Chiropractic and Osteopathy are complementary health professions that enjoy Government imprimatur to the extent that they have Registration Boards in every jurisdiction and a National Uniform Code of Conduct [1]. Also, third party payers such as private health funds, workers compensation authorities and the Department of Veterans Affairs recognise both professions and fund treatment provided by approved chiropractors or osteopaths [2, 3].

The training of chiropractors is by way of degree courses at Macquarie University (New South Wales [NSW]), Royal Melbourne Institute of Technology-RMIT University (Victoria) and a new program at Murdoch University in Perth (Western Australia). For osteopaths there are undergraduate courses at Victoria University of Technology, RMIT University (Victoria) and the University of Western Sydney (NSW) [4]. Importantly, there is no undergraduate program for these professions in Queensland.

After graduation the learning process usually continues by way of an experiential process and also (but not always) from continuing education. The provision of continuing education and other vocational services to chiropractors and osteopaths in Queensland between 1996 and 2002 is the subject of this paper.

To maintain Registration, continuing education for chiropractors and osteopaths is not compulsory in Australia as it is the USA. However, it is compulsory to maintain provider status with the Department of Veterans Affairs (DVA) [2]. As DVA income represents only a relatively small percentage of revenue for chiropractors and osteopaths there is no real financial or statutory imperative to participate in continuing education.

Before arguing for continuing education one must ask a preliminary question regarding its validity. To do this a MEDLINE literature search was conducted from 1980 until 2002, using the key indexing words of "continuing medical education", "chiropractic", "osteopathy", "educational intervention", "clinical audits", "performance indicator", "competency", "patient outcome" and "validity".

A search was also conducted of the literature indexing system for chiropractors and osteopaths known as MANTIS [5]. From this search a key paper by Werth [6] identified a paucity of information on the subject of continuing education concerning chiropractors and osteopaths; this paper reviews and relies on the medical and para-medical literature to review continuing education from a number of different perspectives including continuing education definition, needs assessment, evaluation and compulsory participation. Two significant issues arising from this paper are practitioner performance and health care outcomes after the administration of continuing education.

Davis et al assessed these issues in a review of 50 randomised controlled trials [7]. The conclusion reached by the authors was there is evidence for changes in practitioner performance from continuing education but very little for improved patient outcome. A later paper by the same authors further reviewed studies that met the following criteria: randomized controlled trials of education strategies or interventions that objectively assessed physician performance and/or health care outcomes [8]. These intervention strategies included (alone and in combination) educational materials, formal continuing medical education (CME) activities, outreach visits such as academic detailing, opinion leaders, patient-mediated strategies, audit with feedback, and reminders.

They found 99 trials, containing 160 interventions. Almost two thirds of the interventions (101 of 160) displayed an improvement in at least one major outcome measure: 70% demonstrated a change in physician performance, and 48% of interventions aimed at health care outcomes produced a positive change. Effective change strategies included reminders, patient-mediated interventions, outreach visits, opinion leaders, and multifaceted activities. Audit with feedback and educational materials were less effective, and formal CME conferences or activities, without enabling or practice-reinforcing strategies, had relatively little impact.

Langworthy, in the only published study of clinical audit in chiropractic, concluding that a voluntary national audit scheme succeeded in raising awareness and standards of clinical practice [9]. Mugford et al.'s review of 36 studies of the use of statistical information from audit or practice reviews suggest that it is most likely to affect practice when the recipients have already agreed to review that practice [10]. Cantillon and Jones's review of CME in general practice found 18 evaluations of audits with educational interventions, of which 17 showed a positive influence on doctor behaviour [11]. A Cochrane review has concluded that audit and feedback may be effective in improving the practice of healthcare professionals, especially prescribing [12].

Therefore, it appears that evidence for continuing education in achieving a positive change in practitioner performance and health care outcomes is mixed with some evidence for specific styles of continuing education. On balance, it is plausible to argue that quality continuing education has a general beneficial effect.

The advent of evidence-based health care has increased the demand on health care providers of all persuasions to base their decisions and actions on the best possible evidence. The ability to receive or track down, critically appraise (for its validity and utility), and incorporate a rapidly growing body of evidence into one's clinical practice has been the "mantra" of the past decade [13].

Within the State of Queensland prior to 1996 practising chiropractors and osteopaths had some opportunities to participate in scientific forums specifically designed to improve their information gathering, clinical, scientific appraisal and bio-ethical skills. Dr. Keith Charlton principally developed this with the advent of the Brisbane Spinal Studies Group. However, when Dr. Charlton left for the United Kingdom there was an apparent lull.

Professional associations and their subsidiaries provided much of the continuing education in Queensland prior to 1996. The major associations then were the Chiropractors Association of Australia [14] (CAA) (and its antecedents) and the Australian Osteopathic Association [15] (AOA). It can be argued that these two National organisations are in many ways the equivalent of trade unions. They aim to represent the professions in every respect and to the best of their ability. In the three decades prior to 1996, important political issues such as Government Registration and third party payer acceptance privileges consumed much of these associations' time. Skilled chiropractors and osteopaths who gained political experience "on the job" have generally led both associations.

Apart from their political agenda both associations have historically provided annual and occasional conferences, educational seminars and also respective journals newsletters for their members. These have assisted knowledge advancement. Nevertheless, it was observed by the Chiropractic & Osteopathic College of Australasia (COCA) [16] Executive of the day that there was an educational and vocational hiatus for both professions. It was thought that this was because the associations were not providing enough "best practice" continuing education.

COCA determined that if chiropractors and osteopaths were to progress in the information and evidence-based age they would need access to high level material prepared and delivered by the best mentors available. In the mid 1990's it appeared that the associations (CAA and AOA) were strongly interested in the political agenda of the day and accordingly there appeared to be room for another group or professional body to provide these educational and other vocational services to chiropractors and osteopaths in Queensland.

The identification of this need led to the expansion of the COCA from a predominantly Victorian based organisation into the State of Queensland and later nationally. The objective of this expansion was to develop, provide and foster quality vocational and educational services for chiropractors and osteopaths in Queensland and other States, with the ultimate goal of improving the public health.

The national Executive of COCA reviewed a draft plan to attain these objectives. This plan involved was formulated by the author and involved:

The development of a vocational body (COCA) for chiropractors and osteopaths in Queensland is now a reality. Registrants in the field have supported ("with their feet") the notion of a body that delivers continuing education at an affordable cost and also an organisation that concentrates on the vocational aspects of their practice with a scientific and ethical focus. COCA's objectives are set out and are on the public record [16] and all applicants for membership sign their acceptance of the COCA Code of Ethics [16].

COCA has dedicated materials and resources used in its activities, to serve Queensland members and non-members alike. This has included equipment, staff, volunteers, facilities and financial resources. Without these inputs achievement of the College's objectives would have been futile.

The activities and processes underpinning the programmes delivered to the practitioners were designed to meet their needs and to potentially improve the public health. This has been attempted through teaching, distance learning, information exchange, seeking benefits for members such as indemnity insurance and also lobbying Government. COCA's educational and vocational outputs in Queensland can be measured by the number of seminars and conferences, the number of additional programs such as distance learning modules, the RACGP library access, the number of Journals and Newsletters supplied to members. This has been quite substantial for a relatively small organisation.

Outcomes can also be measured by the number of practitioners who have become members, the satisfaction ratings of attendees at seminars and conferences, the attraction of senior practitioners from within the State to become involved at organisational level.

Like all continuing education providers COCA aims (through its educational programs) to improve the participants knowledge and skills and although these are often considered to be rather short-term outcomes, they may also lead to positive changes in behaviours and then hopefully changes in values, conditions and improvements in the public health.

Further research should concentrate on the objective measurement of these outcomes and in particular patient health outcomes.

There have been limitations to COCA development in Queensland. Limited resources have prevented any attempt at objective measurement of practice outcomes from COCA's continuing education programs. COCA's first 6-years in Queensland have been more about development of and growing the organisation within the State. Nevertheless, the programs have been well received by surveyed participants and it should be noted that practical change by practitioners is unlikely to occur in an unhappy continuing education recipient.

Another major limitation has been the limited number of chiropractic or osteopathic academics on the ground in Queensland; it is postulated that this may be due in part to the lack of an under-graduate program in the State.

The chiropractors and osteopaths in Queensland are now better serviced in the area of continuing education, vocational programs and professional assistance. This has been achieved by the development and expansion of the Chiropractic & Osteopathic College of Australasia within the State. It is hoped that COCA's continuing emphasis on information transaction skills, multi-disciplinary fora, science and ethics will have a positive impact on public health. To continue to be successful COCA must constantly review its modus operandi in the State of Queensland.