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Abstract

Background

There has been rapid growth of chiropractors pursuing career opportunities in both public and private hospitals and other integrated care settings. Chiropractors that prosper in integrated care settings deliver patient-centered care, focus on the institutional mission, understand and adhere to organizational rules, and are proficient in navigating complex systems. The Council on Chiropractic Education Accreditation Standards do not outline specific meta-competencies for integrated care clinical training.

Objective

The purpose of this study was to develop preliminary integrated health care competencies for DC programs to guide the advancement of clinical chiropractic education.

Methods

A systematic literature search was performed. Articles were screened for eligibility and extracted in duplicate. Domains and seed statements were generated from this literature, piloted at a conference workshop, and evaluated via a modified Delphi consensus process. Of 42 invited, 36 chiropractors participated as panelists. Public comment period yielded 20 comments, none resulting in substantive changes to the competencies.

Results

Of 1718 citations, 23 articles met eligibility criteria. After 2 modified Delphi rounds, consensus was reached on all competency statements. A total of 78 competency statements were agreed upon, which encompassed 4 domains and 11 subdomains. The 4 domains were: 1) Collaboration, (2) Clinical Excellence, (3) Communication, and (4) Systems Administration.

Conclusion

We identified 78 preliminary competencies appropriate for preparing DC students and early career chiropractors for clinical practice in integrated healthcare settings. Educational programs may consider these competencies for curricular design and reform to strengthen DC program graduates for integrated practice, advanced training, and employment.

Keywords

chiropractic competencies integrative medicine delphi method education hospitals

Introduction

Integrated health care delivery is a concept that aims to overcome fragmented patient care, particularly where disconnected care leads to a negative impact on a patient’s care experience and clinical outcome. The integrated health care approach is now commonly accepted, throughout the world, as the preferred model to patient care and healthcare system design.¹ Thus, there is an increasing need for health care trainees to be prepared to function within an interdisciplinary team.

Interdisciplinary team-based care has been shown to enhance productivity, safeguard a wholistic approach to patient care, and promote patient care innovation.^2,3 Further, interdisciplinary team-based care has been shown to improve clinical outcomes, particularly in the care for non-communicable diseases.^3,4 In addition, studies have illustrated improvements in patient care access, coordination, and patient safety.^3,5

Chiropractic is the largest complementary integrative health profession in the United States⁶ and focuses on the diagnosis and management neuromusculoskeletal conditions.^7,8 Given the standardization and value of integrated health care, it is essential for all health care professionals to be competent and able to collaborate as part of an interdisciplinary team, working together for the common goal of patient-centered care.⁹ This emerging need for team-based health-care delivery necessitates chiropractors – one of the most common health care professionals to be consulted for spine pain^10-13 - to be prepared to engage in an interdisciplinary team.^14,15 Chiropractors that excel in integrated care settings have been described to go beyond delivery of patient-centered care to align with the institution’s mission, understand the rules of the organization, adhere to the administrative requirements of the position, and understand how to work within the system of the institution.¹⁶

The purpose of this study was to develop an initial set of competencies for chiropractic students preparing to work as part of an interdisciplinary team and enhance integrated care delivery. This project came about because the authors, who mostly practice and provide training for Doctor of Chiropractic (DC) students and post-graduate residents in integrated care environments, perceived that DC students and residents lack the competencies and skills to optimally function within an interdisciplinary team. In response to the authors’ observations, lack of Council on Chiropractic Education (CCE-USA) meta-competency outcomes specific to integrated care, we sought to develop a set of specific preliminary competencies suitable for DCs to function in integrated care settings and as part of interdisciplinary teams that extends across clinical care settings. Similar to public health competencies developed for the chiropractic profession,¹⁷ this may establish an initial step in a pathway to allow CCE-USA and DC programs to consider these meta-competencies and competencies, respectively, when refining guidance and curricula in the future.

Methods

Human Subjects Considerations

The Logan University Institutional Review Board approved the project prior to initiation (#RD1005220595, October 5, 2022). All steering committee (SC), workshop, and modified Delphi panelist participants contributed voluntarily and without compensation. Informed consent was obtained from each Delphi panelist including an agreement to be acknowledged.

Project Steering Committee

The SC of 20 members consisted of chiropractors in practice within integrated healthcare settings, and DC program clinical education experts. Five SC members served as board members for Clinical Compass (https://www.clinicalcompass.org), a non-profit chiropractic evidence synthesis think tank. Regarding employment, 8 SC members practiced within VA, 5 practiced in non-VA hospitals, 3 practiced at FQHCs, and 3 were educators in DC program institutions. Additionally, 3 members of the SC were CCE-USA accredited DC residency program directors and 6 SC members graduated from a CCE-USA accredited DC residency program.

Overview of Plan

A structured strategy for identifying competencies for US pre-licensure DC students was executed in 4 phases from August 2022 through November 2023. The phases of competency development were: In Phase I, the SC conducted a literature search synthesizing existing competency literature. During Phase II, members of the SC presided over an academic conference workshop to review search findings and to seek stakeholder feedback on proposed competency domains. During Phase III, proposed competencies were developed based on feedback from Phases I and II and a modified Delphi consensus process was undertaken. During Phase IV, public comment was sought to include additional stakeholders. (Figure 1)

Figure 1.

Study methodology timeline.

Phase I (Literature Search and Synthesis)

In September 2022, the SC conducted a systematic search and synthesis of existing chiropractic and other health profession competencies relevant to integrated clinical care. Results of the search and synthesis were used to draft competency domains to be presented in Phase II. The results of the evidence review were synthesized into initial drafts of candidate standardized terminology, definitions, and competencies.

Search Strategy

In collaboration with an experienced health service librarian (SW), we conducted a search of PubMed,¹⁸ Index to Chiropractic Literature (ICL),¹⁹ and Cumulative Index to Nursing and Allied Health Literature (CINAHL).²⁰ Our search strategy (Supplemental Table 1) utilized keywords specific to education (e.g., competency or competency-based), health professions (e.g., chiropractic, medicine) and integrated training. The search spanned January 2007 through August 2022 as competency-based medical education did not achieve mainstream attention until the last 15 years.^21,22 We refined our results with inclusion and exclusion criteria (Table 1). Competencies were limited to English language documents.

Table 1.

Literature Review Eligibility Criteria.

Inclusion	Exclusion
• Competencies related to:	• Randomized controlled trials
◦ Integrative medicine	• Clinical trials
◦ Integrated health	• Observational studies
◦ Interprofessional care	• Case report/series
◦ Integrated clinical education	• Surveys
◦ Multidisciplinary practice	• Basic science research
◦ Complementary integrative health	• Surgical competencies
◦ Complementary alternative medicine	• Inpatient related
◦ Outpatient/ambulatory care	• Residential/long-term care/hospice related
	• Not available in English
	• Older than 2007
	• Education competencies not relevant to integration
	• Conference abstracts
	• Undergraduate education
	• Entrustable professional activities (EPA)

Article Selection

Search results were uploaded from Endnote to a website for organizing systematic reviews (Rayyan, Cambridge, MA).²³ After duplicate citation removal, a paired team (AZ, KM) of the SC independently screened titles and abstracts against the eligibility criteria. Those titles and abstracts that met the screening criteria were saved and a paired team (AZ, MK) of the SC independently evaluated full text manuscripts against the eligibility criteria. When consensus was not reached a third member of the SC (CD) adjudicated. The following data were extracted from included citations independently by 2 SC members (AZ, MK): author, year of publication, relevant profession/specialty/discipline, study methods, development target, domains, and competencies by domain.

The SC identified and analyzed domains and competencies from each included source. Members of the SC (CD, ZC, JN, RW) derived preliminary themes through inductive means using an iterative process. Extracted themes were preliminarily grouped into the following categories: Clinical Acumen, Collaborative Team, Digital Health, Interpersonal, Interprofessional, Practice-Based Learning, Professionalism, Roles and Responsibilities, and System/Organization Level.

Phase II (Workshop)

In November 2022, members of the SC (JG, RW, ZC, CD) led an interactive workshop at the World Federation of Chiropractic (WFC) Association of Chiropractic Colleges Education Conference (ACC) (Logan University, Chesterfield, MO).²⁴ A US-based, geographically-diverse workgroup of chiropractic stakeholders (i.e., administrators, clinicians, educators, and researchers), participated in this interactive in-person workshop (Table 2). In a 45-minute workshop, participants (1) reviewed central tenets of competency-based education, (2) considered key literature from the results of Phase I and (3) provided written and verbal feedback on an initial draft of competency domains.

Table 2.

Workshop participant (n = 9) and Delphi panelist demographics (n = 36).

Gender	N (%)
Male	7 (77.8)
Female	2 (22.2)
Primary (or stakeholder) Role
Integrated Care Clinician	3 (33.3)
DC Program Faculty	2 (22.2)
Researcher	2 (22.2)
Private Practice Clinician	1 (11.1)
Other	1 (11.1)
US Geographic Region
Northeast	3 (33.3)
Midwest	3 (33.3)
Southeast	1 (11.1)
West	2 (22.2)

Phase III (Modified Delphi Panel)

Utilizing an iterative process, the SC evaluated materials developed from Phase I and Phase II to generate competency domains, subdomains, and seed statements. Workshop attendees from Phase II were invited to participate in the subsequent consensus process. Some of the invited stakeholders were cross trained as physicians, physical and massage therapists.

We followed the RAND/UCLA appropriateness methods for assessing the drafted statements by using a 1-9 ordinal scale (highly inappropriate to highly appropriate).²⁵ The modified Delphi process was executed until 80% consensus was reached with a median rating of at least 7 for each drafted competency statement. Panelists were emailed the draft competency statements, corresponding rating scales, and an open textbox to type comments. They were instructed that any ratings that were not appropriate (7-9) required a comment with rationale to support the rating. Inappropriate ratings (1-6) without an included comment were treated as incomplete and withheld from analysis.

Data Analysis

Delphi panelists were anonymous and codified to a number by the project coordinator (CE). Members of the SC were blinded to individual panelist names and their ratings were uploaded into SPSS (v.25) (IBM Corp., Armonk, NY). Each statement was assessed for median rating and percent agreement by an SC member (CH). The de-identified individual panelist ratings were distributed to SC members for review of statement ratings, percent agreement, and comments.

Phase IV (Public Feedback)

For transparency and completeness, we sought public feedback on the competencies after they had reached panel consensus (November-December 2023). This allowed opportunity for stakeholders to contribute who were not involved previously. Clinical Compass assisted in public distribution of the competency statements through posting on their website²⁶ and circulated the statements via an email distribution list utilized in the development of prior clinical practice guidelines.^27,28

Results

Systematic Search of the Literature

The literature search yielded 1718 citations. After applying the eligibility criteria, 23 articles remained.^16,29-50 (Figure 2) Themes identified through article extraction resulted in 9 potential domains (Supplemental Table 2).

Figure 2.

Review flow chart. See Supplemental Table 3 for the list of excluded articles.

Domain and Seed Statements

Phase II and Phase III of the competency development process led to consolidation of the 9 initially drafted competency domains into 4 domains, 11 subdomains, and the generation of 78 draft statements for review in the modified Delphi process. After Phase III (2 modified Delphi rounds), consensus was reached on all statements.

Delphi Panel Characteristics

Of the 44 individuals invited to participate, 36 (82%) agreed. All panelists resided in the United States and held a chiropractic degree, with 1 participant dual-trained as a physical therapist. A total of 6 panelists had a PhD, and 16 had a master’s degree (e.g., MS, MBA, MPH). The panelists had a mean of 20.3 years in practice, with a median of 19 years (range 1-51). Most panelists self-identified as male (69%), and White/Caucasian (92%). Other races reported were: unspecified (1), Black/African American (1), and multiracial (1).

Seven panelists were DC residency directors for CCE-USA accredited programs. Twenty-three panelists had a faculty affiliation with a DC program, and 10 reported affiliations with non-DC health professional programs. Twenty-one panelists trained in integrated environments as a DC student and 8 as a post-graduate resident. Twenty-seven panelists worked in integrated settings: DoD (1), FQHC (1), private/public hospital (8), and VA (17).

Delphi Process

Consensus was reached on all competency statements after 2 rounds of a modified Delphi process. Following round 1, only 1 statement did not reach a consensus rating of ≥80% (median rating = 9 on a 1-9 scale). After reviewing the ratings and panelist comments, the SC revised 1 statement that did not reach consensus. The SC substantially changed 11 additional statements based on Delphi panelist feedback. These 12 statements were revised and included in round 2 of the modified Delphi process. In round 2, consensus of the panelists (≥80%) was reached on all 12 statements.

Public Comments

We received 20 comments following the public comment period. The comments were from 6 practicing chiropractors and 1 chiropractic academic (Colorado, Florida, Ohio, Oklahoma, Texas, Washington, and Australia). The SC carefully reviewed all statements and found the majority of comments were generally supportive. Most comments were typographical or stylist in nature and none provided feedback warranting substantive change to the consensus statements.

Consensus Competencies (Figure 3)

Competency Domain 1 – Communication

Subdomain 1.1: Interprofessional

1. Understand the importance of using common language, terminology, and communication (e.g., diagnostic and prognostic terms, outcome assessment tools) amongst the integrated healthcare team.

2. Proficient in communication strategies to facilitate health care team interactions for patient care coordination (i.e., oral, written, and electronic).

3. Proficient in describing patient case presentation (i.e., oral, written, and electronic) to members of the integrated health care team.

4. Demonstrate timeliness in record keeping and communication for care coordination.

5. Respect patient confidentiality in all forms of communication consistent with HIPAA privacy rules.⁵¹

6. Receptive and responsive to constructive feedback from various stakeholders (e.g., patients, supervisors, health care team members).

7. Demonstrate proficiency in conflict management (e.g., disagreement among health care team professionals regarding treatment plans).

8. Educate patients and stakeholders regarding standards of care, and case management that is concordant with guidelines and best practices.

Figure 3.

Final competency domains and subdomains. (Image created by Zachary Cupler, DC, MS, Robert Trager, DC, Clinton Daniels DC, MS).

Subdomain 1.2: Interpersonal

1. Exhibit emotional intelligence through a capacity to understand the emotional expression of others, awareness of one’s own emotions, and emotional self-regulation.¹⁶

2. Demonstrate cultural and professional humility, and respect for beliefs and practices.

3. Develop a trusting relationship with patients and other health care team members while maintaining appropriate boundaries.

4. Demonstrate active listening with the patient to foster a therapeutic relationship (e.g., facilitate goal setting, understand barriers and facilitators to care).

5. Use communication strategies that are conducive for positive patient behavioral change (e.g., motivational interviewing).

6. Encourage patient commitment to use of appropriate self-care practices (e.g., diet, exercise, mind-body practices).

7. Acknowledge patient perception and experiences when developing a therapeutic relationship (e.g., trust, openness, attentiveness, cultural awareness).

8. Differentiate patient education to align with patient’s presentation and health literacy levels.

Competency Domain 2 – Clinical Excellence

Subdomain 2.1: Patient Safety

1. Deliver and document appropriate informed consent process inclusive of procedure description, potential treatment benefits, material risks or alternative management options, and answering all patient questions.

2. Identify when to modify evaluation procedures based on patient presentation and potential risk (e.g., patient is a high fall risk, acute spinal antalgia).

3. Demonstrate knowledge of patient safety best practices (e.g., occupational health regulations,⁵² infection control, local clinical standard operating procedures, equipment cleaning procedures).

4. Ability to apply operational standards of safety in various clinical scenarios and settings (e.g., disaster preparedness, medical emergency response).

5. Recognize signs of risk to patient safety which would warrant referral (e.g., depression, post-traumatic stress disorder,⁵³ substance use disorder,⁵⁴ intimate partner violence,⁵⁵ suicidal⁵⁶ or homicidal ideation).

6. Recognize signs and symptoms of potential contraindications to manual therapies or other interventions and refer when appropriate.⁵⁷

Subdomain 2.2: Professional Literacy

1. Understand the role of scientific evidence, practitioner experience, and patient preferences in pragmatic management of health conditions.

2. Demonstrate ability to use scholarly databases and point-of-care medical resources to aid clinical decision making.

3. Critically apply peer-reviewed literature to case management with attention to quality and level of evidence.

4. Implement chiropractic and relevant musculoskeletal care clinical practice guidelines.^27,28,57-66

Subdomain 2.3: Clinical Acumen

1. Understand the importance and limitations of scope of practice.

2. Demonstrate the ability to obtain a comprehensive health history.^57,66

3. Perform a patient evaluation consistent with a biopsychosocial approach.²⁷

4. Develop a differential diagnosis that recognizes pain classification subgroups (e.g., nociceptive, nociplastic, neuropathic).^27,58-61

5. Recognize clinical indications for diagnostic imaging and testing consistent with American College of Radiology⁶⁷ and American College of Occupational and Environmental Medicine guidelines.⁶⁸

6. Consider relevant imaging and testing findings for correlation with clinical presentation to construct a differential diagnosis, prognosis, and treatment plan.

7. Identify appropriate clinical indications to collaborate with other health professionals (e.g., specialist consultation or referral).

8. Manage complex patients (e.g., patients with multiple comorbidities⁶⁹) through team-based interprofessional shared decision-making.

9. Develop treatment plans that are evidence-informed, patient-centered, and goal-oriented.^70-75

10. Employ active care educational strategies which promote self-care management and optimizes patient-independence.

11. Recognize the impact of how contextual factors (e.g., words used, attire, environment, body language) influence a patient’s experience and clinical outcomes.^76,77

12. Knowledgeable of health screening and disease prevention guidelines for health promotion (e.g., US Preventive Service Taskforce recommendations).^78,79

13. Advocate for health promotion relevant to primary, secondary, tertiary, and quaternary prevention of musculoskeletal conditions.^28,78

14. Understand the unique clinical needs of special populations (e.g., pediatrics, older adults, various racial and ethnic groups, individuals with disabilities, lesbian, gay, bisexual, transgender, queer, intersex, asexual (LGBTQIA+), pregnant, veterans).

15. Appreciate the influence of social determinants of health on health and wellness (e.g., discrimination, education access, healthcare access, economic stability, neighborhood environment).⁷⁹

Subdomain 2.4: Ethics

1. Demonstrate high standards of personal and professional ethical conduct.

2. Place the patient at the center of healthcare delivery.⁸⁰

3. Possess an understanding of the professional legal obligations (e.g., mandatory reporting) consistent with jurisdictional licensure and regulations, healthcare system policies (e.g., credentialing and privileging).

4. Responsibly use existing and burgeoning technology for patient care when appropriate (e.g., health technology, electronic health record systems, artificial intelligence).

5. Proficient in ethical diagnostic and procedural coding that is commensurate with services rendered.

Competency Domain 3 –Collaboration

Subdomain 3.1: Roles and Responsibilities

1. Understand the roles, responsibilities, and contributions of each healthcare team member.

2. Demonstrate and communicate the importance of teamwork in patient-centered care.

3. Recognize how one’s uniqueness (e.g., experience level, culture, hierarchy) impacts interprofessional working relationships.

4. Communicate effectively with health care professionals and health-related agencies.

5. Communicate assessment and care plan recommendations to healthcare professionals.

6. Develop effective relationships with referring, consulting, or collaborating healthcare team members.

7. Articulate professional opinions with competence, confidence, and respect, using inclusive and shared language that avoids chiropractic-specific language.

Subdomain 3.2: Cooperation, Respect and Engagement

1. Seek out, integrate, and value the input of healthcare team members.

2. Engage healthcare team members to develop strategies to meet specific health and healthcare needs of patients and populations.

3. Share accountability for patient outcomes when co-managing with other clinicians.

4. Ability to give timely, sensitive, and constructive feedback to colleagues.

Subdomain 3.3: Self-Reflection

1. Practice critical self-appraisal to identify training gaps for development.

2. Engage in evidence-based continuing education and self-guided learning.

3. Consider one’s own health and well-being as fundamental to healthcare delivery.

4. Demonstrate a commitment to continuous professional and personal self-improvement.

Domain 4 - Systems Administration

Subdomain 4.1: Digital Health

1. Be knowledgeable in the practices of virtual healthcare delivery (e.g., patient preferences, patients that live in rural areas, lack transportation).

2. Be familiar with evidence-based digital format patient education resources.

3. Interact professionally with colleagues and patients through electronic communication and messaging (e.g., e-mail, patient portal, virtual visits).

4. Interact professionally and in alignment with evidence-based practices when utilizing social media.⁸¹

5. Adhere to jurisdictional and facility standards regarding timeliness in record keeping, communicating diagnostic findings, and using decision support tools.

6. Engage with systems to track performance, productivity, and outcomes for continuous quality improvement.

Subdomain 4.2: Organizational Responsibility and Safety

1. Demonstrate understanding of organizational structure, chain of command, and role within a system.

2. Understand institutional credentialing and privileging concepts.

3. Demonstrate an ability to understand and communicate the financial impact of musculoskeletal conditions on healthcare facilities and healthcare systems.

4. Provide services that are consistent with facility service line agreements, functional statements, and/or memorandums of understanding.

5. Identify and report near-misses, accidents, and/or adverse events per facility standards.

6. Demonstrate ability to identify and report disruptive behavior in the workplace per facility standards.

7. Demonstrates knowledge of equipment safety standards.

8. Utilize proper techniques to prevent clinician environmental risks and injury.

9. Understand and apply relevant clinical care pathways.^61,65,70

10. Facilitate efficient care coordination within the healthcare system.

11. Demonstrate understanding of various factors and limitations on a healthcare system (e.g., care access, inefficient or ineffective consultation triaging, physical space availability, commercial insurance reimbursement).

Discussion

This study identified 78 preliminary competencies related to clinical chiropractic education that, ideally, are embodied by DC students, graduates, and DC’s seeking post-graduate training and/or employment within an integrated health care setting. The 78 competencies are organized within 4 domains and 11 subdomains that reflect on Communication, Clinical Excellence, Collaboration, and Systems Administration. The authors are not familiar with any prior efforts to identify competencies associated with chiropractic practice within an integrated health care setting and view this as the first step of a continuous process towards refining competency development. Many of these identified competencies may overlap with existing CCE-USA competencies, which should be evaluated and refined in future studies.⁸²

Similar to the public health competencies that Madigan et al proposed for DC students,¹⁷ we propose unique competencies for the integrated care setting. We advocate for the public health competencies previously proposed and find they align well with our domains of Clinical Excellence and Systems Administration. Rather than propose competencies, a prior study described a conceptual model highlighting specific attributes of the chiropractor who excels in the integrated care setting.¹⁶ Our competencies presented here build upon those concepts and themes. Through key stakeholder interviews and a qualitative analysis, they identified 5 domains (i.e., patient-centeredness, professional, interpersonal, interprofessional, and organization) with themes that typified the chiropractor who excelled at interprofessional teamwork.

Many of the preliminary competencies are appropriate for preparing DC students for both integrated and private practice settings. The preliminary competencies that are particularly unique to integrated settings are focused on the complexities of team dynamics, understanding roles, and systems-based practice. The development and consensus of competencies for preparing DC students for integrated care settings is only the first step to ensure students are given opportunity to achieve the above described competencies.^83,84 Future efforts may include refinement and validation of these preliminary competencies, addressing redundancy with current DC program competencies, identifying metrics to measure and track student performance of these competencies, obtaining input from non-DC stakeholders, and further characterizing competencies unique to integrated care settings.

United States chiropractic education has held to traditional didactic lecture methods of teaching followed by a clinical training phase.⁸³ A majority of clinical training experience occurs at DC program campus clinics and a cadre of independent private practices affiliated with the DC programs, which provide limited opportunities for interprofessional socialization with other health care disciplines. In some select instances, chiropractic student training opportunities are available within integrated healthcare systems, such as within Veterans Affairs healthcare settings.^83,85 This approach is similar to other countries, such as the United Kingdom, Denmark, and Switzerland, which has transformed the delivery of chiropractic training with immediate socialization with other healthcare disciplines through shared coursework and clinical experiences.^86-89

Strengths

Our systematic search of the literature and iterative process of competency domain and seed statement development was augmented by the participation of chiropractors with unique experience in integrated care clinical education. We used a rigorous Delphi methodology yielding high agreement and anonymized participant feedback. As part of this process, we collectively leveraged the forefront of individuals with experience in post-graduate chiropractic education. Of the 10 CCE-USA accredited chiropractic residency sites, 3 residency directors contributed as SC members (JN, RW, CD) and the remaining 7 residency directors participated as Delphi panelists. In addition, the residency directors of 2 private hospitals pursuing CCE-USA accreditation for DC residency programs participated as a SC member (EK) or as a Delphi panelist.

Limitations

Many of the competencies represent the ideal DC trainee or early career chiropractor. Given the current approach to training DC students, widespread achievement of these competencies may not be addressed with the current structure of DC education. Postgraduate residencies are an ideal setting for chiropractors to deepen the knowledge, skills, and abilities of the competencies we have outlined. Residencies remain a rare opportunity for chiropractors and therefore we focused on DCPs to promote a standard of integrated competencies upon graduation. Training of DC students in integrative care competencies could benefit from administrators and educators within DC programs designing curricula that provides an immersive and diverse clinical experience. Due to the complexities of the identified competencies, new evaluation procedures may require development, such as entrustable professional activities, to assess competencies we have outlined.⁹⁰ It is our collective experience that these competencies are not currently being achieved in a widespread manner by DC students and early DC graduates. Thus we suggest DC programs move toward a horizontal and vertical integration of these competency concepts into DC education curricula.^91,92 We present a set of competencies derived from the literature and expert opinion. Strategies to translate these competencies into authentic professional tasks (e.g., entrustable professional activities) was beyond the scope of this Delphi consensus project. The large number of competencies in and of itself may be a barrier to implementation and likely will not be addressed in any singular iteration of curricular revision. Some competencies were crafted in a way that they are not clearly measurable and others had overlap between domains, which suggest the need for additional refinement through further research efforts. For example, a next step might interview stakeholders from DC programs and accrediting bodies to determine both the importance of the proposed competencies and how best to foster development and assessment of these skills that are consistent with existing CCE-USA meta-competency outcomes designs. In addition, we anticipate future iterations to be organized in a consolidated manner.

The opportunities available to United States based DC program trainees in the form of integrated care settings may vary greatly from chiropractic training programs around the world. The competencies developed from this study may not be translatable to other countries. Although dual-trained individuals were invited to participate on the Delphi panel, we did not invite participation from non-chiropractor healthcare professionals (e.g., physicians) who work in integrated settings and provide clinical education to healthcare trainees. We also did not invite participation from DC students, the lay public, or chiropractic patients to include their perspectives. Future integrated care competency development for DC program trainees should consider other healthcare professionals’, students’, and patients’ viewpoints. Finally, the project was not developed in conjunction with accreditors or DC program officials responsible for curricular design and competency assessment. Both of these stakeholders would be reasonable collaborators for future work in development of integrated care competencies for DC students.

Within this study, there was a lack of diversity of race and ethnicity within the SC and Delphi panel and the panelists may have been under representative of female chiropractors, which may leave out important perspectives. The chiropractic profession is 25.4% female and 90.8% White/Caucasian.^93,94 Future updates to these competencies should take a concerted effort to partner with gender, racial, and ethnic minority chiropractic professional associations.

Conclusion

Using a systematic evaluation of the literature followed by a Delphi consensus process, we developed 78 competency statements aligned within 4 domains preparing DC students for practice in integrated healthcare settings. As these are foundational competency statements produced and scrutinized through expert consensus, additional work is required to validate the proposed statements and to implement them within a chiropractic curriculum. These statements may be used for DC program curricular design, and future scholarly work exploring clinical benefits when DCs are trained using these competencies as a guide.

Supplemental Material

Supplemental Material - Development of Preliminary Integrated Health Care Clinical Competencies for United States Doctor of Chiropractic Programs: A Modified Delphi Consensus Process

Supplemental Material for Development of Preliminary Integrated Health Care Clinical Competencies for United States Doctor of Chiropractic Programs: A Modified Delphi Consensus Process in Clinton J Daniels, DC, MS, Zachary A Cupler, DC, MS, Jason G Napuli, DC, MBA, Robert W Walsh, DC, Anna-Marie L Ziegler, DC, MM, MS, Kevin W Meyer, DC, Matthew J Knieper, DC, Sheryl A Walters, MLS, Stacie A Salsbury, PhD, RN, Robert J Trager, DC, Jordan A Gliedt, DC, Morgan D Young, DC, Kristian R Anderson, DC, MS, Eric J Kirk, DC, Scott A Mooring, DC, Patrick J Battaglia, DC, David J Paris, DC, Amanda G Brown, DC, Justin M Goehl, DC, MS, and Cheryl Hawk, DC, LMT, PhD in Global Advances in Integrative Medicine and Health

Supplemental Material

Supplemental Material - Development of Preliminary Integrated Health Care Clinical Competencies for United States Doctor of Chiropractic Programs: A Modified Delphi Consensus Process

Supplemental Material

Supplemental Material - Development of Preliminary Integrated Health Care Clinical Competencies for United States Doctor of Chiropractic Programs: A Modified Delphi Consensus Process

Footnotes

Acknowledgements

Our sincere gratitude to project coordinator Cathy Evans for managing panelist, consents, blinding data, and general organizational efforts. We would also like to thank the Delphi panelist for their participation and expertise: Shery Assal, DC, TPS, NBC-HWC; Gina M. Bonavito-Larragoite, DC, MBA, FIAMA; Wren M. Burton, DC, MPH; Michael B. Clay, DC, MPH; Jesse C. Cooper, DC; Andrew S. Dunn, DC, MEd, MS; Jonathon Egan, DC, MPH, PhD; Stanley Ewald, DC, MPH, MEd; Bart Green, DC, MSEd, PhD; Stephanie M. Halloran, DC, MS; Nathan Hinkeldey, DC, DACRB; Valerie Johnson, DC, DABCI, DACBN; Robert C. Jones, DC, APC; Jeffrey Kamper, DC, MHPE, DCBCN; Jeff King, DC, MS; Matthew H. Kowalski, DC; James Joseph Lehman, DC, MBA, DIANM; Anthony J. Lisi, DC; Michele Maiers, DC, MPH, PhD; K. Sean Mathers, DC, DPT; Jude A. Miller, DC, MS, CCSP; Ryan D. Muller, DC, MS; Ian Paskowski, DC; Charles W. Penza, DC, PhD; Charles R. Portwood, DC, RMSK; Morgan R. Price, DC; Lindsay Rae, DC; Alec L. Schielke, DC; Dean Smith, DC, PhD; Carina A. Staab, DC, MEd; Samuel Staula, DC; John S. Stites, DC, DACBR, DACO; Stephanie Sullivan, DC, PhD; William Tellin, DC; Holly A. Tucker, DC, MPH, CHES; Timothy J. Williamson, DC, MS. We also thank participants from our in-person workshop at the WFC ACC 2022 education conference.

Author’s Note

Portions of this work were presented at the World Federation of Chiropractic Association of Chiropractic Colleges Education Conference (Logan University, Chesterfield, MO, USA) in November 2022, and a Rehabilitation Medicine department meeting at University of Washington in July 2023, and the International Congress on Integrative Medicine & Health conference (Cleveland, OH) held in April 2024.⁹⁵

Author Contributions

JN was the primary investigator, participated in concept development and planning, workshops, draft competency statement generation, and attained Institutional Review Board approval. CD co-drafted this manuscript, secured funding, participated in project planning, workshops, literature search development, oversaw extraction, generated draft competency statements and analyzed data. ZC co-drafted this manuscript, participated in project planning, workshops, literature search development, and generated draft competency statements. RW participated in project planning, workshops, draft competency statement development. SW developed search strategy and carried out the search. AZ screened and extracted articles, participated in draft competency statement development. KM screened articles and participated in draft competency statement development. MK extracted articles and generated draft competency statements. CH analyzed data, provided modified Delphi methodology expertise, and participated in draft competency statement generation. SS, MY, KA, PB, AB, JAG, JMG, EK, SM, DP, and RT all provided expertise and participated in draft competency statement generation. All authors read and approved the final manuscript.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was conducted with financial support from Clinical Compass (formerly Council on Chiropractic and Guidelines Practice Parameters).

Ethical Statement

Other Disclosures

CD, DP, SM, CH are board members for Clinical Compass, CD is a member of the Washington State Health Technology Clinical Committee. KA is on the Board of Governors for the American Chiropractic Association.

Disclaimers

The contents of this study are solely the responsibility of the authors and do not necessarily represent the official views of affiliate institutions, Veterans Health Administration, Department of Defense, or the U.S. Government.

ORCID iDs

Clinton J Daniels

Zachary A Cupler

Kevin W Meyer

Robert J Trager

Kristian R Anderson

Cheryl Hawk

Supplemental Material

Supplemental material for this article is available online.

Appendix

References

Goodwin

. Understanding integrated care. Int J Integr Care. 2016;16(4):6. doi:10.5334/ijic.2530.

Littlechild

Smith

. A Handbook for Interprofessional Practice in the Human Services: Learning to Work Together. London, UK: Routledge; 2013:15.

Bendowska

Baum

. The significance of cooperation in interdisciplinary health care teams as perceived by polish medical students. Int J Environ Res Public Health. 2023;20(2):954. doi:10.3390/ijerph20020954.

Gilbert

Yan

Hoffman

. A WHO report: framework for action on interprofessional education and collaborative practice. J Allied Health. 2010;39(Suppl 1):196-197.

Lemieux-Charles

McGuire

. What do we know about health care team effectiveness? A review of the literature. Med Care Res Rev. 2006;63:263-300. doi:10.1177/1077558706287003.

Meeker

Haldeman

. Chiropractic: a profession at the crossroads of mainstream and alternative medicine. Ann Intern Med. 2002;136(3):216-227. doi:10.7326/0003-4819-136-3-200202050-00010.

Bise

Schneider

Freburger

et al. First provider seen for an acute episode of low back pain influences subsequent health care utilization. Phys Ther. 2023;103(9):pzad067. 10.1093/ptj/pzad067.

Kazis

Ameli

Rothendler

et al. Observational retrospective study of the association of initial healthcare provider for new-onset low back pain with early and long-term opioid use. BMJ Open. 2019;9(9):e028633. doi:10.1136/bmjopen-2018-028633.

McCallin

. Interdisciplinary practice--a matter of teamwork: an integrated literature review. J Clin Nurs. 2001;10(4):419-428. doi:10.1046/j.1365-2702.2001.00495.x.

10.

Breuer

Cruciani

Portenoy

. Pain management by primary care physicians, pain physicians, chiropractors, and acupuncturists: a national survey. South Med J. 2010;103(8):738-747.

11.

Fenton

Fang

Ray

, et al. Longitudinal care patterns and utilization among patients with new-onset neck pain by initial provider specialty. Spine. 2023;48(20):1409-1418. doi:10.1097/BRS.0000000000004781.

12.

Elton

Kosloff

. Using big data to advance value-based spine care. Spineline. 2015;XVI(5):17-22.

13.

Kosloff

Elton

Shulman

Clarke

Skoufalos

Solis

. Conservative spine care: opportunities to improve the quality and value of care. Popul Health Manag. 2013;16(6):390-396. doi:10.1089/pop.2012.0096.

14.

Council on Chiropractic Education . CCE accreditation standards: principles, process, & requirements for accreditation. Published July 2021. https://www.cce-usa.org/uploads/1/0/6/5/106500339/2025-01_cce_accreditation_standards__current_.pdf. Accessed November 30, 2023.

15.

Innes

Cope

Leboeuf-Yde

Walker

. A perspective on Councils on Chiropractic Education accreditation standards and processes from the inside: a narrative description of expert opinion: Part 2: analyses of particular responses to research findings. Chiropr Man Therap. 2019;27:56.

16.

Salsbury

Vining

Gosselin

Goertz

. Be good, communicate, and collaborate: a qualitative analysis of stakeholder perspectives on adding a chiropractor to the multidisciplinary rehabilitation team. Chiropr Man Ther. 2018;26:29.

17.

Madigan

Maiers

Pfeifer

. Public health competencies for chiropractic programs. Pedagogy in Health Promotion. 2020;6(0):291-295.

18.

PubMed. https://pubmed.ncbi.nlm.nih.gov/. Accessed January 18, 2024.

19.

Index to Chiropractic Literature. https://www.chiroindex.org/#results. Accessed January 18, 2024.

20.

CINAHL Database. https://www.ebsco.com/products/research-databases/cinahl-database. Accessed January 18, 2024.

21.

Ten Cate

Billett

. Competency-based medical education: origins, perspectives and potentialities. Med Educ. 2014;48(3):325-332.

22.

Cooney

Chan

Gottlieb

et al. Academic primer series: key papers about competency-based medical education. West J Emerg Med. 2017;18(4):713-720.

23.

Ouzzani

Hammady

Fedorowicz

Elmagarmid

. Rayyan – a web and mobile app for systematic reviews. Syst Rev. 2016;5:210.

24.

Napuli

Cupler

Daniels

Ziegler

Knieper

Walsh

. Developing core competencies for interprofessional relationships in integrated care settings. Presented at: 11th WFC ACC Global Education Conference; November 2, 2022; Chesterfield, MO. https://www.wfc.org/website/index.php?option=com_content&view=article&id=619&lang=en.

25.

Fitch

Bernstein

Aquilar

, et al. The RAND UCLA Appropriateness Method User’s Manual. Santa Monica, CA: RAND Corporation; 2003.

26.

Clinical Compass. https://clinicalcompass.org/. Accessed December 27, 2023.

27.

Hawk

Whalen

Farabaugh

et al. Best practices for chiropractic management of patients with chronic musculoskeletal pain: a clinical practice guideline. J Altern Complement Med. 2020;26(10):884-901.

28.

Hawk

Amorin-Woods

Evans

et al. The role of chiropractic care in providing health promotion and clinical preventive services for adult patients with musculoskeletal pain: a clinical practice guideline. J Altern Complement Med. 2021;27(10):850-867.

29.

Bainbridge

Nasmith

Orchard

Wood

. Competencies for interprofessional collaboration. J Phys Ther Educ. 2010;24(1):6-11.

30.

Behrends

Paulmann

Koop

Foadi

Mikuteit

Steffens

. Interdisciplinary teaching of digital competencies for undergraduate medical students - experiences of a teaching project by medical informatics and medicine. Stud Health Technol Inform. 2021;281:891-895.

31.

Fishman

Young

Lucas Arwood

et al. Core competencies for pain management: results of an interprofessional consensus summit. Pain Med. 2013;14:971-981.

32.

Interprofessional Education Collaborative . Core competencies for interprofessional collaborative practice: 2016 update. Intterprofessional Education Collaborative. 2016.

33.

Goldblatt

Wiles

Schwartz

Weeks

. Competencies for optimal practice in integrated environments: examining attributes of a consensus interprofessional practice document from the licensed integrative health disciplines. Explore. 2013;9(5):285-291.

34.

Henry

Holmboe

Frankel

. Evidence-based competencies for improving communication skills in graduate medical education: a review with suggestions for implementation. Med Teach. 2013;35(5):395-403.

35.

Homberg

Klafke

Glassen

Loukanova

Mahler

. Role competencies in interprofessional undergraduate education in complementary and integrative medicine: a Delphi study. Compl Ther Med. 2020;54:102542.

36.

Jani

Trask

Ali

. Integrative medicine in preventive medicine education: competency and curriculum development for preventive medicine and other specialty residency programs. Am J Prev Med. 2015;49(5 Suppl 3):S222-S229.

37.

Kligler

Brooks

Maizes

et al. Interprofessional competencies in integrative primary healthcare. Glob Adv Health Med. 2015;4(5):33-39.

38.

Lee

Hume

Willis

et al. Pharmacy competencies for interprofessional integrative health care education. Am J Pharmaceut Educ. 2018;82(6):6302.

39.

Locke

Gordon

Guerrera

Gardiner

Lebensohn

. Recommended integrative medicine competencies for family medicine residents. Explore. 2013;9(5):308-313.

40.

O’Keefe

Henderson

Chick

. Defining a set of common interprofessional learning competencies for health profession students. Med Teach. 2017;39(5):463-468.

41.

Macdonald

Bally

Ferguson

Lee Murray

Fowler-Kerry

Anonson

. Knowledge of the professional role of others: a key interprofessional competency. Nurse Educ Pract. 2010;10(4):238-242.

42.

Portney

Johnson

Knab

. Preparing future health professionals for interprofessional collaborative practice part 1: the context for learning. Semin Speech Lang. 2017;38(5):335-341.

43.

Ring

Brodsky

Low Dog

et al. Developing and implementing core competencies for integrative medicine fellowships. Acad Med. 2014;89(3):421-428.

44.

Sockalingam

Chaudhary

Barnett

Lazor

Mylopoulos

. Developing a framework of integrated competencies for adaptive expertise in integrated physical and mental health care. Teach Learn Med. 2020;32(2):159-167.

45.

Sunderji

Waddell

Gupta

Soklaridis

Steinberg

. An expert consensus on core competencies in integrated care for psychiatrists. Gen Hosp Psychiatr. 2016;41:45-52.

46.

Tick

Chauvin

Brown

Haramati

. Core competencies in integrative pain care for entry-level primary care physicians. Pain Med. 2015;16(11):2090-2097.

47.

van der Aa

Aabakke

AJM

Ristorp Andersen

et al. From prescription to guidance: a European framework for generic competencies. Adv Health Sci Educ Theory Pract. 2020;25(1):173-187.

48.

Valentini

Klocke

Güthlin

Joos

. Integration of complementary and integrative medicine competencies in general practice postgraduate education - development of a novel competency catalogue in Germany. BMC Complement Med Ther. 2021;21(1):250.

49.

Wangler

. Usefulness of CanMEDS competencies for chiropractic graduate education in Europe. J Chiropr Educ. 2009;23(2):123-133.

50.

Wood

Flavell

Vanstolk

Bainbridge

Nasmith

. The road to collaboration: developing an interprofessional competency framework. J Interprof Care. 2009;23(6):621-629.

51.

The HIPAA Privacy Rule. U.S. Department of Health and Human Services. Published March 31, 2022. https://www.hhs.gov/hipaa/for-professionals/privacy/index.html#:∼:text=The_HIPAA_Privacy_Rule_establishes,care_providers_that_conduct_certain. Accessed June 22, 2023.

52.

Occupational Safety and Health Administration. Healthcare. United States Department of Labor. https://www.osha.gov/healthcare. Accessed 22 June 2023.

53.

Coleman

Corcoran

DeRycke

, et al. Factors associated with posttraumatic stress disorder among veterans of recent wars receiving Veterans Affairs chiropractic care. J Manip Physiol Ther. 2020;43(8):753-759.

54.

Gliedt

Reynolds

Moonaz

Long

Russell

Schneider

. Identifying and addressing patient substance use: a survey of chiropractic clinicians. Chiropr Man Therap. 2023;31(1):18.

55.

Shearer

Forte

Dosanjh

Mathews

Bhandari

. Chiropractors’ perceptions about intimate partner violence: a cross-sectional survey. J Manip Physiol Ther. 2006;29(5):386-392.

56.

Cupler

Daniels

Anderson

Napuli

Tritt

. The chiropractor’s role in primary, secondary, and tertiary prevention of suicide: a clinical guide. J Can Chiropr Assoc. 2021;65(2):137-155.

57.

Whalen

Hawk

Farabaugh

et al. Best practices for chiropractic management of adult patients with mechanical low back pain: a clinical practice guideline for chiropractors in the United States. J Manip Physiol Ther. 2022;45(8):551-565.

58.

Bussières

Stewart

Al-Zoubi

et al. Spinal manipulative therapy and other conservative treatments for low back pain: a guideline from the Canadian Chiropractic Guideline Initiative. J Manip Physiol Ther. 2018;41(4):265-293.

59.

Bussières

Cancelliere

Ammendolia

et al. Non-surgical interventions for lumbar spinal stenosis leading to neurogenic claudication: a clinical practice guideline. J Pain. 2021;22(9):1015-1039.

60.

Weis

Pohlman

Barrett

et al. Best-practice recommendations for chiropractic care for pregnant and postpartum patients: results of a consensus process. J Manip Physiol Ther. 2022;45(7):469-489.

61.

Qaseem

McLean

O’Gurek

Batur

Lin

Kansagara

. Nonpharmacologic and pharmacologic management of acute pain from non-low back, musculoskeletal injuries in adults: a clinical guideline from the American College of Physicians and American Academy of Family Physicians. Ann Intern Med. 2020;173(9):739-748.

62.

Chou

Deyo

Friedly

et al. Nonpharmacologic therapies for low back pain: a systematic review for an American College of physicians clinical practice guideline. Ann Intern Med. 2017;166(7):493-505.

63.

George

Fritz

Silfies

et al. Interventions for the management of acute and chronic low back pain: revision 2021. J Orthop Sports Phys Ther. 2021;51(11):CPG1-CPG60.

64.

Kreiner

Matz

Bono

et al. Guideline summary review: an evidence-based clinical guideline for the diagnosis and treatment of low back pain. Spine J. 2020;20(7):998-1024.

65.

Pangarkar

Kang

Sandbrink

et al. VA/DoD clinical practice guideline: diagnosis and treatment of low back pain. J Gen Intern Med. 2019;34(11):2620-2629.

66.

Whalen

Farabaugh

Hawk

et al. Best-practice recommendations for chiropractic management of patients with neck pain. J Manip Physiol Ther. 2019;42(9):635-650.

67.

Expert Panel on Neurological Imaging Hutchins

Peckham

Shah

et al. ACR appropriateness criteria® low back pain: 2021 update. J Am Coll Radiol. 2021;18(11S):S361-S379.

68.

Hegmann

Travis

Belcourt

et al. Diagnostic tests for low back disorders. J Occup Environ Med. 2019;61(4):e155-e168.

69.

Wallace

Salisbury

Guthrie

Lewis

Fahey

Smith

. Managing patients with multimorbidity in primary care. BMJ. 2015;350:h176.

70.

Lisi

Salsbury

Hawk

et al. Chiropractic integrated care pathway for low back pain in veterans: results of a delphi consensus process. J Manip Physiol Ther. 2018;41(2):137-148.

71.

Haas

Bronfort

Evans

et al. Dose-response and efficacy of spinal manipulation for care of cervicogenic headache: a dual-center randomized controlled trial. Spine J. 2018;18(10):1741-1754.

72.

Haas

Vavrek

Peterson

Polissar

Neradilek

. Dose-response and efficacy of spinal manipulation for care of chronic low back pain: a randomized controlled trial. Spine J. 2014;14(7):1106-1116.

73.

Eklund

Jensen

Lohela-Karlsson

et al. The Nordic Maintenance Care program: effectiveness of chiropractic maintenance care versus symptom-guided treatment for recurrent and persistent low back pain-A pragmatic randomized controlled trial. PLoS One. 2018;13(9):e0203029.

74.

Hegmann

Travis

Andersson

GBJ

et al. Non-invasive and minimally invasive management of low back disorders. J Occup Environ Med. 2020;62(3):e111-e138.

75.

Price

Cupler

Hawk

Bednarz

Walters

Daniels

. Systematic review of guideline-recommended medications prescribed for treatment of low back pain. Chiropr Man Therap. 2022;30(1):26.

76.

Stewart

Loftus

. Sticks and stones: the impact of language in musculoskeletal rehabilitation. J Orthop Sports Phys Ther. 2018;48(7):519-522.

77.

Pierce

Troutner

Rae

Austin

. Provider-patient communication: an illustrative case report of how provider language can influence patient prognosis. J Can Chiropr Assoc. 2022;66(1):85-91.

78.

Published recommendations. U.S. Preventive services task force. https://www.uspreventiveservicestaskforce.org/uspstf/topic_search_results?topic_status=P. Accessed June 22, 2023.

79.

Healthy People 2030. https://health.gov/healthypeople. Accessed July 17, 2023.

80.

Whole Health . U.S. Department of veterans Affairs. Published December 16, 2022 https://www.va.gov/WHOLEHEALTH/veteran-resources/whole-health-basics.asp. Accessed 30 June 2023.

81.

Axén

Bergström

Bronson

et al. Misinformation, chiropractic, and the COVID-19 pandemic. Chiropr Man Therap. 2020;28(1):65.

82.

Innes

Leboeuf-Yde

Walker

. Similarities and differences of graduate entry-level competencies of chiropractic councils on education: a systematic review. Chiropr Man Therap. 2016;24(1):1. doi:10.1186/s12998-016-0084-0.

83.

Wiles

. Designing a 21st century chiropractic educational program: a time for reflection, a time for action. J Chiropr Educ. 2020;34(2):172-176.

84.

Walker

. The new chiropractic. Chiropr Man Therap. 2016;24:26.

85.

Meyer

Al-Ryati

Cupler

Bonavito-Larragoite

Daniels

. Integrated clinical opportunities for training offered through US doctor of chiropractic programs. J Chiropr Educ. 2023;37(2):90-97.

86.

Humphreys

Peterson

. The Swiss master in chiropractic medicine curriculum: preparing graduates to work together with medicine to improve patient care. J Chiropr Humanit. 2016;23(1):53-60.

87.

Humphreys

Peterson

Muehlemann

Haueter

. Are Swiss chiropractors different than other chiropractors? Results of the job analysis survey 2009. J Manip Physiol Ther. 2010;33(7):519-535.

88.

Chesterton

Deane

Moore

. Implementing an external student placement strategy into an undergraduate chiropractic curriculum in the United Kingdom: an education descriptive report. J Chiropr Humanit. 2023;30:1-8.

89.

Myburgh

Mouton

. The development of contemporary chiropractic education in Denmark: an exploratory study. J Manip Physiol Ther. 2008;31(8):583-592.

90.

Gliedt

Mathers

King

Schneider

Wiles

. The development and introduction of entrustable professional activities at 2 community-based chiropractic student preceptorship sites in the United States. J Chiropr Educ. 2024. Published online.

91.

Brauer

Ferguson

. The integrated curriculum in medical education: AMEE guide no. 96. Med Teach. 2015;37(4):312-322.

92.

Wijnen-Meijer

van den Broek

Koens

Ten Cate

. Vertical integration in medical education: the broader perspective. BMC Med Educ. 2020;20(1):509.

93.

Gliedt

Perle

Puhl

Daehler

Schneider

Stevans

. Evaluation of United States chiropractic professional subgroups: a survey of randomly sampled chiropractors. BMC Health Serv Res. 2021;21:1049.

94.

Himelfarb

Hyland

Ouzts

et al. Practice analysis of chiropractic 2020: a project report, survey, analysis, and summary of the practice of chiropractic within the United States. 2020. Published online https://www.nbce.org/wp-content/uploads/2020-Practice-Analysis-of-Chiropractic-2020-3.pdf

95.

Cupler

Daniels

Napuli

, et al. P09.17LB integrated clinical care competencies for doctor of chiropractic degree programs: a modified delphi consensus process. Global Advances in Integrative Medicine and Health 2024;13:2024. doi:10.1177/27536130241242891

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