Patient-centered communication in chiropractic education: A cross-sectional survey of chiropractic students in North America

Abstract

Objective

The primary objective of this study was to explore chiropractic students’ predisposition to patient-centered communication (PCC), focusing on empathy and cultural humility.

Methods

A survey-based study was conducted across 7 doctor of chiropractic programs in North America. Eligible students were invited to participate in an electronic survey assessing empathy (the revised Kiersma-Chen Empathy Scale) and cultural humility (the Foronda Cultural Humility Scale). Linear regression was used to examine the relationship between (1) doctor of chiropractic program enrollment and empathy and cultural humility and (2) PCC-related coursework completion and empathy and cultural humility.

Results

A total of 426 responses to the electronic survey were collected (7% response rate). Most participants were enrolled in preclinical coursework (61%) and had completed PCC-related coursework (76%). Empathy was lower among clinical students though not statistically significant (β = −1.20; confidence interval, −2.93 to 0.52; p = .169). No significant associations were found between enrollment status or PCC coursework and either empathy or cultural humility.

Conclusion

No significant associations were found between PCC-related coursework or enrollment status and empathy or cultural humility. This study highlights an underexplored area within chiropractic education and calls for comprehensive research to characterize the integration of PCC within chiropractic curricula and clinical training.

INTRODUCTION

Effective communication that prioritizes a patient’s perspective and preferences is an essential component of patient-centered care.^1–3 Accordingly, the use of patient-centered communication (PCC) is widely recognized as a standard of care,^4–6 and PCC-related skills are a required competency among many undergraduate health professions programs.^7–9 Despite this, a gap may exist in the use of PCC in clinical practice.^10,11 Studies indicate patients report that their emotional and informational needs may go unmet during clinical encounters,^11,12 and this may signal gaps in communication and potentially contribute to dissatisfaction with health care experiences.^12–14

Patients with serious illness and those from marginalized backgrounds tend to report poorer communication with health care providers.^15,16 These communication gaps are associated with greater difficulty accessing care, delays in receiving services, increased emergency department use, and higher financial strain.¹⁶ Although a patient’s emotional and informational needs may extend beyond patient–clinician communication,¹⁷ PCC plays a critical role in improving patient experiences and outcomes.^1,18 Evidence demonstrates that PCC results in higher quality of care and more favorable outcomes when compared with care given without PCC.^19–21 Given this impact, it is important to explore how the communication dimensions of patient-centeredness are reflected in health professions education.

Understanding how PCC is enacted requires attention to its interpersonal dimensions that shape how clinicians connect, listen, and respond to patients. For the purpose of this study, these interpersonal dimensions are conceptualized as communication skills, including empathy, cultural humility, and evidence-based interviewing approaches, such as motivational interviewing (MI).²² Empathy in clinical encounters reframes the traditional disease-centered model by centering the relational and emotional dimensions of care.²³ In practice, this entails perceiving the patient’s concerns and distress, allowing oneself to be affected by that experience, and responding with a desire to ease the patient’s suffering,²⁴ forming a foundation for PCC.⁵ Cultural humility is understood as a lifelong practice of self-reflection and openness rather than the attainment of cultural knowledge; it involves acknowledging personal biases and learning from patients’ lived experiences.²⁵ Together, empathy and cultural humility represent key interpersonal dimensions of PCC that shape how clinicians communicate and engage with patients.

Chiropractors have traditionally engaged with patients at a socioemotional level, approaching patient–clinician relationships with patience, kindness, attentiveness, and sympathy.^26–28 However, it remains unclear whether these relational tendencies translate into taught communication competencies consistent with PCC. Many patients seen in chiropractic settings, particularly those with chronic back and neck pain, also represent groups that experience disparities in health care communication. Because chiropractors care for individuals navigating persistent pain within the broader context of biopsychosocial complexity,^29,30 effective communication becomes a cornerstone of high-quality, patient-centered care. Although prior research has addressed patient-centered care more broadly in chiropractic education,^31,32 there remains a gap in exploring the communication dimensions that give meaning to the concept of patient-centeredness. This insight underscores the importance of examining how chiropractic students develop competencies in communication that foster empathy, cultural humility, and collaboration with the patient.

Whereas empathy and cultural humility do not encompass all dimensions of PCC, this study focuses on these constructs as core interpersonal elements of PCC. This approach was informed by prior health professions research that used similar constructs to assess students’ predisposition toward PCC.²² The present study conceptualizes empathy and cultural humility as communication skills central to PCC. The primary objective was to assesses chiropractic students’ predisposition to these skills.

METHODS

Study Design, Target Population, and Recruitment

This study employed a cross-sectional survey design. Quantitative data were collected through a cross-sectional survey that utilized validated questionnaires to evaluate chiropractic students’ self-reported predispositions of PCC skills focused on empathy and cultural humility. The survey was completed between January 21, 2025, and March 5, 2025. Ethics approval was obtained through the Medical College of Wisconsin institutional review board (registration #PRO00052669).

The target population was full-time enrolled chiropractic students in 1 of the following doctor of chiropractic degree programs (DCP) in North America (n = 6076): Canadian Memorial Chiropractic College, Life Chiropractic College West, Northeast College of Health Sciences, Northwestern University of Health Sciences, Parker University, Palmer College of Chiropractic (Florida and Iowa campuses), University of Western States.

Participants included full-time chiropractic students enrolled in either preclinical or clinical phases of their DCP at the time of recruitment. PCC-related coursework completion was assessed as a study variable and was not used as an inclusion or exclusion criterion. There were no additional exclusion criteria. A purposive sampling approach was used to identify organizational collaborators who subsequently distributed the survey within their respective organizations to achieve an attempted census. The primary investigators at the Medical College of Wisconsin (MCW) sent an email invitation containing a link to the electronic survey to a collaborator at each participating DCP. The collaborators at each DCP forwarded the invitation email to all eligible chiropractic students at their respective DCP. Reminder invitation emails with a link to the electronic survey were then sent by the same process from MCW investigators to collaborators and students at 2 and 3 weeks following the initial invitation email.

Survey

The survey was administered electronically using Qualtrics, LLC,³³ and hosted by MCW. The first page of the electronic survey included a full description of the study and included informed consent to participate. The next portion of the survey was used to obtain student demographics (eg, age, gender, race, pre-DCP matriculation education level, DCP enrollment status, PCC-related coursework completion in DCP). DCP enrollment status was defined as either preclinical or clinical. Preclinical status was defined as “the early stage of your curriculum where your primary focus is foundational sciences such as anatomy, physiology, biochemistry, and pathology. Most of your time is spent during this phase without direct patient interaction.” Clinical status was defined as “the later stage of the program where you apply your preclinical knowledge in real-world settings. It involves hands-on experience with patients in clinical environments like hospitals/clinics, under the supervision of licensed professionals.”

The next portion of the survey included items related to predisposition for empathy. Participants reported their predisposition for empathy using the revised Kiersma-Chen Empathy Scale (KCES-R). The KCES-R is a reliable and validated 14-question survey divided into 2 sections.³⁴ The first section assessed global empathy with 7 response categories (1 = unnecessary to 7 = extremely necessary). The second section assessed self-perception of empathy using 7 response categories (1 = does not describe me to 7 = describes me extremely well).³⁵ The range for the total score is 14 to 98 with higher scores indicating greater empathy. The KCES-R has been validated as an empathy scale in allied health professions students.³⁶ The KCES-R was obtained with permission for use in this study from its founders, ensuring adherence to guidelines as outlined by its creators.

Next, participants reported their predisposition for cultural humility using the Foronda Cultural Humility Scale (FCHS). The FCHS is a 19-item survey using a Likert scale (0 = none of the time to 5 = all the time). The scale scores typically range from 19 to 95 with higher scores indicating greater cultural humility. The FCHS was determined reliable (Cronbach alpha = .85) and has been used to assess cultural humility among health professions students.^37,38 The FCHS was obtained with permission for use in this study from its founders, ensuring adherence to guidelines as outlined by its creators. The survey was anonymous, and participants were not required to provide identifying information.

Statistical Analysis

Statistical analysis was completed using STATA version 15.1 (StataCorp). Descriptive statistics were calculated to summarize participant characteristics, including demographic variables. Categorical variables were calculated as percentages, and continuous variables were calculated as mean with ± standard deviation. We completed 4 different linear regression models to explore the relationship between DCP enrollment status, PCC coursework completion in DCP, empathy (KCES-R), and cultural humility (FCHS).

The first linear regression was used to explore the relationship between DCP enrollment status (preclinical or clinical) and empathy (KCES-R), adjusting for covariates. The independent/predictor variable was DCP enrollment status (preclinical or clinical). The dependent/outcome variable was empathy (KCES-R). Covariates included age, gender, race, pre-DCP matriculation education level, PCC-related coursework completion in DCP, and cultural humility (FCHS).

The second linear regression model was used to explore the relationship between DCP enrollment status (preclinical or clinical) and cultural humility (FCHS), adjusting for covariates. The independent/predictor variable was DCP enrollment status (preclinical or clinical). The dependent/outcome variable was cultural humility (FCHS). Covariates included age, gender, race, pre-DCP matriculation education level, PCC-related coursework completion in DCP, and empathy (KCES-R).

The third linear regression explored the relationship between PCC-related coursework completion in DCP and empathy (KCES-R), adjusting for covariates. The independent/predictor variable was PCC-related coursework completion in DCP. The dependent/outcome variable was empathy (KCES-R). Covariates included age, gender, race, pre-DCP matriculation education level, DCP enrollment status (preclinical or clinical), and cultural humility (FCHS).

The fourth linear regression was used to explore the relationship between PCC-related coursework completion in DCP and cultural humility (FCHS), adjusting for covariates. The independent/predictor variable was PCC-related coursework completion in DCP. The dependent/outcome variable was cultural humility (FCHS). Covariates included age, gender, race, pre-DCP matriculation education level, DCP enrollment status (preclinical or clinical), and empathy (KCES-R).

RESULTS

Demographics

A total of 6076 eligible, full-time chiropractic students were invited to participate. A total of 426 participant responses were collected (7% response rate). Table 1 describes demographic characteristics of participants. A greater proportion of participants identified as a woman (59.72%) compared with a man (40.28%). The majority of participants identified as White (80.67%), followed by Asian (6.21%), Black/African American (3.34%), Latinx (5.73%), and other (4.06%). Most participants reported a bachelor’s degree or less as their highest level of education prior to enrollment in the DCP (93.85%). There was variability in preclinical (didactic) and clinical enrollment, with 61.27% reporting preclinical status and 38.73% reporting clinical status. Most participants (75.85%) reported they had completed PCC-related coursework in their respective DCP. The mean score for KCES-R (empathy) and FCHS (cultural humility) was 85.52 and 57.88, respectively. The results related to MI are described elsewhere.

Table 1.

Participant Characteristics

Demographics	No. (%) or Mean (SD)
Age
18–25 years	277 (65.02)
26–35 years	121 (28.40)
≥36 years	28 (6.57)
Gender
Woman	252 (59.72)
Man	170 (40.28)
Race
White	338 (80.67)
Asian	26 (6.21)
Black/African American	14 (3.34)
Latinx	24 (5.73)
Other	17 (4.06)
Education
Undergraduate degree or less	387 (93.85)
Graduate/professional degree	26 (6.15)
Enrollment status
Preclinical	261 (61.27)
Clinical	165 (38.73)
PCC-related coursework completion
No	100 (24.15)
Yes	314 (75.85)
Empathy (revised Kiersma-Chen Empathy Scale)	85.52 (10.88)
Cultural humility (Foronda Cultural Humility Scale)	57.88 (9.72)

Regression Models

Results of the adjusted linear regression model examining the relationship between enrollment status and empathy are shown in Table 2. Participants with a clinical enrollment status had lower empathy compared with participants with a preclinical enrollment status though not statistically significant (β = –1.20; confidence interval [CI], –2.93 to 0.52; p = .169).

Table 2.

Linear Regression Exploring the Relationship between Doctor of Chiropractic Program Enrollment Status (preclinical vs clinical) and Empathy

Variable	Standardized β [95% Confidence Interval]	p-Value
Enrollment (ref: preclinical)
Clinical	−1.20 [−2.92 to 0.52]	.169
Age (ref: 18–25 years)
26–35 years	−1.18 [−3.12 to 0.75]	.229
≥36 years	1.78 [−1.55 to 5.11]	.293
Gender (ref: woman)
Man	−2.19 [−3.91 to −0.47]	.013
Race (ref: White)
Asian	−3.09 [−6.56 to 0.38]	.081
Black/African American	0.82 [−4.11 to 5.75]	.744
Latinx	1.50 [−2.06 to 5.05]	.407
Other	−1.36 [−5.28 to 2.57]	.497
Education (ref: undergraduate or less)
Graduate or professional degree	−3.78 [−7.19 to −0.36]	.030
PCC-related coursework completion (ref: no)
Yes	0.13 [−1.80 to 2.06]	.895
Humility (Foronda Cultural Humility Scale score)	0.65 [0.56–0.74]	<.001

Results of the adjusted linear regression model examining the relationship between enrollment status and cultural humility are shown in Table 3. Enrollment status was not significantly associated with cultural humility (β = 0.21; CI, –1.43 to 1.85; p = .800).

Table 3.

Linear Regression Exploring the Relationship between Doctor of Chiropractic Program Enrollment Status (preclinical vs clinical) and Cultural Humility

Variable	Standardized β [95% Confidence Interval]	P-Value
Enrollment (ref: preclinical)
Clinical	0.21 [−1.43 to 1.85]	.800
Age (ref: 18–25 years)
26–35 years	1.98 [0.14–3.92]	.034
≥36 years	−0.77 [−3.95 to 2.40]	.633
Gender (ref: woman)
Man	−2.27 [−3.90 to −0.63]	.007
Race (ref: White)
Asian	4.38 [1.08–7.67]	.009
Black/African American	2.78 [−1.911 to 7.46]	.244
Latinx	−0.04 [−3.43 to 3.35]	.982
Other	0.96 [−2.78 to 4.70]	.614
Education (ref: undergraduate or less)
Graduate or professional degree	2.60 [−0.67 to 5.86]	.119
PCC-related coursework completion (ref: no)
Yes	0.59 [−1.78 to 1.90]	.951
Empathy (revised Kiersma-Chen Empathy Scale score)	0.59 [0.51–0.67]	<.001

Completion of PCC-related coursework in DCP was not significantly associated with empathy (β = 0.13; CI, −1.80 to 2.06; p = .895). There was no significant association between completion of PCC-related coursework and cultural humility (β = 0.58; CI, −1.78 to 1.90; p = .951).

DISCUSSION

This multisite study examined a small sample of chiropractic students’ predisposition to 2 key components of PCC, empathy and cultural humility. Quantitative findings suggest that neither enrollment status nor completion of PCC-related coursework significantly influenced students’ levels of empathy or cultural humility. However, given the small sample of participants, quantitative findings should be interpreted cautiously.

Interestingly, prior research in medical and nursing education has demonstrated a decline in empathy as students progress through their programs.^39–42 In contrast, our findings suggest no significant difference in empathy levels based on DCP enrollment status or completion of PCC-related coursework. Whereas this may appear neutral or even positive when compared with existing literature, it is worth considering that, if PCC-related coursework was having a measurable impact, one might expect to observe an increase in empathy with curricular exposure. By comparison, multiple studies in other health professions education have shown that tailored education can enhance empathy among students.^43,44 All of the above considered, this may highlight a potential opportunity for more intentional and structured development of these skills within DCPs. Nonetheless, these findings and suggestions should be interpreted with caution as our survey broadly defined PCC-related coursework to include content on empathy, cultural humility, and MI, and our data reflect the perspectives of a small subset of chiropractic students.

Applied skill development in cultural humility remains an area of growth in health professions education.²⁵ Some evidence suggests that educational content on this topic in health professions education has been introduced at a surface level during didactic coursework with limited opportunities for longitudinal or experiential learning.⁴⁵ These limitations have prompted ongoing calls for a more programmatic approach to fostering both cultural and structural humility within health care training.⁴⁶ In response, some health professions have proposed updating entrustable professional activities (EPAs) to explicitly include these competencies.⁴⁵ Whereas the accrediting body for DCPs in the United States, the Council on Chiropractic Education, does not utilize EPAs, its competency-based framework does include expectations related to cultural competence.⁴⁷ Still, the depth and consistency of this integration may vary across not only DCPs, but all health professions education.⁴⁸ To address this, some health professions education programs have proposed the use of simulated patient encounters that address language barriers, cultural and religious differences, mental health needs, and financial barriers with the goal of developing these skills across the educational continuum.^45,49 Similar approaches may be of value to DCPs; however, it is currently unknown the extent of which this is occurring in chiropractic education in North America.

Recent research suggests that culture-related communication training is an area of need across the chiropractic profession. For example, a recent study of chiropractic students in South Africa found that, although students valued culturally and linguistically responsive care, many reported a clear need for stronger curricular emphasis and integration of these concepts.⁵⁰ In addition, a recent national survey of Canadian chiropractors identified discrepancies between cultural awareness and culturally responsive behaviors.⁵¹ These findings, taken together with the student reflections in our study, may suggest that cultural humility and culture-related communication may be underdeveloped areas within chiropractic education.

Although gender was not a focal construct of this study, we did observe a statistically significant association in both empathy and cultural humility.

Future Studies

Given the scope of this study, additional research is needed to further explore how empathy and cultural humility are implemented and modeled in the broader landscape of chiropractic education. Future studies with larger and more diverse samples of chiropractic students may help identify whether specific educational strategies or institutional factors meaningfully influence the development and enactment of PCC skills. Additionally, longitudinal research could also explore how and if these skills evolve over time. Gender may represent a potential direction for future research to explore how gender may interact with PCC-related attitudes and beliefs in chiropractic education.

Strengths

This manuscript offers insight into cultural humility and empathy within this subset of North American DCPs. A strength is that the sample was from multiple institutions across North America.

Limitations

This study has multiple limitations. The survey response rate (7%) was low, and this limits generalizability and increases the risk of nonresponse bias. Although multiple reminder emails were sent, the use of classroom time to complete the survey, a strategy used to improve response rates in student populations, was not permitted at participating DCPs. Additionally, the data being self-reported introduces the risk of recall bias, social desirability bias, and interpretation bias and may not fully capture students’ predisposition to empathy and cultural humility. The limited DCPs included in this study limits the ability to fully capture the broader landscape of empathy and cultural humility in chiropractic education.

CONCLUSIONS

This study explored a subset of chiropractic students’ predisposition to empathy and cultural humility as key components of PCC. No significant associations were found between PCC-related coursework or enrollment status and empathy or cultural humility. Given the paucity of literature in this area within chiropractic education, these findings offer a meaningful starting point for future work. Further research is needed to understand how PCC is integrated into chiropractic education, including studies using more robust recruitment strategies and longitudinal design to assess changes in PCC-related attitudes, beliefs, and skills across the chiropractic education continuum. In addition, future studies could include testing of curricular interventions to enhance PCC-related concepts for students while enrolled in DCPs.

DECLARATIONS

Acknowledgments

The authors acknowledge Katherine Pohlman, DC, MS, PhD, and Dustin Derby, MSEd, MS, EdD, for their assistance with survey dissemination at their respective institutions.

Funding

No funding was received for this study.

Competing Interests

The authors declare no competing interests.

Data Availability

Blinded data are available for editorial review.

Artificial Intelligence

Artificial intelligence was not used in the preparation of this study.

Contributorship

Concept development: AB, KH, DT, JG. Design: AB, DT, JG, MK. Supervision: KH, DT, JG, MK. Data collection/processing: AB, KH, JG, MK, KB, ZM. Analysis/interpretation: AB, KH, DT, JG, MK. Literature search: AB. Writing: AJ, DT, ZM. Critical review: KH, DT, JG, MK, KB, SL, ZM.