INTRODUCTION

The National Institutes of Health defines integrative health as aiming “for well-coordinated care among different providers and institutions by bringing conventional and complementary approaches together to care for the whole person.”¹ In the United States, integration of chiropractic services with primary and specialty care is being actualized in part by a growing trend toward doctors of chiropractic pursuing careers within health care systems. The 2020 National Board of Chiropractic Examiners practice analysis survey demonstrated that more than 18% of respondents practiced within an integrated setting,² double the percentage reported in 2015.³ In particular, the growth of chiropractic services has been rapid within the Department of Defense and the Veterans Health Administration (VHA), increasing the chiropractic services at rates of 10% and 17% respectively.⁴ In the private sector, chiropractic services are utilized within hospitals and other integrated clinical settings, though the rate of growth is currently unknown.^5–7 Chiropractic services have been described in private medical groups,⁸ university hospital systems,^9–11 and Federally Qualified Health Centers.^12–14 Another avenue of chiropractor integration has been the implementation of the Primary Spine Practitioner model within at least 7 hospital, payer, or community systems within the United States.¹⁵

In most jurisdictions, it is not mandatory for chiropractors to complete postgraduate training as part of their practice requirements. For licensure eligibility, doctor of chiropractic program (DCP) graduates have similar requirements to optometry program graduates^16,17 in that they are required to complete clinical didactics, attain a minimum threshold of clinical experience (often referred to as rotations or preceptorship), pass national board examinations, and satisfy local state or territory regulations.¹⁸ This differs significantly from the medical profession, which requires 3–7 years of postgraduate training, depending on the chosen specialty or area of practice. The first year of medical residency, referred to as postgraduate year 1 or internship year, is often spent introducing residents to various departments, building the physician's knowledge of specialties, and aiding them in selecting a career path.¹⁹

Furthermore, exposure to multiple disciplines expands knowledge of different management approaches, fosters the growth of the entire health care system, improves health outcomes, and provides interprofessional education, which is a necessary step in preparing trainees to be collaborative practice ready.²⁰ Medical residents rate interaction with peers as their “highest source of learning.”²¹ Starting in 2014, the VHA has offered a 1-year Chiropractic Integrated Clinical Practice residency to recent graduates. There are currently 10 VHA facilities in the United States that have received or are in the process of applying for accreditation of a chiropractic residency program, and they offer a unique opportunity for graduates to participate in hospital-based clinical care, interprofessional rotations, and scholarship.^22,23

Collaborative practice and interprofessional team skill sets, including a foundational understanding of medical specialties,^19,24 are paramount to facilitating the expansion of chiropractic services within integrated medical settings.^6,25 When surveyed, a majority of chiropractors practicing in integrated settings (60.0%) report comanagement of patients with other health care providers.⁷ Chiropractic students (69.2%) across multiple DCPs recognize clinical training in integrated settings as valuable for the profession²⁶ and welcome the opportunity for participation.²⁷ In a recent study of VHA chiropractors, 31% of respondents reported prior hospital-based integrated experience as part of their student clinical training.²⁸

The Council on Chiropractic Education accreditation standards stipulates (Section H, meta-competency 8 on interprofessional education) that DCP-assessed outcomes include providing opportunities for students to “use appropriate team building and collaborative strategies with other members of the healthcare team to support a team approach to patient centered care” as a requirement for graduation.¹⁸ The Council on Chiropractic Education outlines that interprofessional education may be demonstrated in didactic, clinical, or simulated learning environments but does not explicitly require training in settings with other health care professionals.¹⁸ A preliminary descriptive study reported early implementation of chiropractic student trainees within 4 VHA integrated chiropractic clinics,²⁹ but to our knowledge, no studies have investigated the availability of integrated clinical training opportunities across US DCPs. The purpose of this study was to assess, summarize, and compare the current integrated clinical learning opportunities available for students within US DCPs.

METHODS

The VA Puget Sound Human Research Protection Office reviewed this project and determined it did not meet the definition of research requiring institutional review board approval. Similar to other studies, we reviewed public-facing DCP documents and websites.^30–32 Doctor of chiropractic institutions were identified from the Association of Chiropractic Colleges (ACC) website.³³ Similar to studies by Gliedt et al³¹ and Cupler et al,³² we included the Sherman College of Chiropractic and also included the newly accredited Universidad Central del Caribe, who are not ACC members but whose students are eligible for US board pre-licensure examinations (Table 1).

Table 1 - Included US Doctor of Chiropractic Programs

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We searched public-facing DCP websites and electronic program handbooks from July 2021 through September 2021. Each DCP website was combed for the most recent curriculum or handbook, which was then searched digitally using the “find” function for key terms (Table 2).^31,32 In addition, the DCP websites were manually searched for available integrated clinical opportunities identified via the same search terms. Data were extracted into Microsoft Excel (Microsoft Corp, Redmond, WA, USA) to track the following: information source (handbook or website), presence of integrated clinical opportunity (1 = yes or 0 = no), type of integrated clinical opportunities available (1 = yes or 0 = no), number of opportunities (count), number of each opportunity (count), total number of opportunities (count), and length of training (free type or NA = not available). Integrative clinical opportunities were defined as any experiences where the DCP trainee was involved in care delivery within an integrated health care system and in a separate physical space from the DCP training clinics. For example, if a medical doctor supervises or provides care at an on-campus DCP training clinic, that was excluded. In addition, if a DCP has an affiliation with a single health care system but that system allows DCP students at different locations, it was tallied as only 1 opportunity. However, if a DCP has an affiliation with 2 separate systems within the same organization, these were tallied as 2 integrated clinical opportunities (e.g., multiple VHA affiliations with 1 DCP). Any categories that could not be located via a search of the website or curriculum were reported as “0” for “not available.” Multidisciplinary, interdisciplinary, and transdisciplinary clinics were used synonymously.

Table 2 - Search Terminology

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Two authors (KM and OA) independently performed the data extraction of each DCP. The 2 data sets were then compared and any discrepancies resolved through discussion. Following data extraction, a clinical dean, a director of clinical education, or an apparent equivalent representative at each DCP was e-mailed with a request to verify the accuracy of our collected information. If no response was received from the DCP contact within 1 week, a follow-up e-mail was sent 1 week later. If still no response was received, we proceeded with the publicly available information but denoted lack of confirmation with an asterisk in our data tables. All analyses were descriptive and proportions reported for categorical variables and mean and median for continuous variables.

RESULTS

Seventeen publicly facing DCP curriculums and websites were searched, with the majority of information sourced from DCP websites. The types and number of integrated clinical training opportunities can be found in Tables 3 and 4. A total of 166 opportunities exist for US DCP students to gain experience in integrated clinical settings. A majority, 88.2% (15/17), of DCPs reported offering training in at least 1 integrated setting, with a mean of 9.8 total integrated opportunities (median 4.0) and a mean of 2.5 (median 2.0) different types of settings. The maximum number of integrated training experiences available through a single DCP was 41.

Table 3 - Number of Integrated Clinical Opportunities Available

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Table 4 - Number of Opportunities Available per Integrated Clinical Opportunity Type

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VHA affiliations were the most prevalent integrated clinical experience, accounting for 56.0% (93/166) of total integrated opportunities in affiliation with 64.7% (11/17) of DCPs (Fig. 1). Multi-/inter-/transdisciplinary clinics were the second most common integrated opportunity at 25.0% (42/166) while being offered at the most DCPs (13/17 [76.5%]). In addition, DCPs listed integrated opportunities offered through partnerships with Federally Qualified Health Centers 41.2% (7/17), private/public hospitals 41.2% (7/17), and Department of Defense sites 29.4% (5/17) (Fig. 1, Tables 3 and 4).

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Descriptions of the duration of integrated clinical training were limited in availability and heterogeneous. Several DCPs reported program length by academic calendar (trimesters, quarters, and so on), by traditional calendar (weeks or months), or not at all. When contacted, 8 of the 17 DCPs reported additional opportunities not listed in public documents at the time of data extraction.

DISCUSSION

This work demonstrates that at least 1 integrated clinical opportunity is available to chiropractic students through a majority of US DCPs. However, 6 of the 17 DCPs accounted for 78.9% (131/166) of the integrated clinical opportunities. The public-facing documents revealed that 3 DCPs did not offer clinical training opportunities on-site in integrated medical facilities and that 9 DCPs offered fewer than 10 opportunities in total. VHA is the largest health care training institution in the United States,³⁴ and, consistently, VHA comprised nearly two-thirds of the integrated clinical opportunities identified for DCP student trainees. There are several factors that may contribute to the strong representation of VHA chiropractic integrated clinical opportunities, including a mission dedicated to education and training health care personnel, the presence of national professional leadership, and inherent infrastructure allowing for the development of academic affiliations as a pipeline to accessing trainees.⁴ Continued expansion of DCP affiliations within other integrated settings may improve DCP clinical experiences and help early career chiropractors excel in diverse environments with a spectrum of patients and providers.

It is apparent that DCP students and the chiropractic profession believe integration to be important.^25,27 The steady growth of chiropractors providing care at traditional medical centers^4,15,22 heightens the importance of integrated clinical training in these settings while in the clinical phase of a DCP. Further, integrated clinical training opportunities could serve as an important facilitator to developing interprofessional skills and building relationships for future expansion of chiropractic integration efforts in integrated clinical settings and scholarly research activities. While the VHA chiropractic residency offers an opportunity for integrated training after graduation, very few spots are available at this time, and this lends toward a significant gap in the availability of advanced hospital-based training opportunities for practicing chiropractors.

The positive impact that chiropractic services have on the health care system has been well documented. Several studies have shown that implementation of chiropractic within hospital settings improved disability outcomes in patients with chronic spinal pain^14,35 and reduced the escalation of costly spine services, including opioids,^36–38 diagnostic imaging,^5,39 injections,³⁹ and surgery.⁴⁰ Cost comparisons consistently demonstrate that management of spine care conditions inclusive of chiropractic has resulted in lower associated costs for patient care.^41–43 The colocation of care between chiropractic and physician teams is reported to be important to patients and is likely to facilitate communication, collaboration, and trust between providers.^44,45

A majority of chiropractic students are multimodal learners with a significant preference for kinesthetic learning.⁴⁶ As chiropractic is a very hands-on profession and because high-quality experiences may enhance clinical decision making and overall quality of patient care,⁴⁷ the authors speculate that opportunities to learn and practice chiropractic within integrated clinical spaces may facilitate the retention and translation of these behaviors into clinical practice. A reported two-thirds of chiropractic students are neutral to or in favor of a mandatory postgraduate residency program prior to professional licensure.⁴⁸ Participation in an integrated clinical training program may positively influence the students' recognition of the benefit of and encourage them to apply for residency programs. It is unclear how the presence of integrated clinical training opportunities may affect decision making for potential chiropractic applicants and/or school marketing strategies.

There are many avenues for future research efforts, which may include studying (1) the impact of training in an integrated clinical setting on DCP students' education and the influence such experiences have on career paths, (2) the competitiveness and utilization of integrated clinical training opportunities by chiropractic students, (3) the perceptions and attitudes toward chiropractic training in integrated clinical settings from other health care disciplines and trainees, (4) the quality of learning (number and complexity of cases seen, level of student involvement in patient care, use of integrated electronic health records, and ability to observe and interact with physicians and allied health care providers and health care trainees of other professions) across different environments, and (5) a repeat assessment of integrated clinical training opportunities at DCPs at a later time to evaluate growth and sustainment of opportunities.

CONCLUSION

A spectrum of integrated clinical training opportunities is offered by US DCPs. As of the fall of 2021, 166 integrated clinical training opportunities existed across 17 US DCPs, with 6 DCPs accounting for 78.9% (n = 131) of the opportunities, and most were offered at academically affiliated VHA facilities. This work presents the current state of integrated clinical training opportunities available at US DCPs.