Examining the Wisconsin State Exam
State board under increasing fire for unique testing requirement.
By Peter W. Crownfield, Executive Editor
You've passed your national boards with flying colors, including Part IV, the practical examination, at a combined cost of more than $3,000.1 You can hardly contain your enthusiasm (and relief) as you prepare to open your first practice and begin serving patients.But wait: you have one more test to take – a second practical exam, at an additional cost exceeding $1,400.2 Welcome to chiropractic in Wisconsin, where the Wisconsin Chiropractic Examining Board is under increasing scrutiny for requiring would-be DCs to pass not only Parts I-IV, but also a state examination in order to practice.
Back in 2002, the Wisconsin board voted to require Part IV of the NBCE exam in lieu of the state's exam. Since the NBCE began administering Part IV in 1996, 49 of 50 states have adopted the exam. (Illinois only requires Parts I-III, but does not administer a state examination.)3
Despite opposition from the Wisconsin Chiropractic Association (WCA), which unsuccessfully sued the Wisconsin board4 following elimination of the exam, the testing change stood – until 2009, when the state exam returned as an amendment in Wisconsin's budget bill, reportedly following heavy lobbying by the WCA.5 Administration of the exam began in 2012.
Weighing In: Critics vs. Proponents of the State Examination
On its website, the Wisconsin Chiropractic Association states that it has "always supported a Wisconsin State Licensure Exam ... The Association has never endorsed the National Board of Chiropractic Examiners (NBCE) Part IV requirement." According to the association, its opposition to eliminating the state exam is based on "the historically high failure rate of first-time test takers with the exam prior to its discontinuation in 2002 (40%) in comparison to the NBCE Part IV failure rates (then reported at 13%). It was also determined through first-hand doctor of chiropractic accounts that the quality of student preceptors was declining [when the state exam was discontinued] – with a specific emphasis on the ability to read x-rays."6
According to WCA Executive Director Karen Blackwell, the state exam is "an extra layer of patient protection that we believe is important in the state of Wisconsin. It also helps the chiropractic profession maintain its high standards and professionalism."2
Critics of the exam claim the state testing requirement is unnecessary (after all, Part IV is a practical exam), cost-prohibitive and difficult to pass (while results of the latest examination, administered April 18-19, 2013, have not been released as of press time, only six of 11 exam-takers have passed the exam since its adoption, and only one on the first try).7
The examination also may be reducing the number of new DCs practicing in Wisconsin – by design, claim exam critics.7 "We don't feel (the test)'s there to protect the public," said Steven Conway, executive director of the Chiropractic Society of Wisconsin, which would like the state exam discontinued. Added Conway: "It's truly an injustice to ... students who want to come here and practice."5
Eighty-four Wisconsin chiropractic licenses were granted last year, and of those, 67 were grandfathered in before the test was required and 11 were already-licensed DCs from other states exempted from taking the exam [licensure by endorsement]. This licensure total is much lower than in the three prior years (128, 136, 116), but "in line with the average from 2000-2008."5
"We are not in this to restrict incoming doctors, but rather [to] have this be a tool for professionalism," said Rockwell.5
Fueled by these and other criticisms regarding the state examination, legislation (SB 105) was introduced on March 27 to discontinue the exam again.8 The bill is currently under review.
Questions Without Answers (Yet)
If the above discussion leaves you with more questions than answers regarding the purpose and design of the state chiropractic examination, you're not alone. Here are the questions posed recently to Thomas Ryan, executive director of the Wisconsin Chiropractic Examining Board, and Angie Hellenbrand, public relations officer for the Wisconsin Department of Safety and Professional Services (which oversees the chiropractic board):
Hellenbrand shared the following in response to the above questions: "The state exam for chiropractors incorporates a practical exam, whereas the Part IV exam does not. The state exam was developed by the Chiropractic Examining Board, therefore we do not have data related to the number of person-hours it took to develop the exam. The practical exam given prior to 2002 had two scenarios, while the current exam has three. At this time, there is no plan for a fee increase."
Upon request, Hellenbrand then forwarded the questions to "the executive director [of the board] to coordinate with the chair." James Koshick, DC, vice chair of the Wisconsin examining board, responded, but only addressed the test fee question: "The only information I can give you with certainty now is that the exam fee will not be going up, and may in fact be going down." Koshick also stated that since the state exam had just been administered and the questions required "rather lengthy answers," he would "re-visit [the] questions after the exam results have been tabulated."
Part IV vs. the State Exam: What We Know
While we lack specifics regarding the development of the Wisconsin state chiropractic examination and why the Wisconsin board believes it is necessary considering prospective licensees are also required to pass Part IV, we do know that the state exam9 is a two-day test that includes three separate clinical scenarios, an x-ray exam and a written exam. Each scenario has a "mock patient" and the scoring for each clinical scenario includes: history 30 percent, physical exam 30 percent, recommendations for imaging 5 percent, assessment / diagnosis 15 percent, informed consent 5 percent, and treatment plan & demonstration 15 percent. Additional testing details, including what examinees are tested on for each section, are explored in the candidate guide for the exam.
According to the NBCE, Part IV "tests individuals in three major areas: X-ray interpretation and diagnosis, chiropractic technique and case management," and was developed over a six-year period. "Each Part IV exam involves ten patient encounter stations, where case history-taking skills, orthopedic and neurological examination skills, and physical examination skills are assessed. Each Part IV exam involves five chiropractic technique stations, where adjusting skills are assessed in the cervical, thoracic, lumbar, sacroiliac and extremity areas."
The process of developing the Part IV exam included thousands of hours of staff time to ascertain the "financial, logistical, psychometric and legal issues involved. Over [10,000] chiropractic practitioners were surveyed to determine the types of conditions seen in their offices, and the essential professional tasks required to deliver chiropractic health care in a safe and effective manner. The NBCE received more than 5,000 replies. The NBCE analysis of chiropractic practice is used as a legally defensible basis for the content of the Part IV examination for licensure."
According to the NBCE, approximately 35 DCs and professional consultants and subject-matter specialists work to prepare the materials for each part IV examination. An average of 326 standardized patients and an average of 125 technique patients are used nationally during each examination. The NBCE budget for Part IV exam development is between $312,000 and $325,000 annually.
All of the above is required to make a professional examination fair and defensible. This may explain why 49 of the 50 state licensing boards have abandoned the idea they could offer a practical exam that would meet today's standards.
With SB 105 in the state legislative pipeline and the chiropractic profession in Wisconsin likely wincing from the media spotlight already, something has to give; it's just a question of when and what the outcome will be. Look for a follow-up article reporting on further developments, including what one hopes will be more detailed responses to the questions posed to the Wisconsin Chiropractic Examining Board.
Editor's note: Read DC Publisher Don Petersen Jr.'s perspective on the Wisconsin state chiropractic examination by clicking here.