Training, Professional Skills, and Experiences of Doctors of Chiropractic Working in U.S. Federally Qualified Health Centers: A Mixed Methods Study

Abstract

Objective:

The purpose of this study was to examine the training, professional skills, and experiences of Doctors of Chiropractic (DCs) working in Federally Qualified Health Centers (FQHCs).

Methods:

Identified FQHC-employed DCs in the United States were invited to participate in a survey about their training and practice, administered between November and December 2023. A subset of these DCs, along with FQHC administrators and colleagues, participated in qualitative interviews to explore their experiences and the skills necessary for a DC to practice effectively in FQHCs, between February and May 2024. Survey analysis utilized descriptive statistics and content analysis, while reflexive thematic analysis was applied to the interviews by identifying notable themes and creating a codebook.

Results:

Of 206 DCs invited, 101 completed the survey (49.0%). Respondents averaged 18.2 years in practice (range: 1–48, and 44.8% participated in the Public Services Loan Forgiveness program. Fewer than half reported prior experience in multidisciplinary settings (47.4%), additional training through certificates (43.8%), or advanced degrees (28.1%). Many (41.8%) reported using a non-English language with patients, predominantly Spanish (80.5%). DCs frequently performed joint manipulation and soft tissue therapies, primarily for spinal and chronic pain. Interviews involved 12 DCs, 10 administrators, and 7 colleagues. Each group appreciated DCs’ instructional abilities (eg, communication, patient education), patient-centered orientation, and interprofessional competencies (eg, teamwork, collaboration). DCs valued providing chiropractic access to underserved communities and focusing on patient care over business practices.

Conclusions:

DCs working in FQHCs demonstrated a “team mentality” including patient-centered care, interprofessional collaboration, and communication. Their integration into FQHCs enhances team-based care and expands access to nonpharmacologic pain management. (J Manipulative Physiol Ther 2025;48;237–246)

Introduction

The U.S. Bureau of Labor Statistics estimates that employment of chiropractors will grow by 10% from 2023 to 2033, outpacing the growth rate of most other occupations.¹ Although most Doctors of Chiropractic (DCs) provide care in solo private practice, DCs are increasingly joining multidisciplinary settings in hospitals or multispecialty clinics, including through the Veterans Health Administration (VHA).^2–5 Studies of multidisciplinary settings that have implemented chiropractic services have reported high satisfaction and perceived value from patients, medical providers, and administrators.^3,6 While some research has explored the preferred skills and training of the DCs working in multidisciplinary and VHA settings, we are unaware of any research that investigates DC providers in Federally Qualified Health Centers (FQHCs) specifically.^4,6 This is of particular interest given that FQHCs primarily provide care to medically underserved and marginalized populations, demographics typically underrepresented in chiropractic clinical settings and research.²

Over 50 million Americans experience chronic pain, which disproportionately impacts individuals from medically underserved and marginalized communities.^7,8 Older adults, veterans, and adults who are unemployed or have low socioeconomic status have a higher prevalence of chronic pain.⁹ The majority of chronic pain is musculoskeletal in origin, including low back pain and neck pain, which are a top healthcare expenditure in the United States.^10,11 Individuals at highest risk for musculoskeletal pain have low socioeconomic status, low educational status, and identify as Black.^12–15 Individuals from medically underserved and vulnerable populations often encounter barriers to accessing guideline-concordant treatment for pain, including low health literacy and financial or transportation insecurity.^16,17 In 2023, more than 31 million people, mostly with public insurance or uninsured, relied on FQHCs for access to comprehensive healthcare services.¹⁸

Integrative and multimodal treatment approaches are recognized as best practices for managing chronic musculoskeletal pain.¹⁹ Treatments commonly utilized by DCs, such as spinal manipulative therapy, exercise instruction, and soft tissue therapies, are endorsed as first- and second-line interventions by clinical practice guidelines for pain management.^3,20–22 While DCs deliver high-value pain management, less than 10% of FQHCs offer chiropractic services nationwide.⁵ Little is known about what professional competencies best prepare DCs to work in and contribute to community health care environments like FQHCs. The purpose of this study was to examine the training, professional skills, and experiences of DCs working in FQHCs.

Methods

A mixed-methods approach was used to address an underexplored area of chiropractic research. This study included a survey of chiropractors who work full- or part-time in FQHCs, and follow-up qualitative interviews of FQHC-employed chiropractors, administrators, and professional colleagues (Fig 1). The online survey was administered between November and December 2023. The qualitative interviews were completed between February and May 2024. Participants were instructed that completion of the survey was considered consent, and interview participants provided verbal consent via a recorded video prior to the start of the interview.

Fig 1.

Participant recruitment. Survey includes both quantitative and qualitative data collection; Interviews include qualitative data collection^{. †}A purposeful sample of the chiropractors, administrators, and professional colleagues. DCs, Doctors of Chiropractic.

Ethics

The Institutional Review Board of Northwestern Health Sciences University (NWHSU) provided ethics approval for this study. We adhered to the GRAMMS checklist in the design and reporting of this manuscript.²³

The online survey consisted of 27 structured questions about provider and clinical characteristics, patient populations seen, provider roles within the FQHC, and opportunities for provider collaboration. The survey results were anonymous unless the participants voluntarily chose to include their names and contact information for a follow-up interview. More detailed methods describing the survey development, data collection, and analysis are described elsewhere.⁵ The purpose of the survey was to first gather broad, descriptive data about DCs working in FQHCs to then further explore those findings in greater depth through qualitative inquiry.

Chiropractors who participated in the survey could volunteer to participate in a 30-minute virtual interview regarding their experience providing care in an FQHC. Additionally, DCs had the option of suggesting the names of FQHC administrators or professional colleagues (eg, MD, NP, DDS) within the system to participate in a 30-minute interview regarding their experiences working alongside chiropractic services. The names and email addresses of the DCs who volunteered, along with those of their administrators and professional colleagues, were collected and stored in a password-protected file on the cloud-based server at NWHSU and accessible only by the investigative team.

A purposeful sample of DCs, administrators, and professional colleagues was used to recruit a diverse sample of participants among FQHC systems, professional credentials for colleague and administrator interviews, and geographic regions. The expected sample size per cohort was 15 DCs, 10 administrators, and 10 professional colleagues. Interview participants were offered a $100 gift card for their time.

Three investigative team members (AA, CS, MM) developed semi-structured, open-ended questions for each cohort interviewed (See supplementary file Appendix 1). All 5 investigative team members (AA, CS, AL, PR, MM) received standardized training before conducting interviews, which were conducted via Microsoft Teams (Microsoft, Redmond, USA). Video and audio of the interviews were recorded, and transcripts made available through Microsoft Teams were individually reviewed for quality assurance.

Thematic analysis of interview data was utilized, considering each cohort separately. Full transcripts were imported into Dedoose software (SocioCultural Research Consultants, LLC version 9.2.12).²⁴ Three teams of 2 investigators independently read and coded a single transcript, highlighting notable themes or quotes utilizing Dedoose software functions to create a codebook, utilizing reflexive thematic analysis.²⁵ Following the first independent review of a single interview, the investigators met by videoconference to reach coding consensus. Following consensus, the investigators independently reviewed the next 2 interview transcripts and then met for consensus. This process continued until all transcripts from that cohort were coded. After all interviews were coded, themes were organized by question and retained in a master copy. Themes from qualitative interviews were used to contextualize and expand on survey findings, offering a more holistic representation of the data.

This report includes DC’s responses to the survey and qualitative interview responses from DCs, administrators, and colleagues relating to training, professional skills, and experiences of DCs working in FQHCs.

Results

There were 101 DCs that participated in the survey (49.0% response rate) and 29 interviews: 12 DCs, 10 administrators, and 7 colleagues (Fig 2). Administrative roles included chief executive officers, medical directors, and development officers; colleagues included medical doctors, a dentist, an optometrist, an advanced practice registered nurse, and a nurse practitioner. DCs had an average of 18.2 years in clinical practice (range 1–48) and were graduates of 15 chiropractic educational institutions in the United States. Among DC survey respondents, 44.8% reported participation in the Public Service Loan Forgiveness program.

Fig 2.

Interview participants by region. Regions based on U.S. Census. https://www2.census.gov/geo/pdfs/mapsdata/maps/reference/us_regdiv.pdf. DC, Doctor of Chiropractic.

Training

Although most DCs did not have additional degrees beyond their doctor of chiropractic degree, 28.1% obtained additional degrees. Of these, 53.6% earned a Master’s degree and 30.0% completed a postdoctoral diplomate program. The most common Master’s degrees were Master’s in Business Administration (10.7%), Master’s in Human Nutrition (7.2%), Master’s in Health Sciences (7.2%). Of postdoctoral diplomate programs, the most common disciplines were sports medicine (14.3%), neurology (10.7%), functional medicine (7.1%), and rehabilitation (7.1%).

Approximately 44% of DCs earned certifications to support patient care, including soft tissue techniques (38.1%), sports medicine (23.8%), and nutrition (19.0%). Most DCs (82.5%) agreed that they had the skills necessary to succeed in an FQHC environment. One participant shared, “from a clinical aspect and being able to work with different providers, I thought I was well prepared to do that from my education” (DC 3). Over half of DCs (53.6%) reported not having worked in a multidisciplinary setting before working at an FQHC. Of those with multidisciplinary experience (47.3%), 28.6% of respondents gained exposure as students at an FQHC (33.3%) or a VHA hospital (33.3%).

Skills

Core themes emerged from interviews highlighting the essential skills necessary for a DC to succeed in an FQHC setting, with a high level of consistency between the DC, administrator, and colleague interviews.

Instructional Proficiency

“Communication is #1” (DC 11).

The ability of DCs to provide instruction, whether to inform patients or other providers to coordinate care, was often cited. The ability to effectively converse was central to this proficiency. Among surveyed DCs, 41.8% reporting speaking a language other than English with their patients, predominantly Spanish (80.5%). Effective communication with other medical professionals requires that a DC utilize common medical terminology, “(a DC has) to be able to talk in their language, speak medical” (DC 10).

Delivering patient education was reported several times as an important aspect of DC’s role within the FQHC. This was viewed as foundational for building health literacy and promoting self-efficacy. One DC described, “I will spend as long as it takes to educate (patients) and to help them understand and how to help them recover… so I’m educating about what’s wrong with them, I’m showing them their x-rays, I am going through exercises, I’m going through whatever I need to help them recover faster” (DC 12). Another DC emphasized empowering patients through small, manageable interventions: “by giving patients exercises and just implementing small things like walking or showing them exercises for their low back pain, (patients) have a hand in their own care. So, I feel like that positive reinforcement and letting them know ‘hey, you are actually in control of your own health’ or at least this one thing in your life, that does well with compliance and patient outcomes” (DC 6).

Several professional colleagues indicated limited familiarity with chiropractic practice prior to working with a DC at the FQHC and expressed uncertainty about which patients would be appropriate candidates for referral. A commonly reported strategy to address gaps in knowledge about chiropractic care was for DCs to provide educational outreach to their colleagues and discuss how chiropractic services could integrate into an interdisciplinary care model. In some instances, this initiative was fostered by administration: “We started with a meeting with all of our providers and we wanted them to know (a chiropractor) was coming, but also give them a high-level review of what types of conditions would be appropriate to be treated by chiropractic and then we discussed what the referral process looked like” (Administrator 8). Interprofessional education was highly valued and contributed positively to care coordination among colleagues, “it’s changed how I manage patients, the chiropractic department here is part of the puzzle piece to the Health Center” (Colleague 6). Another DC reflected on feedback from colleagues noting, “they would say ‘Wow, I didn’t know you guys’ exam like that’ or ‘Man, that was really informative’ or ‘I didn’t think of it in that way’, so it’s been a really good thing for (colleagues)” (DC 8).

Patient-Centeredness

“Focus on the patient” (DC 1)

Participants emphasized the importance of adopting a patient-centered, biopsychosocial approach to care. DCs who were perceived as successful in the FQHC setting demonstrated flexibility, creativity in treatment planning, and adaptability in aligning care with patients’ goals and priorities. One colleague noted, “being flexible and being patient, a lot of patients are tough. You know, some of them are homeless, some of them sleep on rotten mattresses and have no other choice” (Colleague 4). Similarly, a DC shared, “I always ask people ‘What is the one thing you would do tomorrow if you woke up with 0 out of 10 pain?’ Whether that’d be grocery shopping by yourself, hiking, picking up grandkids, whatever the case may be, that’s the thing we’re going to try to achieve, right?” (DC 11).

Many participants observed that patients in FQHCs often present with greater medical complexity than those typically seen in private practice, and frequently face considerable barriers related to social determinants of health. One DC described, “our patients lack transportation, they lack housing, they lack food, they have all manner of complex health issues that they are trying to manage, and they are trusting the team at our Health Center to be able to help them” (DC 1).

Colleagues and administrators emphasized the importance of understanding the patient populations and connecting with the values of the surrounding community. One colleague emphasized, “understand the demographics of the patients and align with the mission, vision, and values not only of the clinic, but with the community” (Colleague 2). Cultural competence and agility were also identified as essential skills for delivering compassionate care that considers individual social drivers of health. “A lot of (patients) culturally don’t want to take medications for everything – they want a conservative avenue and someone to teach them how to recover faster so they can go back to work” (DC 12).

Interprofessional Competence

“Has to be a great team member” (Administrator 3)

Interview participants suggested DCs should embody a “team mentality” (Colleague 1) attitude and demonstrate a willingness to collaborate with the broader interdisciplinary team. Participants recommended that DCs understand the integrative care model and recognize how each care team member contributes to addressing patient needs. One DC noted, “The main thing is understanding chiropractic’s place within the team” (DC 1). The ability to engage the care team when clinical concerns extend beyond the DC’s expertise was also emphasized, “how do you handle complexity especially when (a patient) brings up on the chiropractic table that ‘I have suicidal thoughts’” (Colleague 5).

As integrated team members, DCs also contribute to care coordination and improving patient adherence to treatment plans across providers. One DC shared how building rapport with patients reduced stigma and increased a patient’s openness to a referral mental and behavioral health services: “giving (patients) that space and opportunity, it is really beneficial because whenever you mentioned ‘We have integrative behavioral health here’ (patients) automatically assume you got to go sit on a couch and talk about your feelings and so that’s a big turnoff for them. If we’re just able to just have a conversation and we build a little rapport and then maybe 4 or 5 visits down the line, maybe that’s where that opportunity opens up (to a possible referral)” (DC 11).

Excellence in clinical reasoning and differential diagnosis also emerged as recurring themes among interview participants. A DC explained, “particularly with chronic pain patients that have multiple co-morbidities, you have to determine what’s going to be the best benefit for the patient” (DC 5). An administrator shared the reason behind implementing a chiropractic service line was “in response to one of the number one complaint seen in primary care, neck and back pain, and it allows (the system) to provide that care in the context of primary care collaboration with the care team and in a non-opioid related service” (Administrator 9). DCs overwhelmingly reported treating patients with spinal conditions and chronic pain (Fig 3), utilizing manipulation and soft tissue techniques (Fig 4).

Fig 3.

Frequency of conditions addressed (n = 98). DCs, Doctors of Chiropractic; MSK, musculoskeletal. Preventative care measures, for example, blood pressure screening, other screening recommendations. Advice on health habits, for example, exercise, tobacco use, stress management.

Fig 4.

Frequency of treatment procedures (n = 98). DCs, = Doctors of Chiropractic. Joint manipulation/mobilization included manual or instrument-assisted techniques. Soft tissue therapies (eg, myofascial release, ART, Graston). Attended therapy (eg, ultrasound, e-stimulation, laser). Behavior health (eg, motivational interviewing, health coaching).

Chiropractic Experience: Rewards and Challenges

Overall, DCs describe their experience of working in an FQHC as rewarding. Building positive relationships and trust between healthcare providers and administrators was gratifying. DCs were welcomed into the system and reported having positive relationships with their colleagues, “I was treated with incredible amounts of respect, I felt like I was kind of expecting to have to prove myself, but everybody was just instantaneously accepting” (DC 2). DCs commonly highlighted that transitioning into a larger healthcare system and assuming an employee role were notable changes when starting their employment at an FQHC. Some DCs shared this has allowed them to focus on patient care, “When I’m done with patients, I can go home, I don’t have to worry about the business, and I can take time off” (DC 3). Overwhelmingly, DCs report that the most rewarding aspect of their job is providing care to patients who might not otherwise be able to access chiropractic services. “It’s very rewarding to see people that sometimes don’t even have electricity or running water, but they’re able to get adjusted” (DC 2).

Systematic challenges were cited as a frustrating barrier among interview participants. One common significant barrier involved arbitrary limits on patient visits imposed by insurance carriers. Administrators also pointed to the current reimbursement model as a substantial constraint, noting that it poses a barrier to growth within the chiropractic service line in FQHCs. The high demand reported for chiropractic appointments could create a barrier to timely access for patients, “lack of access in terms of how many chiropractors we have available and their availability” (Colleague 3). Transportation insecurity was another frequently mentioned barrier, often leading to missed or delayed appointments. “Schedules are more of a guideline working in an FQHC, so many patients are relying on public transportation” (DC 7), a DC shared, reflecting on the unpredictability of patient attendance.

Discussion

The current study contributes to existing literature about the experience of chiropractic integration in multidisciplinary settings, using mixed-methods and a range of key informants. The results of this study demonstrate both similarities and important contrasts with a recent practice analysis of chiropractic.² According to the practice analysis, most DCs are sole proprietors, and report dedicating several hours, outside of patient care, to business management activities such as employee oversight and marketing.² Whereas the majority of FQHC-employed DCs previously reported are employees with no effort allocated towards business practice.⁵ The DCs in this study often reported that the ability to focus mostly on patient care was a benefit. Like practice behaviors generally, FQHC-based DCs commonly employ spinal manipulation, manual therapies, and patient education to manage spinal conditions.²

Many of the skills valued by the participants in this study align with those identified in other multidisciplinary settings including clinical acumen, mission alignment, teamwork, and emotional intelligence.⁶ Notably, this study uniquely highlights how the care management approaches of DCs are influenced by the psychosocial characteristics and social determinants of health impacting their patients. The current study emphasizes the importance of public health and clinical acumen needed to care for special populations, which have been reported as lacking in chiropractic education.²⁶ Additional emphasis of these competencies in continuing education and Doctor of Chiropractic program curricula may better prepare DCs to contribute to FQHCs and similar practice environments.

Postgraduate training opportunities for DCs are increasing in integrative settings with residencies within several VHA hospitals and fellowships at large private educational institutions.²⁷ As the chiropractic workforce increases and integrative opportunities continue to develop, there is a need for chiropractic educational institutions to prioritize and promote interprofessional education and clinical opportunities for students. A team of investigators from a single chiropractic education institution surveyed students regarding perceptions of interprofessional care teams.²⁸ While most students responded positively to collaboration with other providers, they lacked the knowledge and understanding of their role within an interprofessional healthcare team. ²⁸ Similarly, participants in this study emphasized that as key skill for DCs to succeed in an FQHC setting is a clear understanding of their role within the interdisciplinary care team. Chiropractic educational institutions can address these gaps by emphasizing interprofessional education, promoting integrative postgraduate practice opportunities, and cultivating relationships with diverse, multidisciplinary settings, like FQHCs, for student clinical internship rotations.

In 2025, the Council on Chiropractic Education (CCE) published updated accreditation standards of the required competencies for Doctor of Chiropractic degree educational programs.²⁹ This study’s findings align with several CCE meta-competencies as they pertain to assessment and diagnosis, management, health promotion and disease prevention, communication and record keeping, cultural competency, chiropractic adjustment/manipulation, and interprofessional education.²⁹ The updated CCE accreditation standards align more closely with recommendations for competencies for integrative practice identified by Academy Collaborative for Integrative Health.³⁰ Our findings also substantiate the results of a 2024 Delphi panel, which identified 4 domains for competencies appropriate for preparing DC students for clinical practice in an integrated healthcare setting: collaboration, clinical excellence, communication, and systems administration.³¹ Similarly, the professional training and skills noted by participants in this study align with competencies identified in a 2025 scoping review which identified several knowledge and cognitive, functional, behavioral, value and ethical competencies.³²

DCs were reported to be valuable members of the integrative healthcare team within FQHCs to support care delivery for underserved and marginalized populations with complex, co-morbid conditions. FQHC administrators in this study facilitated the integration of DCs into interdisciplinary care teams as a conservative treatment option for spinal conditions and chronic pain by implementing strategies such as interprofessional education and supporting collaborative case management. Future research should examine clinical patient reported outcomes when chiropractic is made available within the integrative care model of an FQHC, as well as care coordination between healthcare providers.

Limitations

There are limitations and risks of bias to both the quantitative and qualitative aspects of this study. Limitations of the survey portion of this study were published in a previous publication, and included the possibility of outdated FQHC websites, the dynamic nature of employment status, and some FQHC-employee emails that were blocked by firewall as spam.⁵ Limitations to the qualitative data in this study are primarily related to risk of bias. Only DCs who completed the survey were eligible to participate in the qualitative interviews. Further, only DCs who completed the survey submitted names of administrators and collaborators who were subsequently approached for participation in this study. It is likely that only those suspected of having a positive view of chiropractic were nominated, creating participant bias. Individuals who receive care in FQHCs were not interviewed. Their perception of the training and skills of DCs in this environment remain unknown. It is also unknown to what degree our findings are transferable to other FQHCs or community health centers. While all FQHCs are independent from one another, there was consistency across participants in the key themes reported here, and we feel that a saturation of themes was accomplished. Although all researchers took part in qualitative training before this study and utilized a standardized interview schedule, 3 members of the investigative team had limited experience conducting and analyzing qualitative interviews. To reduce the risk of interviewer bias, investigators with less experience were paired with more experienced investigators to analyze interviews in teams.

Conclusion

This study provides foundational information regarding the training, professional skills, and experiences of chiropractic integration into FQHCs. While fewer than half of the surveyed DCs had prior experience in multidisciplinary settings or pursued advanced or clinical training, they reported possessing the skills necessary to succeed in the FQHC environment. Interviews across DCs, FQHC administrators, and FQHC colleagues consistently emphasized the importance of instructional prioficiency, patient-centeredness, and interprofessional competence. Despite systemic barriers such as insurance limitations and access challenges, DCs report high levels of professional fulfillment, particularly from serving underserved populations. These findings highlight a unique role of chiropractic care in safety-net settings.

Supplementary Material

Supplementary material associated with this article can be found in the online version at doi:10.1016/j.jmpt.2025.09.007.

Practical Applications.

• This study provides foundational information regarding the professional training, skills, and experiences of chiropractors providing care in Federally Qualified Health Centers.

• This study describes administrators’ and professional colleagues’ perceptions and experiences of chiropractic services within Federally Qualified Health Centers.

• These findings can help inform chiropractic education and better prepare chiropractors to be successful in settings that primarily serve low-income and medically underserved populations.