Since 1974, standards for chiropractic education have been established and monitored by the Council on Chiropractic Education (CCE), a not-for-profit organization located in Scottsdale, Arizona (CCE, 1995). Recognized by the U.S. Department of Education as the specialized accrediting agency for chiropractic education, the CCE sets standards for the curriculum, faculty and staff, facilities, patient care, and research. One of the CCE's major functions is to assess chiropractic institutional effectiveness and outcomes. This involves a periodic cycle of accreditation where member institutions perform a self-study of their strengths, weaknesses, and educational outcomes as they relate to CCE Standards. A visitation team made up of educators and practitioners conduct a site visit to review compliance with CCE Standards and the institution's mission and goals. The visitation team to the CCE Commission on Accreditation generates a report. The Commission holds a hearing for the institution for further clarification and verification of information and then renders a decision. The maximum length of accreditation is 7 years. Member institutions file yearly reports of their activities as they relate to CCE Standards.

All 16 chiropractic educational institutions currently have accredited status with the CCE. Regional accrediting bodies such as the North Central Association of Schools and Colleges also accredit 13 of the colleges. Admissions requirements of chiropractic colleges are influenced by CCE Standards and chiropractic licensing board requirements. A minimum of 2 years of undergraduate education are required with successful completion of courses with a grade of "C" (a 2.5 grade point) or better in Biology, General Chemistry, Organic Chemistry, Physics, Psychology, English/Communication, and the Humanities (CCE, 1995). Each required science course must include laboratories. The cumulative grade point average must not be less than 2.25. The total college preprofessional credit units must be at least 60 semester units. Two colleges currently require 75 semester units and one requires 90 semester units. Four colleges will soon require a bachelor's degree for admission. Currently, six State Licensing Boards require a bachelor’s degree in addition to the doctor of chiropractic degree for licensure (Federation of Chiropractic Licensing Boards, 1997).

The chiropractic college admissions process usually includes an application review, assessment of academic transcripts, letters of reference, and an interview. Currently, there is no standardized admissions test. At most chiropractic colleges a "rolling" admissions process is used with qualified applicants being admitted on an ongoing basis. The "typical" (median) successful applicant has completed more than 90 college credits with a "B- " (2.7) average (Coulter, submitted).

A chiropractic program consists of 4 academic years of professional education averaging a total of 4,822 hours, and ranging from 4,400 hours to 5,220 hours in the 16 colleges.¹ This includes an average of 1,975 hours in clinical sciences and 1,405 hours of clinical clerkship. The minimum hours for accreditation by the Council on Chiropractic Education is 4,200 hours.

The program of study at all chiropractic schools is divided into Basic and Clinical Sciences. The average total number of basic science contact hours is 1,420, which accounts for 30 percent of the entire chiropractic program.² Basic sciences education includes an average of 570 hours of anatomy (40 percent of all basic science hours), 305 hours of physiology (21 percent), 205 hours of pathology (14 percent), 150 hours of biochemistry (11 percent), 120 hours of microbiology (8 percent), and 70 hours of public health (5 percent).

On average, 70 percent of the program is composed of clinical education. Chiropractic schools devote an average of 3,380 contact hours to clinical education: 1,975 hours (58 percent) are spent in chiropractic clinical sciences and the remaining 1,405 hours (42 percent) are spent in clinical clerkships. These contact hours are in lectures, laboratories, and clinics. Table 5 shows the distribution of hours in these three settings for both basic and clinical sciences.

Variable	Chiropractic Schools
	Total	Basic Science	Clinical Science
Lecture hours	2675	1020	1655
Laboratory hours	1115	400	715
Clinical hours	1010	0	1010
Total	4800	1420	3380

Clinical subject	Hours	% of Total
Adjustive technique/spinal analysis	555	22%
Physical/clinical/laboratory diagnosis	410	17%
Diagnostic imaging, radiology	305	12%
Principles of chiropractic	245	10%
Orthopedics	135	6%
Physiologic therapeutics	120	5%
Nutrition/dietetics	90	4%
Professional practice & ethics	65	3%
Biomechanics	65	3%
Gynecology/obstetrics	55	2%
Psychology	55	2%
Research methods	50	2%
Clinical pediatrics & geriatrics	50	2%
First aid & emergency	45	2%
Dermatology	30	1%
Otolaryngology	25	1%
Other	160	7%
Total hours of clinical training	2460	100%

Participation in Continuing Education by chiropractors is commonplace as 47 of 50 States have mandatory continuing education requirements to maintain or renew a license to practice (FCLB, 1997). The annual number of required hours ranges from zero in 3 states to 50 in Kansas (FCLB, 1997) (see Table 12 in Chapter V). The most prevalent requirement is 12 hours per year (25 of the 50 States). In addition, a number of States specify that topical content areas are to be included in annual continuing educational requirements. Examples include diagnostic imaging, chiropractic technique, risk management, public health (infection control and AIDS prevention), and professional boundaries issues. Several State Licensing Boards limit who may sponsor continuing educational activities (e.g., accredited chiropractic colleges or approved associations) and what the program is about (e.g., practice management seminars are typically excluded).

Chiropractic continuing education programs often involve a 1- to 2-day seminar or conference (8-16 hours) focusing on a variety of topics related to chiropractic principles, clinical skills development, diagnosis, patient care, and practice management. These programs are usually sponsored by chiropractic colleges and other educational institutions, professional associations, and sometimes by commercial vendors or individual entrepreneurs. There is a growing interest in practice-based continuing education and distance learning (Jamison, 1991; Ebrall, 1995).

Comparison with Medical Education and Training

A recent study comparing chiropractic and medical education collected data on all chiropractic and medical schools in North America and performed an in-depth analysis of three chiropractic and three medical schools (Coulter, submitted). Three States providing a broad geographic representation of the United States were chosen: California, Iowa, and Texas. These States account for almost half of the chiropractic colleges in the United States. A single chiropractic college and school of medicine were studied in each State.

The chiropractic schools included in this study had enrollments of 521, 773, and 1880, compared with a mean enrollment for all colleges of 878 (CCE Report, 1996). The three medical schools had enrollments of 691, 734, and 745, all moderately above the national average of 536 (JAMA, 1995).

 Program Length

The chiropractic programs consist of 4 years of undergraduate education totaling approximately 4,800 contact hours. The medical programs consist of 4 undergraduate years, with approximately the same number of contact hours (4,667), but typically with an additional 3-year residency to meet the requirements for practice.

 Selection of Students

Medical schools require at least 3 years of college education prior to admission, while chiropractic colleges require a minimum of 2 years. In fact, most medical students complete 4 or more years of college (Coulter, submitted). However, national data on graduate chiropractors show that 78 percent have degrees other than chiropractic, of which 54 percent are Bachelor’s or higher. Most chiropractors completed these degrees prior to the D.C. degree (Christensen, 1993).

Medical schools use the results of a standardized examination, the MCAT, as part of the selection process. Chiropractic schools have no standardized equivalent.

 Prerequisites

There is considerable overlap in the two professions in terms of the courses they require as prerequisites for entrance. Both require biology, general inorganic chemistry, organic chemistry, and general physics. In medicine it is common to require mathematics, which is not required in chiropractic. Both require a humanities prerequisite with chiropractic also requiring a social science/psychology credit as well as English and/or communication skills.

The Curriculum

Two questions are of paramount importance in comparing the curricula of the two professions; what subjects are taught and how much is taught? The two programs are relatively similar in total student contact hours: an average of 4,822 hours in chiropractic schools compared with 4,667 hours in medical schools (Coulter, et al, submitted).

Basic science comprises 25-30 percent of the total contact hours in both the chiropractic and medical programs (Table 9) and the two programs have roughly similar contact hours in biochemistry, microbiology, and pathology (Table 10). Chiropractors receive substantially more hours in anatomy education and physiology but many fewer in public health.

Table 9. Comparisons of the Overall Curriculum Structure for Chiropractic and Medical Schools

Source: Center for Studies in Health Policy, Inc., Washington, DC. Personal communication of 1995 unpublished data from Meredith Gonyea