Perceptions of the Chiropractic Profession: An American perspective

James J. Lehman, DC, MBA, DIANM

OPEN ACCESS

PUBLISHED: 30 September 2025

DOI https://doi.org/10.18103/mra.v13i9.6839

ISSN 2375-1924

Abstract

The chiropractic profession was created in America by a former Canadian, D.D. Palmer in 1895. Although chiropractors are licensed in all fifty states in America, the profession is still misunderstood. Insurance companies continue to label chiropractic as a specialty rather than a profession. The integration of chiropractic medicine and chiropractic postdoctoral training into medical organizations has been occurring since the 1970s. Yet the majority of chiropractors, medical doctors and medical organizations know little about chiropractic postdoctoral training. This editorial intends to illustrate the perceptions of chiropractic patients, Federally Qualified Health Centers, medical physicians, and chiropractic physicians in the United States of America. Searches of the literature included peer-reviewed articles, professional magazines, and tabloids.

Keywords

• Chiropractic
• Healthcare
• Patient perceptions
• Medical integration
• Postdoctoral training

Introduction

This article intends to illustrate the perceptions of the chiropractic profession by chiropractic patients, Federally Qualified Health Centers (FQHC), medical providers, and chiropractic physicians in the United States of America. This discussion mentions six projects that attempt to describe the perceptions of chiropractic patients, FQHCs, Chiropractic Boards of Examiners, medical providers, and chiropractic physicians.

Lou Sportelli announced the AMA plan to contain and eliminate the chiropractic profession when he delivered The John A. Sweaney Lecture at the Biannual Assembly of the World Federation of Chiropractic in Durban, South Africa, on April 12, 2013. He continued to inform chiropractors and the public of the political and professional attempts to destroy the chiropractic profession in books and articles.

The contain and eliminate campaign of the AMA had three main objectives: to prevent chiropractic from obtaining academic recognition from the US Office of Education, to prevent chiropractic from obtaining inclusion in Medicare, and to continue to prevent the profession from uniting as a single cohesive organized group. The AMA was unsuccessful in preventing either the accreditation or the Medicare inclusion efforts, but the profession even in the year 2019 still remains intransigently divided.

Subsequently, the majority of chiropractors have marketed their businesses as private practices and outside of the American healthcare system. For the past 130 years, since DD Palmer discovered chiropractic, the American Medical Association (AMA) has been attacking the chiropractic profession and attempting to prevent integration of chiropractic into medical organizations. The AMA boycotted American chiropractors and prevented them from collaborating with allopathic physicians. Chiropractors were not able to refer to medical facilities for examinations such as imaging services. Despite the AMA efforts to eliminate the chiropractic profession, the Wilk vs AMA lawsuit saved the chiropractic profession from the AMA quackery committee. Because of the AMA’s boycott on chiropractic, chiropractors were not able to collaborate with medical physicians or refer patients to medical facilities, which resulted in restricted trade and potential harm to patients’ well-being.

The prime mission of the AMA’s Committee on Quackery was first, the containment of chiropractic and, ultimately, the elimination of chiropractic. However, the committee did not complete its mission and quietly disbanded in 1974. This was the same year that the chiropractic profession finally gained licensure in all 50 of the United States; received recognition from the US Commissioner of Education, Department of Health, Education and Welfare; and was successfully included in Medicare.

Weeks reported that in the United States the care provided by chiropractic physicians is considered to be safe and patients report favorable outcomes. Hence, chiropractic patients in America report a prominent level of patient satisfaction. Although adults in America perceive chiropractic care to be beneficial, the cost of care and the frequency of treatments are perceived to be negatives. Entrepreneurial chiropractors and patient demand have supported the growth of the profession outside of the American healthcare system. Currently, it is common for chiropractic physicians to treat patients in private practice scenarios rather than the confines of healthcare systems.

Most chiropractors operate in private practices, with 49% working in solo-practitioner offices and 36% in multi-chiropractor settings. Chiropractors practicing in multidisciplinary healthcare facilities represent the bulk of the remaining practice environments at 12%.

Chiropractic Perceptions of Resident Training

According to the Association of Chiropractic Colleges (ACC) there are approximately 10,000 chiropractic students in 19 nationally accredited, chiropractic doctoral graduate education programs across the United States. Schut reported a total of 49 postgraduate training opportunities (PTO) for chiropractors in the United States. Of these, there were only 18 board specialty diplomate programs, 24 residences and 6 fellowships. The Council on Chiropractic Education has accredited 11 chiropractic residencies including 10 VA hospitals and one Federally Qualified Health Center. None of these residencies lead to board certification in a chiropractic specialty.

A chiropractic residency at the Lindell Hospital in St. Louis, Missouri was one of the first of its kind. Carmichael described this innovative postdoctoral chiropractic residency, which occurred during the 1980s. This hospital residency was strategically located in St. Louis, near the Logan College of Chiropractic in Normandy, Missouri, a St. Louis suburb. This study suggested that chiropractic resident training within a hospital was the future for chiropractic clinical training.

In spite of the value of resident training for medical physicians, Schut reported that chiropractic Boards of Examiners do not recognize resident training for continuing education in forty-one states. It is obvious that the majority of chiropractors do not complete resident training and chiropractic state Boards of Examiners do not recognize resident training for continuing education credits. It appears that the chiropractic profession does not perceive postdoctoral resident training to be of value as a clinical training process. Johnson showed that chiropractic education must support competency-based education including clinical competence. It is this author’s opinion that resident training leading to board certification as a specialist supports clinical competency.

The findings show that the chiropractic education body of knowledge contains essential material to support competency-based education. These competencies include knowledge and cognitive competence, functional and clinical competence, personal and behavioral competence, and ethical competence.

Lovelace Medical Center and Physician Perceptions

Piland and Smith described the history of the Lovelace Medical Center in Albuquerque, New Mexico. Organized in 1922, the Lovelace Clinic successfully provided health care services throughout the Southwest utilizing a group practice format under the aegis of a nonprofit foundation. In 1984, the Foundation contracted with Hospital Corporation of America to form a for-profit health care organization which allows the provision of high quality health care through a group practice professional corporation, a 238-bed inpatient facility, a 70,000-member health maintenance organization, and an independent research and education foundation.

The Lovelace Clinic became a super clinic like Mayo Clinic and famous for the examination of the first astronauts. The clinic gained additional recognition for the integration of the chiropractic specialty service. By 1990 the Lovelace Clinic became a hospital with twelve satellite patient care facilities, a 120,000 member HMO, a multispecialty physician group practice, and affiliation with a medical research institute. Lovelace became New Mexico’s leading integrated health care organization. The clinic opened its first chiropractic office on June 24, 1991. The facility was located in Albuquerque and was called Lovelace Chiropractic. It became the newest addition to the multidisciplinary approach of the Lovelace Division of Occupational Medicine within the Orthopedic Department.

A three-year experiment during 1991-1993 at the Lovelace Medical Center in Albuquerque, New Mexico demonstrated that the integration of chiropractic specialists into the healthcare system (Orthopedic Department) gained the support of the medical physicians. The necessary component for successful integration was the trust of the chiropractic specialists by the medical physicians. The medical physicians reported that if they trusted the chiropractic providers, they would make patient referrals for chiropractic services. Another study in Minnesota demonstrated that chiropractic physicians successfully integrated into a large private hospital system. It was obvious that medical physicians were willing to refer patients for chiropractic services if they trusted the chiropractic physicians. In Canada, a shorter experiment duplicated the Lovelace conclusion. Twelve providers, including chiropractic and medical providers, were followed for 18 months of integration into a multidisciplinary team. The Canadian medical providers expressed an increased willingness to trust the chiropractors in shared care.

Patient Perceptions in New Mexico

During 2008, one-hundred and thirteen years following the creation of the chiropractic profession, a study attempted to determine the perceptions of chiropractic patients in New Mexico regarding chiropractors serving as primary care providers with a limited prescriptive authority. Four chiropractic physicians located in Albuquerque and Santa Fe, New Mexico participated in the study. A total of two hundred and seventy-five completed patient questionnaires collected by the investigators provided patient perceptions data. The purpose of this study was to determine chiropractic patients’ perceptions of chiropractors serving as primary care providers with limited prescriptive authority. Usually the patients (98.5%) sought chiropractic care for the management and treatment of painful neuromusculoskeletal conditions. Over 50% of these patients considered their chiropractic physicians to be their primary care providers. Surprisingly, over two thirds of the patients (85%) preferred that their chiropractic physicians be qualified to prescribe medications and provide manual medical services. It was surprising that so many of the patients (97.5%) perceived their chiropractic providers to be chiropractic physicians. Obviously, these New Mexican patients perceived their chiropractic physicians to be valuable providers of health care services.

University of Bridgeport Chiropractic Residency

The University of Bridgeport in Connecticut has provided chiropractic specialty services within Federally Qualified Health Centers (FQHC) since 2011. The Health Sciences Postgraduate Education Department has offered a three-year, full-time training program within a Federally Qualified Health Center in Connecticut since 2013. The residency setting is within a primary care setting and a community health center system. To successfully complete the residency the chiropractic physicians licensed by the state of Connecticut to practice as a chiropractic physician, credentialed by the FQHC, complete a 300-hour virtual residency, and pass a two-part board specialty examination. The University of Bridgeport (UB) expects the residents to complete an online virtual residency program within the first two years of the three-year residency and pass the board specialty examinations during the third year. The chiropractic specialty focus is non-surgical orthopedics and neuromusculoskeletal medicine. The International Academy of Neuromusculoskeletal Medicine accredits the residency. UB offers a career pathway for the residents that elect to continue with university employment as clinician educators. The University of Bridgeport and the FQHC perceive postdoctoral resident training to be a necessary phase of clinical training for chiropractic graduates.

Although this chiropractic residency program provides a career pathway in America, would this postgraduate training increase the number of chiropractic specialists in Europe and other parts of the world? The chiropractic profession is represented in 90 countries, usually in high-income countries, but there is no evidence of resident training for chiropractic graduates that leads to board certification in a chiropractic specialty.

Federally Qualified Health Centers

According to the Health Resources and Services Administration (HRSA), FQHCs qualify for funding under Section 330 of the Public Health Service Act (PHS) and enhanced reimbursement from Medicare and Medicaid. They serve an underserved area or population and offer a sliding fee scale. They provide comprehensive services (either on-site or by arrangement with another provider), including preventive health services, dental services, mental health and substance abuse services, transportation services necessary for adequate patient care, hospital and specialty care (including chiropractic specialty services), and have an ongoing quality assurance program. FQHCs serve over 31,000,000 Americans.

The Community Health Center, Inc. (CHCI) of Middletown, CT invited the University of Bridgeport (UB) to integrate chiropractic specialty services in 2010. A pilot study at the Meridian CHCI primary care site in 2011 demonstrated an elevated level of patient satisfaction (98.5%), provider satisfaction, and improved function of patients. Subsequently, CHCI and UB have expanded the chiropractic specialty services to ten sites because both patients and primary care providers perceive chiropractic specialty services to be of value. Currently, chiropractic clinician educators train both chiropractic residents and chiropractic clerks in three Connecticut FQHCs because the FQHCs perceive chiropractic specialty services to be of value to their patients.

Chiropractic Specialist and Advanced Practice Primary Care Fellowship Proposal

Health care in America is extremely expensive and often with poor outcomes. The quality should improve and evidence-based medicine has been suggested as part of a new healthcare system solution. The literature has revealed that our healthcare system has fragmented because of managed care interference that reduces compensation to healthcare providers without improving patient care. Consequently, primary care providers elect to discontinue primary care and pursue specialty resident training, which reduces the number of primary care providers. Although the United States leads the world in health care spending, it fares far worse than its peers on coverage and most dimensions of value. Cost and coverage are intertwined. Many Americans cannot afford health insurance, and even those with insurance face substantial cost-related barriers to care.

Hoffer claimed that even though a well-functioning primary care system is widely acknowledged as critical to population health, the number of primary care physicians (PCPs) practicing in the United States has steadily declined, and PCPs are in short supply. In 2007, the first formal postgraduate nurse practitioner (NP) residency program was launched at Community Health Center, Inc., a large Federally Qualified Health Center in Connecticut, and focused on primary care and community health.

Consequently, nurse practitioner residencies and fellowships are an emerging trend in postgraduate education. Another healthcare profession has the potential to reduce the shortage of primary care providers with specialty training. The chiropractic profession totals approximately 75,000 providers in America. In the United States (US) a shortage of primary care physicians has become evident. Other health care providers such as chiropractors might help address some of the nation’s primary care needs simply by being located in areas of lesser primary care resources. Therefore, the purpose of this study was to examine the distribution of the chiropractic workforce across the country and compare it to that of primary care physicians. Lehman proposed that chiropractic neuromusculoskeletal medicine specialists could pursue a Fellowship in primary care medicine in community health centers/FQHCs. If chiropractors should pursue the opportunity to become Advanced Practice Providers in primary care, it would be necessary to expand the chiropractic scope of practice to include all primary care medications. The Consortium of Advanced Practice Providers has agreed to consider accrediting the chiropractic fellowship in primary care, which demonstrates the perception of chiropractic specialists capable of becoming advanced primary care providers.

Conclusions

It appears the FQHCs and their primary care providers, Lovelace Medical Center’s medical physicians, and chiropractic patients perceive chiropractic specialty care to be of value. Yet, the majority of the chiropractic profession do not perceive the value of chiropractic postdoctoral training and board certification. This perception by chiropractors is problematic for a misunderstood profession that functions outside of the American healthcare systems.

It is the opinion of this author that the chiropractic profession must acknowledge the changes taking place in the American healthcare system and embrace opportunities to integrate as chiropractic specialists into medical organizations including Federally Qualified Health Centers. Chiropractic resident training and board certification as chiropractic specialists enhance career pathways and integration into healthcare systems. Integration of chiropractic specialty care into the Veterans Administration hospitals, Federally Qualified Health Centers, Rural Health Centers, medical clinics, medical schools, and hospitals will improve access to safe and salubrious chiropractic services and promote the growth of the chiropractic profession. Chiropractic specialists that complete an advanced practice Fellowship in Primary Care Medicine may reduce the shortage of primary care providers in America and improve access to holistic healthcare.

Yet, there are a couple significant questions for the chiropractic profession to answer. Will American chiropractors perceive the value of integration, resident training, and board certification as a chiropractic specialist? Will any chiropractic physicians pursue a fellowship in primary care medicine?

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