Analysis of the Chiropractic Section
of the Occupational Outlook Handbook
Stephen Barrett, M.D.
The chiropractic section of the 2002 edition of U.S. Department of Labor's Occupational Outlook Handbook presents an overly optimistic picture to students faced with one of the most important decisions they will ever make. Here is a line-by-line analysis of the document with my comments in brackets.
- Employment of chiropractors is expected to increase faster than average, and job prospects should be good. [I am not aware of any data supporting this broad statement.]
- Chiropractic care of back, neck, extremities, and other joint damage has become more accepted as a result of recent research and changing attitudes. [This is a gross oversimplification of a very complex situation. Spinal manipulation is useful for appropriately selected cases of low-back pain, but the supportive studies do not consider what actually happens in chiropractic offices, where patients may be exposed to a wide variety of inappropriate practices. There is very little research support for chiropractic treatment of other parts of the body; and there is no reason to believe that chiropractors can do anything about "joint damage."]
- In chiropractic, as in other types of independent practice, earnings are relatively low in the beginning, but increase as the practice grows. [Although it is true that income rises with experience, the average chiropractor's income has been falling steadily for more than ten years.]
Nature of the Work
Chiropractors, also known as doctors of chiropractic or chiropractic physicians, diagnose and treat patients whose health problems are associated with the body's muscular, nervous, and skeletal systems, especially the spine. Chiropractors believe interference with these systems impairs normal functions and lowers resistance to disease. [Yes, most chiropractors say that, but it is not true.] They also hold that spinal or vertebral dysfunction alters many important body functions by affecting the nervous system, and that skeletal imbalance through joint or articular dysfunction, especially in the spine, can cause pain. [Yes, most chiropractors spout such ideas. However, the previous statements are misleading overgeneralizations based on the false notion that spinal problems are an underlying cause of disease. Instead of simply parroting what chiropractors say, the Handbook should warn prospective students that the field is riddled with false beliefs and that this problem may ultimately destroy the chiropractic profession.]
The chiropractic approach to healthcare is holistic, stressing the patient's overall health and wellness. It recognizes that many factors affect health, including exercise, diet, rest, environment, and heredity. [All health professions recognize that these factors are important.] Chiropractors provide natural, drugless, nonsurgical health treatments, and rely on the body's inherent recuperative abilities. [This is a backward way of saying that chiropractors have a very narrow range of treatments and therefore that there are very few conditions they should attempt to treat.] They also recommend lifestyle changes-in eating, exercise, and sleeping habits, for example-to their patients. [So do other health professions. But the relevant question is whether their recommendations are appropriate. The vast majority of chiropractors who give nutrition advice make inappropriate recommendations to use dietary supplements and other products.] When appropriate, chiropractors consult with and refer patients to other health practitioners. [The relevant question is whether they do this enough. The answer is no.]
Like other health practitioners, chiropractors follow a standard routine to secure the information needed for diagnosis and treatment. They take the patient's medical history, conduct physical, neurological, and orthopedic examinations, and may order laboratory tests. [The relevant question is whether they do this properly. A large percentage of them do not. In fact, some chiropractors do not believe they should diagnose patients.] X rays and other diagnostic images are important tools because of the emphasis on the spine and its proper function. [Many chiropractors take too many x-rays, and some take full-spine films that have little or no genuine diagnostic value.] Chiropractors also employ a postural and spinal analysis common to chiropractic diagnosis. [There are many types of "spinal analysis." Most have not been validated, and most lead to recommendations for treatment that is inappropriate.]
In cases in which difficulties can be traced to involvement of musculoskeletal structures, chiropractors manually adjust the spinal column. Some chiropractors use water, light, massage, ultrasound, electric, and heat therapy. They also may apply supports such as straps, tapes, and braces. Chiropractors counsel patients about wellness concepts such as nutrition, exercise, lifestyle changes, and stress management, but do not prescribe drugs or perform surgery. [Most chiropractors are not qualified to counsel patients about nutrition or stress management. Many—perhaps 50%—prescribe worthless homeopathic products.]
Some chiropractors specialize in sports injuries, neurology, orthopedics, pediatrics, nutrition, internal disorders, or diagnostic imaging. [This statement might lead students to think that chiropractic specialization is analogous to medical or dental specialization. It is not. Chiropractic neurologists and orthopedists are probably better qualified than the average chiropractor to diagnose conditions within their scope, but there is nothing special about the treatment they offer. "Chiropractic pediatrics" is not a legitimate field because no childhood diseases are within chiropractic's scope. Moreover, most chiropractors who treat children do unnecessary spinal manipulation and advise parents against immunization .]
Many chiropractors are solo or group practitioners who also have the administrative responsibilities of running a practice. In larger offices, chiropractors delegate these tasks to office managers and chiropractic assistants. Chiropractors in private practice are responsible for developing a patient base, hiring employees, and keeping records.
Chiropractors work in clean, comfortable offices. The average workweek is about 40 hours, although longer hours are not uncommon. Solo practitioners set their own hours, but may work evenings or weekends to accommodate patients. [Most chiropractors are solo practitioners. Jobs for new graduates pay poorly, are hard to get, and typically require unethical patient recruiting.]
Chiropractors, like other health practitioners, are sometimes on their feet for long periods. Chiropractors who take x rays must employ appropriate precautions against the dangers of repeated exposure to radiation.
Chiropractors held about 50,000 jobs in 2000. Most chiropractors are in solo practice, although some are in group practice or work for other chiropractors. A small number teach, conduct research at chiropractic institutions, or work in hospitals and clinics.
Many chiropractors are located in small communities. There are geographic imbalances in the distribution of chiropractors, in part because many establish practices close to chiropractic institutions.
Training, Other Qualifications, and Advancement
All States and the District of Columbia regulate the practice of chiropractic and grant licenses to chiropractors who meet educational and examination requirements established by the State. Chiropractors can only practice in States where they are licensed. Some States have agreements permitting chiropractors licensed in one State to obtain a license in another without further examination, provided that educational, examination, and practice credentials meet State specifications.
Most State boards require at least 2 years of undergraduate education, and an increasing number require a 4-year bachelor's degree. All boards require completion of a 4-year chiropractic college course at an accredited program leading to the Doctor of Chiropractic degree.
For licensure, most State boards recognize either all or part of the four-part test administered by the National Board of Chiropractic Examiners. State examinations may supplement the National Board tests, depending on State requirements.
To maintain licensure, almost all States require completion of a specified number of hours of continuing education each year. Continuing education programs are offered by accredited chiropractic programs and institutions, and chiropractic associations. Specialty councils within some chiropractic associations also offer programs leading to clinical specialty certification, called "diplomate" certification, in areas such as orthopedics, neurology, sports injuries, occupational and industrial health, nutrition, diagnostic imaging, thermography, and internal disorders. [Thermography is not a legitimate test. Specializing in "internal disorders" would be a very foolish thing to do. Chiropractors cannot get adequate training for diagnosing "internal disorders," and their treatment is outside of chiropractic's limited scope.]
In 2000, there were 16 chiropractic programs and institutions in the United States accredited by the Council on Chiropractic Education. All required applicants to have at least 60 semester hours of undergraduate study leading toward a bachelor's degree, including courses in English, the social sciences or humanities, organic and inorganic chemistry, biology, physics, and psychology. Many applicants have a bachelor's degree, which may eventually become the minimum entry requirement. Several chiropractic colleges offer prechiropractic study, as well as a bachelor's degree program. Recognition of prechiropractic education offered by chiropractic colleges varies among the State boards.
During the first 2 years, most chiropractic programs emphasize classroom and laboratory work in basic science subjects such as anatomy, physiology, public health, microbiology, pathology, and biochemistry. The last 2 years stress courses in manipulation and spinal adjustments, and provide clinical experience in physical and laboratory diagnosis, neurology, orthopedics, geriatrics, physiotherapy, and nutrition. Chiropractic programs and institutions grant the degree of Doctor of Chiropractic (DC).
Chiropractic requires keen observation to detect physical abnormalities. [Chiropractic "vision" also seems to entail the ability to find alleged "subluxations" that only chiropractors can see.] It also takes considerable hand dexterity to perform adjustments, but not unusual strength or endurance. Chiropractors should be able to work independently and handle responsibility. As in other health-related occupations, empathy, understanding, and the desire to help others are good qualities for dealing effectively with patients.
Newly licensed chiropractors can set up a new practice, purchase an established one, or enter into partnership with an established practitioner. They also may take a salaried position with an established chiropractor, a group practice, or a healthcare facility. [Few "healthcare facilities" hire chiropractors.]
Job prospects are expected to be good for persons who enter the practice of chiropractic. Employment of chiropractors is expected to grow faster than the average for all occupations through the year 2010 as consumer demand for alternative healthcare grows. [These are chiropractic claims, but there's no good evidence to support them. The percentage of Americans who use chiropractors is less than 10 percent and has not been growing. I believe that the field is overcrowded. ] Chiropractors emphasize the importance of healthy lifestyles and do not prescribe drugs or perform surgery. As a result, chiropractic care is appealing to many health-conscious Americans. [These words may be appealing, but there's not much evidence that chiropractors do a good job of lifestyle counseling. Most people see them for backaches.] Chiropractic treatment of back, neck, extremities, and other joint damage has become more accepted as a result of recent research and changing attitudes about alternative healthcare practices. The rapidly expanding older population, with their increased likelihood of mechanical and structural problems, also will increase demand.
Demand for chiropractic treatment is also related to the ability of patients to pay, either directly or through health insurance. Although more insurance plans now cover chiropractic services, the extent of such coverage varies among plans. [Insurance companies tend to feel negatively toward chiropractic. Much of the existing coverage is forced by state laws. Most insurance companies don't knowingly pay for "maintenance care" in which the chiropractor keeps the patient coming back to have "subluxations" diagnosed and treated. Managed-care programs, which strive to eliminate unnecessary care, try to avoid practitioners who provide unnecessary services. Chiropractic schools have been turning out more new chiropractors than are needed. As a result, the field is overcrowded, inflation-adjusted chiropractic incomes have been falling, and new graduates can have a very difficult time earning a living.] Increasingly, chiropractors must educate communities about the benefits of chiropractic care in order to establish a successful practice. [In other words, it is getting harder to earn a living. The difficulty is reflected in the fact that chiropractic graduates have by far the highest student loan default rates of any of the health professions.]
In this occupation, replacement needs arise almost entirely from retirements. Chiropractors usually remain in the occupation until they retire; few transfer to other occupations. Establishing a new practice will be easiest in areas with a low concentration of chiropractors.
Median annual earnings of salaried chiropractors were $67,030 in 2000. The middle 50 percent earned between $44,030 and $105,520 a year. [Students might find it useful to compare this with median earnings for the previous ten years, which show a steady decrease.]
Self-employed chiropractors usually earn more than salaried chiropractors. According to the American Chiropractic Association, in 2000, the average income for all chiropractors, including the self-employed, was about $81,500 after expenses. [That's $5,000 less than the comparable figure for 1996 and $20,000 less than the comparable figure for 1989. Why doesn't the Handbook put the number in perspective? U.S. Department of Commerce data indicate that the total reported net income for chiropractic offices and clinics rose from $6.56 billion in 1992 to $7.68 billion in 1998, which is about 2.8% per year. Since the number of practicing chiropractors has been increasing, and taking inflation into account, these figures show that real chiropractic income has been decreasing steadily. Why doesn't the Handbook mention this?] In chiropractic, as in other types of independent practice, earnings are relatively low in the beginning, and increase as the practice grows. Earnings also are influenced by the characteristics and qualifications of the practitioner, and geographic location. Self-employed chiropractors must provide for their own health insurance and retirement.
Chiropractors treat and work to prevent bodily disorders and injuries. So do dentists, occupational therapists, optometrists, physical therapists, physicians and surgeons, podiatrists, and veterinarians. [There is an important difference, however. Chiropractic is based on a false theory and is riddled with quackery and pseudoscience. It would be more appropriate to compare chiropractors with acupuncturists, naturopaths, and massage therapists.]
Sources of Additional Information
Disclaimer: Links to non-BLS Internet sites are provided for your convenience and do not constitute an endorsement.
General information on chiropractic as a career is available from:
- American Chiropractic Association, 1701 Clarendon Blvd., Arlington, VA 22209.
- International Chiropractors Association, 1110 North Glebe Rd., Suite 1000, Arlington, VA 22201.
- World Chiropractic Alliance, 2950 N. Dobson Rd., Suite 1, Chandler, AZ 85224-1802.
- Dynamic Chiropractic, P.O. Box 40109, Huntington, CA 92605. [This is a chiropractic newspaper.]
- Council on Chiropractic Education, 7975 North Hayden Rd., Suite A-210, Scottsdale, AZ 85258.
This list is composed of chiropractic organizations that present only a favorable view of chiropractic opportunity. Prospective students would be wise to read Inside Chiropractic: The Patient's Handbook, by Samuel Homola, DC.]
For information on State education and licensure requirements, contact:
- Federation of Chiropractic Licensing Boards, 901 54th Ave., Suite 101, Greeley, CO 80634.
For information on requirements for admission to a specific chiropractic college, as well as scholarship and loan information, contact the admissions office of the individual college.
[Overall, the Occupational Outlook Handbook presents an overly optimistic view and fails to disclose any problems or refer readers to sources that provide a realistic view of the profession. Chirobase is the most comprehensive and accessible source of such information.]
This article was posted on February 22, 2004