Although I could not be more proud of the dramatic improvement and leading performance of Life University students on National Board of Chiropractic Examiners exams, the steps required to get there do not best answer the question, "How do we educate better prepared and qualified chiropractors?" Instead, those steps have reflected a classic case of the tail wagging the dog. The NBCE exams solidly reflect what is currently taught on a contemporary chiropractic college campus, but the rigid timing in which they're offered and sequencing of material puts them out of sync with a well-integrated clinical education.
Ruled by Schedules, Not Scholarship
The national boards are offered just twice each year and must basically be taken in sequence, with students ineligible to proceed to the next section without passing the one that precedes it. On the surface, that sounds sensible. In reality, it ties educators to an arbitrary pacing of the curriculum to ensure coursework syncs with national board exam schedules and topics, rather than being sequenced and integrated in the most meaningful way for an effective clinical education.
We're stuck in a reactive mode whereby we're almost forced to arrange the teaching of subjects in direct correlation to when students will be tested on them in national boards. The result is students memorizing reams of basic science information (that will be covered in Part I of the exams) before they've had any opportunity to synthesize the meaning of the information in the classroom and clinical setting and see how it relates to chiropractic practice. In fact, there is so much material to be digested that it's next to impossible to find time for a palpation, technique, X-ray or philosophy course.
Contemporary pedagogical understanding clearly demonstrates the benefits of a more integrated teaching approach. Ideally, students might start their day in anatomy class in the morning and study the intricacies of the atlas. As they move on to physiology class the focus would shift to learning how the atlas actually moves. In technique, they'd learn how to palpate the atlas; in clinic, students might observe someone adjusting the atlas; and by philosophy class they'd be learning about and debating the underpinnings of upper cervical technique.
The key is to get students to see themselves as and think like a doctor of chiropractic from day one. That way, when they're mastering the details of any part of anatomy and physiology, they are also connecting how that information might apply to patients in a clinical chiropractic setting.
Unfortunately, today many academic decisions are ruled by the details of national board testing schedules. Part I covers the basic science subjects of general anatomy, spinal anatomy, physiology, chemistry, pathology, and microbiology. There's no question these are vital subjects. But offering them stacked one atop another for nearly two years at the beginning of a student's chiropractic education just to prepare them for a fixed testing date accomplishes little more than cramming their heads full of data without the context to make meaningful linkages between the information and how it applies in clinical practice.
If a student fails Part I, or even one or two of its six parts, they can quickly be backed up waiting until the test is offered again and unable to proceed with the following parts of the exam. And what about the student who is sick on test day? By providing online testing, other health professions have reduced the cost of taking the exam, provided instant feedback on grading, guaranteed that all classwork is completed before testing is permitted and accommodated individual needs. NBCE will argue it's too expensive to set up, yet others have done it. Plus, without individualized options, as are so common with exams such as the GMAT and GRE, students can find themselves unable to complete the exams they need in time for graduation and entry into practice.
Outcomes That Don't Consider Inputs
Another issue that concerns me is the growing reliance in education on outcome measurement. Again, on the surface, such an approach sounds eminently sensible, but without careful and nuanced implementation, it can set the tail wagging the dog again.
Measuring outcomes (typically through standardized tests such as NBCE exams) and then comparing one educational institution against another based on those scores without considering the input (the students who came into the organization) provides a highly skewed picture of the educational experience provided.
That's what I'm afraid we'll see with the new Council on Chiropractic Education's Board of Directors Policy 56, which establishes certain performance requirements of students enrolled in accredited chiropractic programs and requires that those pass rates are reported to the CCE. The policy requires that first-time pass rates of the four most recent exams be not be less than 60 percent for Parts 1 and 2 and not less than 70 percent for Parts 3 and 4.
It sounds perfectly logical at first blush. How simple it makes it to compare Institution A and its 74 percent pass rate with Institution B and its 69 percent pass rate. Although the higher pass rate might indicate quality teaching, it might also just indicate a more prepared student population. What about the institution with a specialized mission of bringing underserved segments of the population (who often perform less well than their more advantaged counterparts) into the profession? They may actually provide far better instruction than the more highly ranked institution, but simply serve a population with greater need.
Of course, we should look at the competencies students have mastered after a certain component of instruction, and measure the ability of the teachers and institutions to provide that mastery. But if we don't measure the inputs and the outputs, we're comparing apples and oranges.
Increasing Flexibility and Progress
We have substantially overhauled our curriculum at Life University and I know we're offering a high-quality education with as much connection among subjects and between subject matter and clinical application as we can squeeze in. But I also know we could do even better if we allowed quality education practices to rule the day, rather than preparation for national testing dates and arbitrary comparisons among institutions. I'd love to see the NBCE extend a greater willingness to all of the chiropractic colleges to work toward creating a more flexible testing schedule that respects the need to integrate clinical connections into the curriculum much earlier on. And I urge the CCE to consider inputs while also measuring outputs to ensure these new metrics truly reflect educational progress.
Interested in the NBCE's perspective on these issues? Click here.
Dr. Guy F. Riekeman, current president of Life University in Marietta, Ga., has held leadership positions in chiropractic education essentially since his graduation from Palmer College of Chiropractic in 1972. He was appointed vice president of Sherman College in 1975 and has served as president of all three Palmer campuses and as chancellor of the Palmer Chiropractic University System. In 2006, he was elected to the board of directors of the Council on Chiropractic Education.