Restructuring of the jurisprudence course taught at the Canadian Memorial Chiropractic College

Abstract

Introduction:

The process by which the jurisprudence course was restructured at the Canadian Memorial Chiropractic College is chronicled.

Method:

A Delphi process used to restructure the course is described, and the results of a student satisfaction survey are presented.

Results:

When asked “I think this material was clinically relevant,” over 81% of the 76 students who respondents strongly agreed or agreed with this statement; 100% of students agreed or strongly agreed that scope of practice; marketing, advertising and internal office promotion; record keeping; fee schedules; malpractice issues and; professional malpractice issues and negligence was clinically relevant.

When asked “I think this material was taught well,” a minimum of 89% of students agreed or strongly agreed with this statement.

Discussion:

This is the first article published that described the process by which a jurisprudence course was developed and assessed by student survey.

Summary:

Based on a survey of student perceptions, restructuring of the jurisprudence course was successful in providing students with clinically relevant information in an appropriate manner. This course may serve as an important first step in development a ‘model curriculum’ for chiropractic practice and the law courses in terms of content, format and assessment strategies.

“I will refrain from any act of wrongdoing and will regard the keeping of a patient’s confidentiality as a moral obligation, using any such information only in his or her best interests.”

Excerpt from the ‘Chiropractic Oath’¹ sworn to by graduates of the Canadian Memorial Chiropractic College during Convocation.

Introduction

As many of the readers of this journal will undoubtedly know – since many of them are graduates of the Canadian Memorial Chiropractic College (CMCC) – the course that taught chiropractic students jurisprudence and business management was coordinated and principally delivered by Allan M. Freedman, B.A., LLB, a long-time veteran of CMCC whose contributions to the chiropractic profession were recently chronicled by Dr Douglas M. Brown in the JCCA.² Mr. Freedman taught this content for over 30 years, starting in the mid-1970s, until he resigned from the faculty in 2008 (he continues to provide legal advice to CMCC). His departure provided an opportunity to review the content of that course and decide whether or not a restructuring of the course was appropriate.

Contemporaneously, a fourth year business management course (taught during the student’s clinical internship) was likewise under review. Developed in the mid-2000s this course had several iterations and passed through several different hands, and has now developed a degree of permanence with respect to its content and instructors. With that course now more firmly entrenched in fourth year, and strictly focusing as it does on issues relating to business management, there was an opportunity to restructure the jurisprudence course (delivered in third year) in concert with the business management course. In other words, with the resignation of Allan Freedman an opportunity presented itself whereby the course that delivered issues germane to chiropractic jurisprudence could be coordinated with the business management course in such a way as to avoid unnecessary redundancies but simultaneously segueing and providing a relatively seamless transition from one course to the next.

The purpose of this article is to describe the process by which the restructuring of the jurisprudence course at CMCC took place. As an indication of whether or not the restructuring of the course was progressive or regressive in nature, the results of a student assessment survey are presented. The survey sought to determine (i) students’ perception of the clinical relevance of the material (topics) delivered, (ii) whether or not the course material was delivered well; (iii) comments about the course in general (organization, fairness of assessment and so on) and (iv) general comments about the course instructors.

Method

This study was approved by the ERB at CMCC.

Course Content Development: Delphi Process

Essentially, a Delphi process was initiated to gather more information as to what deficiencies, if any, the jurisprudence course may have had in its previous incarnation. A panel was convened comprised of the Dean of the Undergraduate program, chair of the department in which this course is situated (Chiropractic Practice and Principles), the faculty person who principally instructs CMCC students on ‘ethics,’ two senior (fourth year) class representatives, two outside chiropractic content-experts (representatives of two provincial licensing boards) and this author. This group met on three different occasions during the winter of 2007–08. Each member of the group expressed what they perceived were strengths and weaknesses of the jurisprudence course, what was worth preserving and what needed to be changed, as well as the strengths and weaknesses of the fourth year business management course. Lastly, the group provided a road map of what specific content ought to be added, preserved or deferred from the jurisprudence course to the business management course. A series of action steps were developed, with appropriate timeline and deliverables; this included scheduling submissions to the requisite internal committees to obtain approval of any proposed course changes.

Course Content Development

Armed with the general information from the Delphi process, a job posting was placed to hire a new course coordinator for the jurisprudence course, now called ‘Chiropractic Practice and the Law’ (CPL). The successful candidates were this author and a co-applicant, Joel Friedman B.Sc., LLB (no relationship to Allan Freedman), a lawyer and the Director, Policy and Research, at the College of Chiropractors of Ontario (CCO), the regulatory body of chiropractors in Ontario.

Friedman and this author reviewed the course syllabus from Mr. Freedman and, based on the input from the Delphi group, decided to defer the following content to the business management course:

• banking; insurance (life, disability, office content and so on);

• taxes (including issues related to practice incorporation);

• office policies and procedures (including staff hiring and other human resource issues);

• ‘types of practice’ options (solo practitioners, associateships, multi-disciplinary clinics, for example) and;

• ‘employment opportunities available to chiropractors’ (private practitioner, researcher, teaching faculty, third party assessor etc.).

In place of this content, the course coordinators posited that the jurisprudence course ought to provide more robust and specific information on a number of issues germane to jurisprudence and the law, from a national or federal perspective. The content areas that were to be covered in depth included:

• law (administrative, criminal, tort, civil);

• privacy and confidentiality;

• current legal issues related to chiropractic (inquests, class actions suits);

• capacity legislation;

• consent legislation;

• use of personal health information;

• ‘who’s who’ (description of the various chiropractic organizations in Canada and abroad, along with their respective mandates);

• ‘what’s what’ (differentiation between case law, regulations, standards of practice, guidelines, policies and by-laws);

• codes of conduct and ethics [this included the 33 Health Professional Procedural Codes of Ontario,³ codes of conduct from various provinces and the codes of conduct developed by the Canadian Chiropractic Association⁴];

• scope of practice;

• marketing, advertising and internal office promotion;

• independent chiropractic examinations;

• fee schedules;

• quality assurance initiatives (practice/peer assessments, continuous education requirements, self-assessment protocols);

• record keeping;

• contracts;

• prohibition against sexual relationship with patients;

• standards of practice unique to each province and;

• the complaints and discipline processes.

The reorganization of the course content from the jurisprudence course to the business management course resulted in a reduction of hours of the CPL course from 52 to 28 hours.

To achieve the goal of providing as much as information from a national or federal perspective as possible, the course coordinator (the author) emailed representatives from provinces across Canada and requested they send him a copy of their respective provincial codes of conduct, regulations, standards of practice and so on. Eight provinces (British Columbia, Alberta, Saskatchewan, Ontario, Nova Scotia, New Brunswick, Newfoundland and PEI) responded to this request.

It must be emphasized that many of the innovations Allan Freeman introduced to the jurisprudence course were preserved (Table 1). For example, a few years ago, Freedman required students to attend a discipline hearing at any regulatory body, perhaps in hopes of demonstrating the unpleasantness of the process and strengthening the resolve of students to avoid being caught in that process themselves. [In point of fact, this process is unpleasant for all involved parties, as discussed in an editorial entitled “The Burden of Discipline” (in press) written by this author]. Another innovation of the course held over from Freedman was the requirement of all students to submit for grading a ‘medical-legal report.’

Table 1.

Components of the Assessment Strategy for the Chiropractic Practice and the Law/Jurisprudence course

Submission of medical-legal report Attendance at Disciplinary Hearing (any regulated health provider) In-class, open book quizzes Multiple-choice, short answer and essay examinations Jeopardy-style review Development of Business Plan (submitted for grading to the Business Management course)

Additionally, and more importantly, several years ago, Freedman required students to submit a business plan for his review and grading. Students were required to create a business plan proposal, similar to a plan they would have to develop for themselves upon graduation. This plan is often in the form of a proposal to a lending institution (bank) in hopes of securing the necessary finances to fund a chiropractic practice (see Table 1). Currently, this ‘Business Plan’ assignment, while introduced in the CPL course, is now the primary means of assessment for the fourth year business management course.

The repositioning of the business plan assignment from the CPL course to the business management course necessitated changes be made to the CPL course assessment strategy. Specifically, assessment for the CPL course now consisted of four in-class, scheduled, open-book quizzes, two tests (consisting of multiple choice, short answer and essay questions), the medical-legal report and the discipline hearing report. A unique innovation brought to the CPL by this author was the development of a ‘Jeopardy-style’ game for the students to participate in during the last class of the course in order to review all course work. For ‘Jurisopardy’ all the students are randomly divided into three color-coded groups. Questions are created beforehand and formatted onto a 1997-PowerPoint program with two step animation; one step to reveal the question, the other step reveals the answer once one of the students (representing their team) answers the question correctly. Just like the televised game show, our version of Jeopardy contains ‘daily doubles’ and ‘final jeopardy.’ Points are accrued until the completion of the game, and the winning group of students is awarded an appropriate prize; in this case, a box of Timbits (!).

(Author’s note: To assist field doctors in their business endeavors still further, CMCC is currently undertaking the development of an eCommerce course via its Continuing Education Division. This eCommerce program is being piloted for review for the summer of 2009 and should be commercially available by the fall).

In order to determine if the inaugural year of the CPL course was a successful, and to identity any areas of strengths and weaknesses of the course, an on-line anonymous survey was designed.

Student Survey

Using a program called Survey Monkey, an internal anonymous student survey was developed that sought to assess students’ attitudes and opinions on a number of issues presented in this course. Unlike many similar surveys, since the course material provided was novel and had not been taught previously in this manner, the survey was divided into the following question headings: (i) student’s perception of the clinical relevance to chiropractic practice of each topic taught; (ii) ‘how well’ the course was delivered; (iii) what students liked about the course; (iv) what could be done to improve the course; (v) their attendance and (vi) general opinions of the teaching skills of the course instructors.

For the survey, a 6-point rating scale was used. For this survey, students were given the following response options: 0 (No Opinion); 1 (Strongly Disagree); 2 (Disagree), 3 (Neutral); 4 (Agree) and 5 (Strongly Disagree). Students were instructed to log into the college’s email system and were able to anonymously participate in the survey, using a unique identifier (each student could only complete one survey). Upon completion, the survey was electronically filed within the college’s data base. It must be emphasized that students were asked to complete this survey upon the completion of the course, after all the assignments and examinations were graded and those grades were submitted to the Dean’s Office: This would allow students to provide whatever comments they chose to provide without fear of retribution from the course instructors. Students were also informed that the results obtained from this survey may be used for research purposes, and approval was obtained from the ERB of CMCC to do so.

For ease of discussion in this article, the 6 survey options were collapsed into the following 4 groups: No opinion; Strongly Disagree/Disagree; Neutral; Agree/Strongly Agree. Seventy-six (76) students completed the survey, out of 179 third year students.

Results of Student Survey

Students’ Opinion of Clinical Relevance of Course Material Delivered

When asked, the vast majority of students reported they either agreed or strongly agreed with the statement that every topic delivered during the CPL course was ‘clinically relevant’ (see Table 3). Only three subject topics of the 25 topics delivered – Overview of tort law, the Canadian Legal System and Other Standards Across Canada – scored below 85% with respect to this question. Conversely, 100% of students agreed or strongly agreed with the statement that the following topics were clinically relevant: scope of practice; marketing, advertising and internal office promotion; record keeping; fee schedules; malpractice issues (delivered by representatives of the CCPA) and; professional malpractice issues and negligence. The other topics presented in the course were perceived by students to generally be clinically relevant (see Table 3).

Table 3.

Student response to the question: “I think this material was clinically relevant” (n = 76)

Topic	Strongly Agree	Neutral	Strongly Disagree	No Opinion
Introduction (who’s who, what’s what)	86.4%	9.1%		4.5%
Canadian Legal System	84.9%	12.1%	3%
Overview of Self-Regulation	97%	3%
Codes of Conduct and Ethics	97%	1.5%		1.5%
Scope of Practice	100%
ICEs	91.9%	9.1%
Fee Schedules	100%
Marketing, Advertising and Internal Office Promotion	100%
Quality Assurance	95.5%	3%	1.5%
Peer Review	92.4%	7.6%
Continuous Education	94%	4.5%	1.5%
Record Keeping	100%
Prohibition Against Sex with Patients	98.5%	1.5%
Other Standards Across Canada	81.3%	16.7%	3%
Complaints Process	95.5%	4.5%
Discipline Process	97%	1.5%	1.5%
Malpractice Issues (CCPA)*	100%
Professional Malpractice and Negligence	100%
Consent Legislation	97%	3%
Privacy Law (PHIPA)	95.5%	4.5%
Capacity Law	92.4%	7.6%
Use of Personal Health Information	97%	3%
Current Legal Issues in Chiropractic**	97%	3%
Contracts	97%	3%
Overview of Tort Law	84.9%	4.5%	10.6%

^*Examples include Scope of Practice Review in Ontario by DCs and PTs, Class Action Suit in Alberta, Inquests.

^**Taught by representatives of Canadian Chiropractic Protective Association.

Students’ Opinion with respect to ‘how well’ content was delivered

When asked, respondents reported that only two subjects – Introduction to the Canadian Legal System and ‘Contracts’ – scored less than 92% with respect to this question (Table 4). Conversely, students who responded to this survey overwhelming reported they perceived each topic was well delivered.

Table 4.

Student response to the question: “I think this material was well delivered” (n = 76)

Topic	Strongly Agree	Neutral	Strongly Disagree	No Opinion
Introduction (who’s who, what’s what)	91.9%	6.1%	3%
Canadian Legal System	81.9%	13.6%	4.5%
Overview of Self-Regulation	92.5%	4.5%	3%
Codes of Conduct and Ethics	97%	1.5%	1.5%
Scope of Practice	98.5%	1.5%
ICEs	97%	1.5%	1.5%
Fee Schedules	96.5%	3%	1.5%
Marketing, Advertising and Internal Office Promotion	97%	3%
Quality Assurance	98.5%	1.5%
Peer Review	94%	4.5%		1.5%
Continuous Education	95.5%	1.5%	1.5%	1.5%
Record Keeping	98.5%	1.5%
Prohibition Against Sex with Patients	100%
Other Standards Across Canada	98.5%	1.5%
Complaints Process	98.5%	1.5%
Discipline Process	100%
Malpractice Issues (CCPA)	100%
Professional Malpractice and Negligence	98.5%	1.5%
Consent Legislation	98.5%	1.5%
Privacy Law (PHIPA)	98.5%	1.5%
Capacity Law	98.5%	1.5%
Use of Personal Health Information	100%
Current Legal Issues in Chiropractic	98.5%	1.5%
Contacts	89.4%	1.5%	9.1%
Overview of Tort Law	98.5%	1.5%

As further evidence of this sentiment, a representative sample of student comments are provided in Table 5. Overall, there were 43 positive comments provided by the 76 students who responded to the survey when asked “what did you like about the course?” When asked, ‘what could be done to improve the course?’ 32 students provided comments, although half of these comments were ‘nothing’ or ‘it’s good.’ The only consistently negative comments reported from some students was their perception that one of the lecturers occasionally spoke too fast during lectures, one lecturer was less animated than the other and a few students did not like that the course was often scheduled to start at 8am.

Table 5.

Sample of student comments about the “Chiropractic Practice and the Law” course at CMCC (2009)

“Every aspect of this course was fantastic. The quizzes, the assignments, the examination, the lectures by both instructors – all aspects of this course were very well conducted” “Essential to any chiropractor. This course taught me a lot about how the CCO works and what it does and what is ‘expected’ in Chiropractic practice when it comes to patient management and the Law. Instructors did a very good job of putting material together.” “I enjoyed the instructor’s stories that he included in the lectures. Scope of practice, fees, advertisement, etc ... all the things surrounding actually practicing and running a practice.” “ – well organized – made to be engaging and interesting as it could be – Jeopardy Review at the end was fantastic – open book quizzes promoted attendance without Adding stress to an already stressful time, and still promoted learning by allowing Us to see the types of questions that would be on the exams, plus emphasizing the Important points of lectures – both instructors were highly passionate about their Material, attempted to connect with the students etc.” “it was real! It was relevant! It was practical and useful! It was extremely well presented by the two main lecturers. Quizzes were fair and a good way to ensure we stayed on top of the course material ... also allowing us to split up the marks off of a 100% exams. The fact that the quizzes were announced ahead of time helped as well.” “The content of this course is important to anyone who is going into practice. every person who graduates from CMCC needs to be aware of the Code of conduct, Malpractice Issues, Consent, etc. I also liked that the instructor was organized throughout the course ... Instructor made the material clinically relevant ... This is one of the best courses in the 3rd year program.” “All material covered in this course is relevant to our practice as future chiropractors.” “course was very informative touching on key basics that will aide in me in my Chiropractic future. Examples used in class were insightful and applicable. It was to the point and wasn’t designed to trick/mess with student’s heads during the examination process. This is an area we don’t want to have people confused about.”

Discussion

A literature search was conducted and revealed a general paucity of references pertaining to the topic of (i) chiropractic jurisprudence and (ii) business management courses. A 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 set. In both databases the search strategy used a combination of 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 of the Journal of Chiropractic Education.

This search strategy yielded 26 articles on the topic of chiropractic jurisprudence and 45 articles on the topic of business management course. Those studies that were retrievable generally provided broad and otherwise non-specific information pertaining to the importance of educating students with respect to issues germane to jurisprudence and business management.

For example, with respect to articles pertaining to chiropractic jurisprudence, 12 of the 26 citations were ‘letters to the editor’ and ‘letters to the editor in reply’ pertaining to an article written by this author describing the demographic trends of technique systems in chiropractic and their impact on issues of jurisprudence in Canada.⁵ In that article, Gleberzon wrote about ‘chiropractic technique’ (how they can be defined), ‘standards of care and guidelines,’ ‘self-regulation,’ ‘informed consent’ and ‘guiding professional practice standards of care’ (using as an example the previous prohibition against the use of instrumented adjustive techniques in Saskatchewan).⁵

An article by Henson et al provided the results obtained from 64 chiropractors who were surveyed with respect to their perception of the need of business skill education for chiropractors.⁶ The respondents indicated the need was either ‘high’ or ‘very high’ for chiropractors to learn about the following business activities: organizational behavior and human resources; strategic management; finance; marketing; law and ethics; accounting; managerial decision making and; operational and systems management.

The same respondents perceived that the existing level of knowledge among chiropractors was low with respect to the aforementioned topics (ranging from 3% to only 19%). Lastly, the researchers reported that there was a significant ‘gap’ between what was needed to know and was known (existing knowledge) with respect to: accounting (72% gap); finance (70% gap); strategic management (68% gap); organizational behavior and human resources (67% gap); marketing (66% gap); managerial decision making (60% gap); law and ethics (56%) and operations and systems management (47% gap). These findings led the authors to conclude:

“The chiropractic profession needs significant greater business and practice management skills. The existing gap between needed business skills and existing skills suggests that current training and education programs are not providing adequate business skill training”

(6p145)

Good⁷ explained the methods he employed at New York Chiropractic College to teach students ethics and professionalism, using a set of provocative items derived from the media. He also stated he redesigned the assessments to be more rigorous. Good described this effective strategy as a teaching method with ‘a little bit of attitude.’^7p14 Lund and Pryor reported the results of a survey of clinics at the Life University with respect to ethical behavior, awareness of technology and its applications, and role modeling.⁸

Donaldson and Lewis⁹ described a process whereby they identified the barriers and potential benefits of converting paper records to digital records at Life Chiropractic College West. Cambron and Langworthy¹⁰ surveyed students with respect to their informed consent practices. In general, these researchers reported that the majority of graduating students from the National University of Health Sciences were informing their patients about ‘the therapeutic processes as well as the associated risks and benefits’^10p41 but the majority of students did not cover the area of consent regarding diagnostic processes.

McAulay and Newlin provided the results of a second survey conducted at Life University that sought to determine what variables were necessary for a successful practice.¹¹ These authors advanced on the results from a survey published a few years earlier that reported service (practice volume), not income, is what drives a successful practice.¹² In this study, McAulay and Newlin presented 12 hypotheses of the relationship of outcome variables (income, patient volume, patient retention and low job stress) and antecedent variables (sincerity of practitioner, ability to capably educate patients, having an effective fee system and so on).¹¹

Summary

Based on a survey of student perceptions, the course content of the Chiropractic Practice and the Law course at CMCC, restructured (while incorporating key elements) from the previous jurisprudence course, was successful in providing students with clinically relevant information in an appropriate manner. Future surveys will continue to monitor student satisfaction with the course content and its delivery. Since the format of this course was met with such a high level of student satisfaction, and bearing in mind the lack of consistency with respect to the course content of jurisprudence and business management courses taught at accredited chiropractic colleges throughout the profession,¹³ this course may serve as an important first step in developing a ‘model curriculum’ for chiropractic practice and the law courses in terms of content, format and assessment strategies.

Table 2.

Items to be included in the ‘Business Plan’ submitted by students for assessment

a description of where the proposed office is to be located; demographic information of that area; the type of practice to be conducted; services provided; office policies and procedures; layout of the office; equipment and chattels; fee schedules; projected profit/loss balance sheets; insurances required; a lease or agreement to purchase; associateship agreements (if applicable); sublet agreements (if applicable); advertising costs (including phone cost, yellow page advertisements, websites); leasehold renovations, including permits and costs, if required; radiographic equipment (along with proof of adherence to relevant legislation governing use of x-rays); personal expenses (rent, student loan repayment, food, transportation, entertainment costs) and; other costs incurred while operating a chiropractic clinic.