60/310) 28.0 (28/100) b Unorthodox use of radiographic imaging, % (n) 15.6 (49/314) 26.7 (27/101) No formal communication with an MD in previous year, % (n) 17.4 (54/311) 22.8 (23/101)
37.0 (27/73) b 38.8 (31/80) b 27.5 (22/80)
23.7 (116/490) 21.5 (108/502) 20.3 (101/498)
CMCC, Canadian Memorial Chiropractic College; MD, medical doctor. a “Total n” may be greater than the sum of the other columns because the “Total n” includes those respondents who graduated from schools outside of English Canada and the US. b Significantly (P b .05) greater than the expected 20% unorthodoxy.
Table 5. The Percentage of Patients Referred to an MD in the Previous 1 Year According to Chiropractic School Cluster CMCC
Liberal Conservative US Schools US Schools Total
% Formally 9.7 (14.1) 8.7 (12.8) referred, Ave (SD) % Informally 20.7 (18.6) 17.2 (16.3) referred, Ave (SD)
5.1 (7.3)
8.7 (13.0)
17.8 (16.4)
19.5 (17.8)
CMCC, Canadian Memorial Chiropractic College.
Vaccination Attitudes and Behaviors Concerns have been raised about the beliefs and behaviors of DCs as they relate to immunization. Consistent with a previous survey of Alberta DCs, 54 our study suggests that a majority of Canadian DCs understand the role of microorganisms in infectious disease; they agree that there is good scientific evidence to support vaccination theory and that vaccination has improved public health. The comparison of vaccination consistency scores indicates that attitudes regarding the cause of infectious disease and the role of vaccination in public health are significantly associated with the ideological foundation of the chiropractic schools where DCs received their formal chiropractic education. Unorthodox attitudes were significantly more likely to be found among respondents who matriculated from conservative US schools and least likely from graduates of CMCC. When examining vaccination-related behaviors that could promote interprofessional collaboration (ie, referring patients to an MD or public health nurse for information) or, alternatively, behaviors that could marginalize the profession (ie, advising parents against vaccinating their children), respondents from conservative US schools were approximately 4 times as likely to report giving antivaccination recommendations as respondents from CMCC. Respondents who graduated from CMCC were nearly 4 times as likely to recommend a discussion with an appropriate medical health professional. Although an earlier investigation of Alberta DCs did not find any association between vaccination attitudes or behaviors and country of matriculation from chiropractic school, 54 that
analysis did not account for the ideological differences between US schools. The current study suggests that the largest proportion of DCs in Canada prefer to leave discussions about childhood vaccination to other appropriate health care providers. A previous survey investigation suggested that it was common for Alberta DCs to advise patients on freedom of choice, 54 and similarly, the current study found that discussing the pros and cons of vaccination with parents was an approach preferred by many Canadian DCs. Earlier investigation of Alberta DCs found a much greater proportion of respondents would advise parents against vaccinating their children (27%), 54 than did our study (6.7%). However, upon analyzing only the survey data from respondents practicing in Alberta, 16.2% (12/74) indicated that they would provide information against childhood vaccinations. This is both higher than the national average in our data and lower than previous work. 54 Potential differences between national results and those of Alberta DCs may be explained by regional differences regarding where DCs received their formal chiropractic education. Our data (Table 2) suggest that Alberta and Manitoba may have higher proportions of licensed DCs who matriculated from US schools that have a conservative ideological grounding.
Limitations Our study has a number of limitations. The clustering of US schools was based on a previous analysis of the ideological grounding, as self-reported by school administrations and not all schools were represented. 22 The current study did not confirm the results of the 2005 analysis and does not suggest which of these schools continue to espouse a conservative ideological grounding. The data presented here were self-reported and thus were not subject to independent verification. As such, the responses may have been influenced by a social desirability bias. The response rate (68%) may be considered a strength that increases the validity of the findings 55; however, we do recognize that this was a select sample and that both nonsurveyed and nonresponders may have differed systematically from responders in ways that we are unable to predict.
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Table 6. The Distribution of Responses to the Question: “If a Patient Asked for Information Regarding Childhood Vaccinations, How Would You Usually Respond?” and Average Vaccination Consistency Scores Grouped According to Chiropractic School Cluster Advise to vaccinate, % (n) Advise against vaccination, % (n) Give pros and cons, % (n) Refer to MD or health nurse, % (n) Refer them to specific website, % (n) Suggest they search the internet, % (n) Vaccination consistency scores, Ave (SD) b
CMCC
Liberal US Schools
Conservative US Schools
Total a
3.1 (9) 4.1 (12) 33.6 (99) 47.1 (139) 5.8 (17) 6.4 (19) 6.9 (2.7)
3.2 (3) 6.5 (6) 43.0 (40) 33.3 (31) 4.3 (4) 9.7 (9) 7.4 (3.0)
2.8 (2) 16.9 (12) 52.1 (37) 12.7 (9) 7.0 (5) 8.5 (6) 8.6 (2.8)
3.0 (14) 6.7 (31) 38.4 (178) 39.0 (181) 5.6 (26) 7.3 (34) 7.3 (2.8)
CMCC, Canadian Memorial Chiropractic College; MD, medical doctor. a “Total n” may be greater than the sum of the other columns because the “Total n” includes those respondents who graduated from schools outside of English Canada and the US. b Scores could range from 3 to 15; lower scores reflect a more positive attitude toward vaccination. A significant (P b .05) difference was found between school clusters.
Our survey only sampled from English-speaking Canadian provinces, and it is plausible that the professional characteristics of DCs in the Canadian Territories and Frenchspeaking Canada may be different than those reported here.
Future Research This analysis was not designed to provide evidence of causation; the results only indicate an association between practice characteristics and chiropractic school attended. Although it would be helpful to design longitudinal studies that compare students' attitudes before and after receiving a formalized chiropractic education, it should be noted that the development of professional identity is understood to begin (at least in some cases) before formal education. 11,56 Value judgments and attitudes toward professions—and potentially its subgroups—may come initially from cultural sources, including the media, which may or may not accurately portray reality. 57 In addition, although formal chiropractic education can be expected to nurture professional attitudes and values, 58 there is evidence that additional self-directed, post-graduate education also contributes to changes in practice characteristics. 59 Future studies should examine the contribution of formalized school curricula as well as independent training seminars marketed to students and postgraduate training to the emergence of orthodox and unorthodox professional identities.
CONCLUSIONS The survey results indicate a significant relationship between ideological cluster of chiropractic educational institution and identification with orthodox vs unorthodox professional factions. Perceived treatment efficacy, use of plain film radiographic imaging, and vaccination attitudes were also significantly associated with the school from which DCs received their professional education. Although
most Canadian DCs appear consistent with orthodox practice, with regard to the items investigated, practitioners from conservative colleges in the US are more frequently associated with unorthodox faction membership and practice characteristics that may challenge chiropractic's relationship with mainstream health care. These findings suggest that the current chiropractic education system may contribute to multiple professional identities.
FUNDING SOURCES OF INTEREST
AND
POTENTIAL CONFLICTS
This project was internally funded by the CMCC Research Division. No conflicts of interest were reported for this study.
CONTRIBUTORSHIP INFORMATION Concept development (provided idea for the research): A.P., and C.R. Design (planned the methods to generate the results): A.P., C.R., and S.I. Supervision (provided oversight, responsible for organization and implementation, writing of the manuscript): A.P., M.M., and S.I. Data collection/processing (responsible for experiments, patient management, organization, or reporting data): A.P., and C.R. Analysis/interpretation (responsible for statistical analysis, evaluation, and presentation of the results): A.P., J.D., and M.M. Literature search (performed the literature search): A.P., J.D., and M.M. Writing (responsible for writing a substantive part of the manuscript): A.P., and J.D. Critical review (revised manuscript for intellectual content, this does not relate to spelling and grammar checking): A.P., C.R., J.D., M.M., and S.I.
Journal of Manipulative and Physiological Therapeutics Volume 37, Number 9
Practical Applications • There is a relationship between ideological cluster of chiropractic educational programs in the US and practitioners' identification with orthodox vs unorthodox notions of practice. • Most Canadian DCs appear consistent with orthodox practice. • Canadian DCs that matriculated from conservative programs in the US are more frequently associated with unorthodox practice behaviors.
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