Chiropractic qualifying examinations: Honoring the profession's commitment to society

More than 100,000 chiropractors around the world work toward a common goal, caring for humanity or training chiropractors to do the same.¹  Since the late 1800s, preparation to become a doctor of chiropractic has evolved into rigorous and programmatic forms of education that meet high standards. Our education leads to qualification so that we may skillfully apply our chiropractic art, as guided by our core principles and our ever-evolving science. Specialized training, conferring of degrees, and vetting of new doctors through appropriate examinations are critical traits that identify chiropractic as a profession.^2,3  This is a promise that our services are safe and effective for the good of the public.^4–10  Each of us knows implicitly that we are held accountable to those we serve.⁵  In summary, providing health care is not a right, but a privilege bestowed upon our profession by society.

In gaining trust from the people we serve, and as part of our pact of accountability, the chiropractic profession is afforded a high degree of autonomy and is authorized to self-regulate. This honor carries with it the assumption that the profession evolves through various quality improvement efforts, including those in education. However, engaging in systematic and continuous actions that lead to measurable improvements in education is not easy when the profession is faced with adversity. The chiropractic profession has endured and continues to face disruptive internal challenges. As well, external pressures demand immediate attention, such as battles regarding reimbursement and continued inclusion in various health plans, which threaten the livelihoods of the majority of the profession's members. Lobbying for legislation and political actions to protect the profession, although necessary, continually require our awareness. The list of crises seems endless. With such compelling demands on the profession and with finite resources, it is imperative that we stay focused on quality improvement of our certifying processes.

Despite diversions, the profession has not forgotten its pact with the public with regard to the vetting of candidates through various forms of prelicensure examinations. Over the past decades, significant improvements have been made to qualifying examinations in the United States administered by the National Board of Chiropractic Examiners (NBCE). Test-writing committees constantly renew and update the bank of test items. A practical licensing examination of core skill sets has been used for nearly 30 years and continues to improve. Enhancements in test administration and psychometrics have occurred for many years. The National Board of Chiropractic Examiners has published in-depth Practice Analyses for 27 years to provide information regarding relevance of the board examinations, and papers have been published that explore correlations between variables and prelicensing examination scores. Communication between chiropractic school leaders, the NBCE, and the national accrediting agency for chiropractic, the Council on Chiropractic Education (CCE), have occurred on many occasions. Certainly, improvements have been made.

Unfortunately, the public and many in the profession are unaware of these achievements. Critical dialogue in the peer-reviewed literature about board examinations to demonstrate efforts toward continuous improvement of our examinations is absent. Publications about the validity, reliability, or content analyses of board examinations are not readily obtainable by our profession or the public. Descriptions of methods used to improve board examinations, including group processes and the involvement of the faculty, are not available in our peer-reviewed literature. Aside from the NBCE Practice Analyses,¹¹  public access to scholarly research on this topic is scant. Up to now, this information has not been published in a scholarly journal for wide dissemination to the chiropractic profession, other professions, and to the public at large.

This theme issue of the Journal of Chiropractic Education begins to address this void in the literature by placing a spotlight on current efforts to better understand, prepare, and administer these exams and utilize data from them as part of program evaluation. Experts in assessment, academic administration, licensing examinations, and chiropractic education contributed manuscripts to this issue. Each original paper was rigorously reviewed using the standard peer-review process of the journal. The authors of the papers discussed how the issue might be organized to best present the topics, agreeing that it would comprise contributed papers, papers from the NBCE, and a final commentary. It is our hope that these papers will initiate greater dialogue and provide emerging evidence to the public and the profession about improvement efforts for our qualifying examinations.

It is often assumed that students entering chiropractic training programs using traditional entrance requirements will have better performance on board examinations. The thought is that alternative admissions track students will be less successful academically. However, Manrique and Giggleman¹²  and Derby and colleagues¹³  challenge these ideas. Their papers show that alternative admissions tracks may or may not have influence on successful completion of the Part I test of the NBCE. Having more than one admission route may produce doctors with the same qualifying examination pass rates. Assessing changes made in our entrance requirements and evaluating them to see if these changes have any bearing on the quality of doctor produced at the end of training are important and help us honor our commitment to better understand our educational processes and qualifying tests.

There are many myths surrounding qualifying exams. To address this, a survey explored the traits expected of a profession by stakeholders and society. Responses from international respondents revealed that the profession globally holds a sense of responsibility to reassure the public that the profession qualifies its graduates and that this is a critical component of defining chiropractic as a profession. Concerns about qualifying examinations, solutions to perceived problems, and thoughts on the future of these tests on an international level demonstrate that the profession has many commonalities but also has diversity in its world views.¹⁴ 

How NBCE examinations are scored, the psychometrics involved in developing the tests, and why changes are made have at times been somewhat of a mystery to many in the profession. In the papers in this issue, leaders of the NBCE discuss recent and future changes to the examinations designed to keep the examinations consistent with best practices in educational measurement. They also discuss how the NBCE sees that these changes relate to the future of US chiropractic qualifying examinations and the potential effects of these changes on stakeholders.¹⁵  With recent changes to NBCE examinations, such as conversion from classical test theory to item response theory methodology, computer-based testing, and digital imaging, much debate has evolved among training program administrators, faculty members, students, and others. Concerns exist about the appropriateness of these changes, validity of new methods, and whether the new procedures are fair to students. Three studies are presented by the NBCE that describe the development and psychometric processes used in producing the new examinations.^16–18  These papers demonstrate the efforts being made by the profession to update and improve its prelicensing examinations.

As we look to the future of where additional research in this area is needed, two academic administrators and the president of the CCE provide an insightful commentary. Wiles and colleagues¹⁹  point out that ongoing, transparent communication is necessary to facilitate further discussion among chiropractic program leaders in order to strengthen the relationships between the NBCE, CCE, chiropractic training programs, and state licensing boards. They recommend that such communication is vital to stakeholders to confirm practitioner competence to governments and the profession, and most importantly, to reassure the public of the competence of licensees.