Jurisprudence and business management course content taught at accredited chiropractic colleges: A comparative audit

Abstract

Introduction:

the purpose of this study was to conduct a comparative audit of the jurisprudence and business management courses offered at a number of different accredited chiropractic colleges.

Methods:

Faculty members responsible for teaching students jurisprudence and/or business management courses at a number of accredited colleges were contacted and asked to electronically submit their course outlines for review.

Results:

Of the 62 different topics delivered at the 11 chiropractic colleges surveyed, not one topic was taught at all of them. The following topics were taught at 10 of the 11 respondent chiropractic colleges: business plan development; ethics and codes of conduct and; office staff/employees. Several topics were only taught at one accredited chiropractic college.

Conclusion:

While most chiropractic colleges provide some education in the areas of jurisprudence and business management, it would appear that there is no consensus opinion or ‘model curriculum’ on these topics towards which chiropractic programs may align themselves. Based on a literature search, this study is the first of its kind. A more extensive study is required, as well as a Delphi process to determine what should be taught to chiropractic students with respect to jurisprudence and business management in order to protect the public interest.

“I will sell Chiropractic, serve Chiropractic, and save Chiropractic if it takes me twenty lifetimes to do it. I will promote it within the law, without the law, in keeping with the law, or against the law in order to get sick people well and keep the well from getting sick.”

BJ Palmer c1910

Introduction

One hundred years ago, BJ Palmer recognized the interface between clinical practice activities and jurisprudence, even going so far as to express a certain degree of disdain for the law in favor of promoting the profession. And while perhaps such a cavalier attitude towards government oversight was necessary given the context of the nineteenth century- a time when chiropractors were under siege and often jailed for practicing ‘medicine without a license’ – the advance of the profession’s position in the health care delivery system since that time would argue in favor of a more prudent approach to adhering to the legislation, regulations, standards of practice and policies that govern chiropractic practice activities.

More recently, attendees of the 2009 Association of Chiropractic Colleges and Research Agenda Conference (ACC-RAC) can attest to the observation that virtually all keynote, plenary and panel presenters spoke to the importance of regulation in chiropractic. Indeed, virtually every speaker emphasized that advancement in the cultural authority of the profession can only be achieved if all licensing bodies exercise their legislative authority and were ever-vigilant with respect to disciplining chiropractors who operated at the fringe of the profession, especially in terms of unethical practice activities.

One method in determining whether or not a health care discipline has secured its cultural authority is by considering its statutory authority with respect to the privilege of self-regulation. Although it may sound trite, self-regulation is a privilege and not a right and if this privilege is not handled with the appropriate degree of gravitas it requires, then this privilege can be revoked, as was the case with respect to the profession of law in the United Kingdom where government regulators perceived the legal profession was acting more as an advocacy group and less as a regulatory body.¹ Imagine the horror for the chiropractic profession if that were to happen to it – if government regulators were to withdraw the privilege of self-regulation for chiropractors and appoint other health care providers (medical doctors, for example) as overseers of the profession or, worse still, if bureaucrats were given the responsibility of regulating chiropractic ‘in the public interest.’

Fortunately, many jurisdictions have in place governing legislation bestowing the privilege of self-regulation to the chiropractic profession, and licensing bodies are enabled, by statute, to develop their own regulations, standards of practice, policies and guidelines with respect to a scope of practice, use of controlled acts, advertising, quality assurance initiative, prohibition against engaging in sexual relationships with patients, codes of conduct, fee schedules, billing practices, record keeping and so on. That said, in order to safeguard this privilege, it would seem imperative that, not only should curricula at accredited chiropractic colleges teach students the rules under which they must practice, but ought to be some level of standardization throughout the profession with respect to the topics taught. Since many of the principles that govern professional activities are identical regardless of the location in which a chiropractor practices and it is not uncommon for practitioners to relocate from one jurisdiction to another. At the same time, there have been a few published studies,^2–6 and considerable ruminations emanating from the field that opine chiropractic colleges do not adequately prepare students to operate a successful chiropractic practice.

Bearing all this in mind, the purpose of this study was to conduct a comparative audit of the jurisprudence and business management courses offered at accredited chiropractic colleges. Ultimately, this information may enable the development of a ‘model curriculum’ for jurisprudence and business management courses.

Method

This study was approved by the ERB of CMCC.

Recruitment

This author contacted academic deans or other faculty at chiropractic colleges in North America, Europe and Australia-New Zealand, using either the author’s list of contacts or an Internet search of chiropractic colleges. A total of 18 colleges were contacted. Eventually the author was transferred by email to the person(s) responsible for teaching jurisprudence and business management at various chiropractic colleges (this content is often presented in the same course or by the same lecturer). Subsequently, an internet request was made by this author that the course coordinators email a course of the outline/syllabus/curriculum of the courses in question.

Confidentiality of respondents

Respondents were guaranteed anonymity to the extent that only the author would know the identity of respondent colleges and that any published results would refer to a respondent college only as “college 1,” “college 2” and so on.

Results

Although several colleges declined to participate in this study, 11 chiropractic colleges responded to the author’s request. The content, in the form of topic headings, was extracted from submitted course outlines and tabulated (see Table 1). As a point of interest, a North American naturopathic college was contacted and the course coordinator of the jurisprudence and business management courses there graciously agreed to participate in this study as well. The data extracted from that college’s course outline appears in Table 1 as ‘College 12.’ (Thus total response rate of all colleges was 66.6%).

Table 1.

Comparative audit of jurisprudence and business management courses taught at accredited chiropractic colleges (#1–#11) and one naturopathic college (college #12)

	College
Course content	1	2	3	4	5	6	7	8	9	10	11	12
Accounting
Advertisement
Anti-discrimination/Diversity
Anti-kickback
Asset protection
Billing codes
Business plan development
Business structure
Communication with other professionals
Communication/public speaking/media
Complaints process
Computer programs
Confidentiality
Consent/informed consent
Contract: associate agreements
Contract: lease
Contract: purchase agreements
Contracts (unspecified)
Court and trial procedures
Defence to claims
Demographics (practice location)
Discipline procedure
Doctor-patient relationship
Equipment/chattels/fixtures
Estate planning
Ethics and codes of conduct
Fee schedules/block payments
Financing (banking)
Fraud enforcements
Health promotion
Human Rights/Equality
Independent chiropractic exams (ICEs)
Insurance (malpractice, life, disability)
Issues related to AIDS patients
Malpractice
Mandatory reporting: child abuse
Mandatory reporting: communicable disease
Marketing
Medicolegal reports
Multidisciplinary practices
Negligence
Office layout/size
Office policy and procedures
Office staff/employees
Other agreements (managed care/diagnostic)
Practice promotion
Practice management
Privacy
Products (orthotics, supplements)
Professional associations
Quality assurance (CE)
Recent court decisions/issues
Record keeping
Referral/dismissal procedures
Scope of practice
Search warrants/depositions
Sexaul abuse/boundries/misconduct
Sexual harassment
Sources of reimbursement (WSIB, HMOs)
Standards/statutes
Taxes
Tort law

The course outlines from a total of 9 North American chiropractic college were collected (Table 1). Two non-North American colleges participated in this study (one college from Australia/New Zealand and one from the United Kingdom), in addition to North American naturopathic college, bringing the total of respondent colleges to 12.

Upon review of the 12 course outlines submitted to the author, 62 different topics were identified as being taught during either the jurisprudence or practice management courses. Of particular interest, of the 62 different topics delivered at the 11 chiropractic colleges, not one topic was taught at all of them. That said, the following topics were taught at 10 of the 11 respondent chiropractic colleges: business plan development; ethics and codes of conduct and; office staff/employees. Conversely, only one respective chiropractic college instructed students each of the following topics: anti-kickback legislation; anti-discrimination; asset protection; estate planning; human rights/diversity; independent chiropractic exams (exams ordered by third party payors); mandatory reporting of communicable diseases and; issues related to treating patients with AIDS. Of note, a representative from one chiropractic college (college #11) wrote that there were no courses that teach ‘jurisprudence’ or ‘business management’ per se, but rather much of that conduct is embedded into course work of other courses throughout the program. Nevertheless, that representative did email this author an outline of a course entitled ‘contemporary clinical and professional practice’; topic headings from that course did resemble course content from other jurisprudence and business management chiropractic courses taught elsewhere. Table 2 lists the number of colleges that teach each of the 62 topics covered by all 11 of the respondent chiropractic colleges.

Table 2.

Number of colleges that instruct chiropractic students on generated list of 62 different topics of jurisprudence and business management (n=11)

	Topic # of colleges that include it in course outline
Accounting	5
Advertisement	8
Anti-Discrimination/Diversity	1
Anti-kickback	1
Asset protection	1
Billing codes	5
Business plan development	10
Business structure	8
Communication with other professionals	3
Communication/public speaking	2
Complaints process	2
Computer programs	4
Confidentiality	3
Consent/informed consent	6
Contract: associate agreements	4
Contract: lease	5
Contract: purchase agreement	4
Contracts (unspecified)	5
Court and trial procedures	5
Defense to claim	2
Demographics (practice location)	5
Discipline process	3
Doctor-patient relationship	4
Equipment/chattels/fixtures	5
Estate planning	1
Ethics and codes of conduct	10
Fee schedules/block payment	5
Financing (banking)	9
Fraud enforcement	3
Health promotion	2
Human Rights/Diversity	1
Independent chiropractic exams	1
Insurance (malpractice, life, disability)	6
Issues related to AIDS patients	1
Malpractice	3
Mandatory reporting: child abuse	3
Mandatory reporting: communicable disease	1
Marketing	8
Medico legal reports	4
Multidisciplinary practices	3
Negligence	3
Office layout/size	4
Office policy and procedures	6
Office staff/employees	10
Other agreements(managed care/diagnostic)	4
Practice promotion	2
Practice management	5
Privacy	2
Products (orthotics, supplements)	2
Professional associations	3
Quality assurance (continuous education)	2
Recent court decisions/issues	3
Record keeping	8
Referral/dismissal procedures	7
Scope of practice	4
Search warrants/depositions	2
Sexual abuse/boundaries/misconduct	6
Sexual harassment	3
Sources of reimbursement (WSIB, HMOs)	2
Standards/statutes	5
Taxes	3
Tort law	2

As a point of comparison, the topics taught within the jurisprudence and business management courses at the naturopathic college (college #12) revealed that that program is very comprehensive, covering 37 of the 62 listed topics. Only college #2 covered more topics (47 in total).

Discussion

There are a myriad of professional options available to newly graduated chiropractors. Some enter private practice, as either sole practitioners or as associates, some join multi-disciplinary facilities, others become teaching faculty, some are drawn to research activities, and some continue with their education, entering residency programs, for example. And of course some graduates do a combination of any of these, whereas other graduates never practice as chiropractors in any capacity whatsoever. But, with the exception of not practicing at all and not maintaining their certificate of registration, graduates who engage in any other practice activity must abide by the statutory legislation that governs chiropractic within the jurisdiction they practice. However, based on the data collected from this study, there is a wide variety of topics covered by chiropractic colleges and no two colleges offer the same curricular content. Indeed, some chiropractic colleges offer a number of unique topics, not taught anywhere else at all. One can only imagine how this may frustrate a chiropractor who travels from one state to another or from one country to another.

Accrediting agencies provide some guidance with respect to what should be included in a jurisprudence and business management curriculum. One of the few documents that provide educational requirements of what must be taught to chiropractic students is the Canadian Federation of Chiropractic Regulatory and Educational Accrediting Boards (CFCREAB, sometimes simply referred to as ‘the Federation’) which declared:

“Health care providers have an obligation to the patients they serve, and to society, to provide competent and effective care, and to do so in a professional manner. Doctors of chiropractic must exhibit ethical values and behaviors, recognize their responsibility to first serve the patient, and to follow sound business practices. It is important that doctors of chiropractic maintain knowledge and clinical skills through continuing education, and be able to access, understand and critically appraise the research literature”^7p62

The Federation document then proceeds to delineate a number of attitudes, knowledge and skills that students must demonstrate with respect to “Professional Issues,” “Record Keeping” and “Doctor-Patient Relationship.” These include;

• recognize the need that records relevant to patient’s care be legible, accurate, complete and current;

• know what elements should be included in the record;

• know what is accepted with respect to record maintenance, storage and security;

• provide abbreviation codes;

• appreciate importance of compassion, empathy and touch;

• legal necessity of informed consent;

• know and employ procedures to reduce potential risk and professional liability;

• exhibit behavior and a communication style that projects a professional image;

• supporting and participating in professional activities and organizations;

• exhibit ethical attitudes regarding provision of patient care;

• refrain from illegal and unethical patient care and practice management procedures (undefined);

• be aware of and comply with professional reporting requirements;

• develop ethical practices with respect to marketing;

• understand need to follow sound business practices involving leases, loans etc

However, the Federation document does not, and probably cannot, provide an exhaustive list of what topics should be included in jurisprudence and business management courses. For example, although the Federation document specifically lists under ‘Doctor-Patient Relationship’ the student must demonstrate the ability to ‘recognize the need to establish and maintain appropriate boundaries in doctor-patient interactions,’^7p61 it does not specifically mention the prohibition against engaging in sexual relationship with one’s patients.

A literature search was conducted of the Index to Chiropractic Literature (ICL) and MEDLINE through PubMed for peer-reviewed articles on the teaching of jurisprudence and/or practice management in an undergraduate setting, published in English. No date limit was used. In both databases the search combined text words (natural language) and controlled vocabulary; ChiroSH (Chiropractic Subject Headings) in ICL and MeSH in PubMed. ICL subject headings included Jurisprudence, Practice Management, Curriculum and Education as a subject keyword. MeSH terms included Practice Management, Jurisprudence/education, Curriculum and Education, Medical, Undergraduate. The search also included text words such as business and marketing, and hand-searching the Journal of Chiropractic Education. This search strategy uncovered very few published studies that discussed chiropractic jurisprudence or business management education, as well as jurisprudence and business management issues from other health care disciplines as well [There are a few published studies that describe a specific college’s experience with teaching a particular topic: these are discussed in a companion article].⁸ A few authors concluded, based on findings derived from their own chiropractic colleges, that more education is generally required to satisfy the needs of new graduates. For example, a study by Fleetwood and King² reported, based on a survey of 70 ‘experienced’ British chiropractors that respondents rated the overall importance of having knowledge of business management matters as being high or very high and that ‘more prominence should be given to this skill as part of chiropractic training.’^2p3 The same search strategy found articles from the medical^3–5 and dental⁶ professions that expressed the same concerns.

Based on this search, no previous studies have been published that have conducted a comparative audit of what is taught at different accredited chiropractic colleges, or of colleges that teaches other health care disciplines. Therefore, this study appears to be the first of its kind.

Limitations of the Study

There were several limitations to this study. Chief among them was that the course syllabus submitted to this author may not contain all the information taught in a particular course. The author resisted the temptation to contact each course coordinator at each respective college to seek clarification with respect to this issue, instead only relying on the information extracted from the course outline. The rationale for this decision was that it was posited that, were the author to ask a course coordinator ‘I notice that topic X is not included in your course outline- do you not teach it?,’ the course coordinator, not wishing to seem derelict in their duties or responsibilities, may imply that the content was in fact taught, albeit ‘tangentially’ or ‘in passing,’ thus not providing any additional illumination with respect to it being taught formally or not. In other words, since a course coordinator may not want to be perceived by an outside observer as providing a non-comprehensive course, there might be pressure for a course coordinator to insinuate a topic is covered to an extent that it is not. College websites were not reviewed to obtain this information from non-respondent colleges since course descriptions posted on such websites tend to describe a course in general terms only.

Alternatively, it is possible that some topics, such as codes of conduct or ethics, doctor-patient boundaries, financing, and issues germane to office staff/employees are deferred to other courses in the program, during electives or during continuing education programs offered at this or that chiropractic college. Similarly, instruction on topics such as record keeping, prohibition against engaging in sexual relationship with patients and scope of practice may be deferred to a student’s clinical internship. In fact, the representative of one North American chiropractic college confirmed that that was the case at the college where he teaches, and that much of the jurisprudence and business management content was delivered to students by their clinicians, although he admitted that part of the curriculum is unstructured and the content delivered is highly variable from one clinician to another. Lastly, it is possible that some of the 62 topics are taught together, such as marketing, advertising and practice promotion, or business plan development and business structure.

Conlusion

While most chiropractic colleges provide some education in the areas of jurisprudence and business management, it would appear that there is no consensus opinion or ‘model curriculum’ on these topics towards which chiropractic programs may align themselves. Moreover, some colleges do not provide any formalized education on these topics in the form of courses specifically devoted to teaching this content. Instead they defer this component of chiropractic education to the unstructured environment of a student’s internship or this content may be covered incidentally throughout a chiropractic program. While it is certainly unfeasibility for an America chiropractic college, for example, to instruct students on all the different regulations, standards of practice, policies and guidelines from all 50 states, a cogent argument can be made that the underlying principles of those issues germane to chiropractic jurisprudence and business management ought to be taught. Thus, it might therefore be prudent for chiropractic educators to develop a standardized curriculum on these topics in order to strengthen chiropractic’s cultural authority, similar to the process that developed a ‘model curriculum’ for chiropractic geriatric education that began in the late 1990s⁹ and was recently revised.¹⁰

It is certain imperative that chiropractic educational programs meet the mandate of protecting the public interest while providing graduates with the necessary tools they need to operate a successful chiropractic practice. The data gathered from this study could begin the process of developing a model curriculum for jurisprudence and business management content for chiropractic students in order to meet these important goals. However, a more expansive study must be conducted in order to better assess what is currently being taught, what ought to be taught and where it should be taught (undergraduate courses, clinical internship or continuing educational programs) at accredited chiropractic colleges with respect to jurisprudence and business management.