Chiropractic identity, role and future: a survey of North American chiropractic students

Background The literature pertaining to chiropractic students’ opinions with respect to the desired future status of the chiropractic physician is limited and is an appropriate topic worthy of study. A previous pilot study was performed at a single chiropractic college. This current study is an expansion of this pilot project to collect data from chiropractic students enrolled in colleges throughout North America. Objective The purpose of this study is to investigate North American chiropractic students’ opinions concerning professional identity, role and future. Methods A 23-item cross-sectional electronic questionnaire was developed. A total of 7,455 chiropractic students from 12 North American English-speaking chiropractic colleges were invited to complete the survey. Survey items encompassed demographics, evidence-based practice, chiropractic identity and setting, and scope of practice. Data were collected and descriptive statistical analysis was performed. Results A total of 1,247 (16.7% response rate) questionnaires were electronically submitted. Most respondents agreed (34.8%) or strongly agreed (52.2%) that it is important for chiropractors to be educated in evidence-based practice. A majority agreed (35.6%) or strongly agreed (25.8%) the emphasis of chiropractic intervention is to eliminate vertebral subluxations/vertebral subluxation complexes. A large number of respondents (55.2%) were not in favor of expanding the scope of the chiropractic profession to include prescribing medications with appropriate advanced training. Most respondents estimated that chiropractors should be considered mainstream health care practitioners (69.1%). Several respondents (46.8%) think that chiropractic research should focus on the physiological mechanisms of chiropractic adjustments. Conclusion The chiropractic students in this study showed a preference for participating in mainstream health care, report an exposure to evidence-based practice, and desire to hold to traditional chiropractic theories and practices. The majority of students would like to see an emphasis on correction of vertebral subluxation, while a larger percent found it is important to learn about evidence-based practice. These two key points may seem contradictory, suggesting cognitive dissonance. Or perhaps some students want to hold on to traditional theory (e.g., subluxation-centered practice) while recognizing the need for further research to fully explore these theories. Further research on this topic is needed. Electronic supplementary material The online version of this article (doi:10.1186/s12998-014-0048-1) contains supplementary material, which is available to authorized users.


Introduction
The last thirty years in health care have brought about many changes in thoughts and practice ideologies. One of these recent trends is an emphasis on cost-effective treatments and interprofessional collaboration [1][2][3]. Additional changes in health care over this time have included an increase in medical specialization and sub-specialization, the concept and implementation of evidence-based practice, and a greater acceptance of complementary and alternative medicine (CAM) therapies in mainstream medicine. Amid all of these transformations and shifts in the health care arena, a primary spine care specialist role has not been established. The current state of spinal care has been classified as a "supermarket approach" consisting of multiple practitioners including primary care providers, chiropractic physicians, acupuncturists, physical therapists, physiatrists, orthopedic surgeons, neurosurgeons, massage therapists, and naturopathic physicians with multiple treatment philosophies, high salesmanship and little interprofessional communication [4]. Chiropractic physicians possess many attributes that would be required of a primary spine care practitioner, and with specific modifications in education and practice, chiropractors may be in a position to make a relatively lateral transition to occupy this role [4]. As factions of the chiropractic profession are establishing a pathway for chiropractors to assume an evidence-based primary spine care practitioner role integrated in mainstream health care, it has been asserted this may not be the route many field providers desire to pursue [5]. Although most professions may have internal factions with conflicting viewpoints, such factions within chiropractic are particularly contentious [6]. According to McGregor et al., progressing toward a collaborative focus will demand a more visible appreciation of the professional strata that exist, and the mutual goals that exist between them [1]. Because chiropractic students represent the future of the profession, examining their views on professional identity might provide insight into the future of the profession. However, to date, there has been little research done among this population, with only one related specifically to this topic; this study, in fact, served as the pilot study for the current project [7]. The aim of this investigation was to survey chiropractic students' opinions about chiropractic identity, role and future. Results may yield an insight into future practitioners' perspective about the future of the profession, thus aiding in chiropractic's progression. This study may further act as a catalyst for future studies directed to current practicing chiropractors.

Survey development
A 23-item survey instrument (Additional file 1) was developed by the lead investigators at Logan University, based on the pilot survey previously used by the principal investigator among chiropractic college students at one university [7]. The survey instrument was reviewed by all remaining investigators and feedback was provided about the content, with subsequent revisions made. Survey items encompassed demographics, evidence-based practice, chiropractic identity and setting, and scope of practice. The first 8 survey items collected demographic information that included participants' current chiropractic institution in which they are enrolled, age, sex, current enrollment status, education and degrees achieved prior to enrollment, and student chiropractic organization affiliations. The enrollment status question was constructed to standardize the various institutions' use of semesters, trimesters, and quarters into 1st, 2nd or 3rd year. The remaining 15 survey items (9-23) explored participants' opinions concerning evidence-based practice, chiropractic identity and setting, and scope of practice. Of the final 15 items, 11 were constructed in 5-point Likert scale with the following ratings: 1 = Strongly Agree; 2 = Agree; 3 = Neutral; 4 = Disagree; 5 = Strongly Disagree.

Sample population
Initially, the research directors of all 19 accredited North American chiropractic colleges were invited by email to participate by administering the survey at their institution and contributing to the analysis and reporting of results. Of these 19 institutions, 12 participated (63%), each with at least one designated on-site representative to administer the survey. The participating institutions were:

Eligibility criteria
Students enrolled in an accredited Doctor of Chiropractic (DC) degree program at the time of survey administration at a participating institution were eligible. Students enrolled in a bachelor, master or non-chiropractic doctoral degree program without concurrently being enrolled in a DC program, or those enrolled part-time in a DC program, were ineligible.

Survey administration
An anonymous cross-sectional survey to identify chiropractic students' opinions regarding chiropractic identity, role and future was administered among 12 North American English-speaking chiropractic colleges. The lead institution's (Logan University) Institutional Review Board (IRB) approved this study and all participating colleges that required IRB submission of the project obtained approval from their respective institutions. A notice of participant consent was included at the beginning of the electronic survey. Participation in this study was voluntary and no compensation was provided to students for participating in this study. The electronic survey was conducted through Survey Monkey. Logan University's Survey Monkey Platinum account ensured HIPAA compliance at the highest level to all survey participants. Survey Monkey is electronic survey administrations system in which questions appear on the screen and scroll to the next item after being answered. Respondents were able to return to questions and change their responses at any time until they submitted the questionnaire; at that time it was no longer accessible by that respondent. We used a setting which only allows one survey response per IP address, in order to avoid duplication. Responses were then downloaded into an Excel file.
The study's program coordinator uploaded the survey instrument into Survey Monkey. A representative at each participating institution disseminated student recruitment invitations and the survey instrument to all eligible chiropractic students via email between November 2013 and April 2014. However, specific survey recruitment varied depending upon policies and procedures in place at each institution. Due to logistical difficulties and also to avoid duplicate responses, reminders were not sent to the students.

Data analysis
Results were downloaded from Survey Monkey directly into SPSS (v.22). Descriptive statistics were computed. Frequencies were computed for all variables, including those items with Likert scale categories (strongly agree, agree, neutral, disagree, strongly disagree and missing). Responses were compared for each item, stratified by year in program. Using a Chi square test, an alpha level of .05 was used to indicate statistically significant differences among responses by year in program.

Results
A total of 1,247 surveys were completed. Among the 12 institutions participating, response rates varied from 38.0% to 6.1%, with a mean response of 16.72. Table 1 details the response rates by institution. Table 2. The majority of respondents were between the ages of 18-25 years (50.9%) and male (53.6%). However, when comparing the sample by year in program, the proportion of men was less for earlier years in the program (50.3% for year 1, 53.2% for year 2, and 58.6% for year 3). Most respondents (83.4%) reported obtaining a bachelor's degree prior to enrollment in chiropractic college, with few respondents indicating further education beyond a bachelor's degree. The majority of respondents (62.1%) reported belonging to neither Student International Chiropractic Association (SICA) nor Student American Chiropractic Association (SACA). Respondents' current status in the Doctor of Chiropractic (DC) program were well represented throughout each year of enrollment with 394 respondents (31.6%) reporting a status of 1st year, 400 (32.1%) as 2nd year, and 446 (35.8%) as 3rd year. A significant number of 3rd year respondents (86.0%) reported having completed a course in evidencebased practice in their chiropractic curriculum.

Respondent demographics are reported in
Responses to statements regarding evidence-based practice, identity and settings, and scope of practice are outlined in Table 3. Most respondents agreed (34.8%) or strongly agreed (52.2%) that it is important for chiropractors to be educated in evidence-based practice. Approximately half (51.9%) of the respondents strongly agreed (21.6%) or agreed (30.3%) that contemporary and evolving scientific evidence is more important than traditional chiropractic theory. Nearly half (45.8%) of respondents strongly agreed (17.4%) or agreed (28.4%) that it is important for chiropractors to hold strongly to traditional chiropractic theories and practices. Many respondents strongly agreed (39.5%) or agreed (29.7%) that it is important for the progression of the chiropractic profession to include clinical chiropractic training internships and post-graduate residencies in integrative medical settings. A majority agreed (35.6%) or strongly agreed (25.8%) the emphasis of chiropractic intervention is to eliminate vertebral subluxations/vertebral subluxation complexes; however very few respondents strongly agreed (6.5%) or agreed (6.6%) that chiropractic intervention should consist of chiropractic adjustment only. A large number of respondents (55.2%) were not in favor of expanding the scope of the chiropractic profession to include prescribing medications with appropriate advanced training. Table 4 shows additional responses relating to identity and setting, and scope of practice. Most respondents deemed that chiropractors should be considered mainstream health care practitioners (69.1%). The largest proportion of respondents (46.9%) deemed the most important chiropractic practice paradigm is one that focuses on primary spine/musculoskeletal care; 25.5% thought it should be primary care; and 15.4% that it should focus on subluxation correction only. The highest proportion of participants (46.8%) reported that chiropractic researchers should focus future efforts primarily on physiological mechanisms of chiropractic adjustments.
Responses were additionally analyzed by year of respondents' current DC program status. Table 5 illustrates respondents' responses to statements about practice and identity, by topic and year in DC program. Items included in Table 5 were only those in which there was a statistically significant difference among years in program. Nearly all respondents agreed that chiropractic providers should maintain portal of entry status (84.7% 1st year, 90.1% 2nd year, and 90.1% 3rd year). Respondents tended to disagree with the idea of expansion of chiropractic scope to include prescribing medications more so in 2nd (61.6%) and 3rd (60.2%) year respondents compared to 1st year (53.5%). Respondents in their 3rd year (18.7%) agreed that chiropractic intervention should consist of chiropractic adjustment only more so than 1st (11.3%) and 2nd (10.9%) year respondents, although most respondents disagreed with this statement regardless of year in DC program. Table 6 shows respondents' opinions by year in DC program. Items included in Table 6 were those in which there was a statistically significant difference among years in program. A greater percentage of respondents viewed primary spine/musculoskeletal care as the most important practice paradigm for the chiropractic profession in 3rd year (54.2%) respondents compared to 1st (48.7%) and 2nd (45.7%) year respondents. Interestingly, students in favor of a subluxation correction only focus paradigm tended to increase in 3rd year (21.0%) respondents compared to 1st (15.6%) and 2 year (12.0%) respondents. Respondents tended to view physiological mechanisms of chiropractic adjustments as the most important focus for chiropractic researchers less as they progressed in the DC program (54.7% 1st year, 49.1% 2nd year, and 46.4% 3rd year). Additionally, respondents in favor of outcomes/cost-effectiveness of chiropractic care as a primary chiropractic research focus increased By the third year of chiropractic education, most (86.0%) students reported taking a class in evidencebased practice. A majority of respondents expressed an appreciation for education in evidence-based practice (87.0%), the importance of contemporary scientific evidence (51.9%), and the appropriateness of enriching chiropractic theories based on current scientific advancements (86.9%). Comparison of respondents based on year in DC program showed little variance in issues related to opinions on evidence-based practice.

Discussion
This study suggests that North American chiropractic students appreciate evidence-based practice, have a desire to participate in mainstream health care, be considered mainstream practitioners, concentrate in musculoskeletal/ primary spine care, and are not in favor of expanding the chiropractic scope of practice to include prescribing medications. Results of this study also suggest that chiropractic students desire to hold onto aspects of traditional chiropractic theories and practices such as emphasizing subluxation/vertebral subluxation complex as part of the evaluation and treatment of patients. However, a majority of the students also expressed the desire for researching physiological mechanisms of chiropractic adjustments.
This may indicate a trend that future chiropractors want to maintain traditional principles while pursuing a more scientific understanding of those principles. According to the Institute for Alternative Futures (IAF) Chiropractic 2025 report, general recommendations were set out for the chiropractic community to pursue including: 1. Integrate chiropractic into health care systems and integrative care models, 2. Increase research, including why chiropractic adjustments produce cost-effective outcomes, why they often show positive non-musculoskeletal effects, and how they influence gene expression and self-healing, 3. Continue to strive for high standards of practice, including promoting the use of evidence-based guidelines [8]. Results of this survey suggest that chiropractic students' ideologies mirror these aforementioned recommendations of IAF which might suggest positive strides toward continued chiropractic acceptance and growth.
The opinions and perceptions of these students may indicate future implications for the chiropractic profession. According to IAF, chiropractic has remained largely secluded from integrated health care delivery systems. [8] It is expected that 30-85% of health care will be comprised of these integrated systems. [8] Inclusion in these models, which students in this study supported, may yield greater public acceptance and utilization of chiropractic services [8]. This may additionally require modifications and shifts in traditional emphasis in chiropractic It is appropriate for the chiropractic profession to distinguish and promote two separate subgroups of broad scope (providing manual and other non-drug procedures) and limited scope (providing subluxation correction only). curriculum such as increased exposure to integrative settings, emphasis in primary spine care management in an integrative setting, accelerating research, and emphasis on evidence-based guidelines. The majority of students (61.4%) would like to see an emphasis on correction of vertebral subluxation in chiropractic practice. In addition, a larger percent (87.0%) said it is important to learn about evidence-based practice. These two key points may seem contradictory, suggesting cognitive dissonance. Or perhaps some students want to hold on to traditional theory (e.g., subluxation-centered practice) while recognizing the need for further research to fully explore these theories, as suggested by the data that showed 86.9% of the sample said that it is appropriate to update chiropractic theories based on scientific advancements. More research on this topic is needed.
As health care continues to evolve and take strides toward the establishment of collaborative multidisciplinary teams and a shift from fee-for-service reimbursements to bundled payments, risk sharing, and/or capitation [8], chiropractors must decide their identity and role in relation to this new model of health care. The chiropractic profession has been handcuffed with internal discord [9,10] and multiple strata within the profession exist. Current chiropractic students will play a role in contributing to choosing the path the profession chooses to pursue in this time of health care reorganization and this study shows the current climate of North American chiropractic students' ideologies in relation to professional identity and role. Future studies should focus on assessing practicing chiropractic physicians, and this study can provide a springboard for future investigations. The chiropractic profession should expand its scope of practice to include prescribing of medication, with appropriate advanced training. Year

Limitations
This study, much like other studies of similar nature, had limitations. The low response rate (16.7%) was the greatest limitation; a 2008 study reported online surveys to have an average response rate of 33% [11]. There is consequently likely to be a response bias. Repetitive survey distributions or reminders may have provided an increase in response rate. The survey may not have been representative due to response bias; we were only able to assess response bias in terms of gender and SACA membership. Nearly half of respondents (45.3% of total respondents and 49.7% of 1st year respondents) of this study were female. This represents a higher percentage of females in the chiropractic profession than previously reported [12]. In 2009 only 22.4% of the chiropractic profession was made up of females, unlike the typical chiropractic patient which is estimated to be approximately 60% female, compared to 48.8% of female medical graduates that year [12]. This high proportion of women students might suggest that women were overrepresented in our sample. Approximately one fourth (26.1%) of respondents reported membership in Student American Chiropractic Association (SACA). Recent reporting of enrollment in United States (US) based chiropractic colleges has been described as 9,946 students in 2010 [8]. As of June 2014, SACA membership is 3,429 students (Hall LC, ACA Director of Membership Operations/SACA Liaison, personal communication Jun 3, 2014), representing approximately 35% of US based chiropractic students, which is comparable to the results of this study. This provides evidence of the representativeness of our sample in terms of SACA membership.
A substantial proportion of respondents reported a "neutral" stance for multiple survey items. As with all surveys constructed with a middle response option, potential sources of response error exist. [13] A vast majority of respondents reported having a course in evidencebased practice; however responses to this survey item, along with responses to all items of the survey instrument, may be incomplete due to the bias of the sample available to this study.
Our sample in this study may not be representative of all North American chiropractic colleges in terms of approach to chiropractic philosophy, although this study did include colleges with diverse philosophical approaches [8].
Results of this study represent only a subset of North American students at a particular time in history. Particularly given that there were only 63% of North American chiropractic colleges that participated in this study, and there are more chiropractic colleges located outside of North America, results of this study may not be representative of chiropractic students as a whole.

Conclusion
Results of this study indicate that North American chiropractic students show a preference for participation in integrative health care, have been exposed to evidence-based