The accreditation role of Councils on Chiropractic Education as part of the profession's journey from craft to allied health profession: A commentary

Background Chiropractors see themselves as well positioned to provide safe, effective and economical care for the on-going financial burden that spinal pain imposes. However, in many places of the world, the chiropractic profession continues to find itself struggling to gain acceptance as a mainstream allied health care provider. There is evidence of the existence of undesirable chiropractic practice patterns and it is in part due to some of the world’s accredited chiropractic programs. This indicated a need for scrutiny of international chiropractic educational accreditation standards, which are the responsibility of Councils on Chiropractic Education (CCEs). To this end we reviewed an emerging body of evidence about the chiropractic educational system in order to identify issues and make recommendations that may enhance professional acceptance through improved graduate outcomes and hopefully the quality of patient care. This commentary summarises the findings of that research. Main text We reviewed recent relevant studies, including our own, into the role and function of CCEs and found that there is sufficient evidence to identify areas of concern that could be addressed, at least in part, by improvements to CCEs’ educational standards and processes. Areas included a lack of definitions for key terms such as, ‘chiropractic’, ‘diagnosis’, and ‘competency’, without which there can be no common understanding at a detailed level to inform graduate competencies and standards for a matching scope of practice. Further, there is some evidence to suggest that in some cases this level of detail is avoided in order to enable a “big tent” approach that allows for a diversity of approaches to clinical care to co-exist. This combined with the held view that chiropractic is “unique”, highly valued, and best understood by other chiropractors, explains how students and practitioners can cling to ‘traditional’ thinking. This has implications for public safety and patient quality of care. Conclusion If chiropractic care is to gain mainstream acceptance worldwide then it needs to adopt, through revitalised CCE accreditation standards and processes, those of other allied healthcare professions and wholeheartedly embrace science, evidence-based practice and patient centred care

Attempting to explore chiropractors and their clinical choices: An examination of a failed study

Background Recent studies have shown that psychological factors, attitudes and beliefs impact on the quality of chiropractic student clinical decisions. This association has not been studied among qualified chiropractors. Our objective was to investigate if personality, psychological factors and/or unorthodox beliefs among chiropractors are related to choices of management in specific clinical scenarios. Method In February 2018, a subsample of chiropractors (N = 700) from a practitioner-based research network in Australia known as ACORN (N = 1680), were invited to respond to an on-line anonymous questionnaire. Questions included items relating to management of specific clinical scenarios, intolerance of uncertainty (IU) and the 'Big-5' personality score, adoption of a prescriptive technique system, self-rating of chiropractic abilities, and the level of importance of subluxation and chiropractic philosophy in the delivery of care. Descriptive analysis was to be reported and associations examined between i) personality and psychology factors, unorthodox beliefs and ii) scores obtained for management of specific clinical scenarios, numbers of interdisciplinary referrals, and guideline-based X-ray use. Results The number of respondents was 141 (20%) and 33 of their responses were largely incomplete resulting in a final response rate of 108 (15.4%). In addition, some questions were left unanswered. These related mainly to IU and Big-5 personality measurements. Some sample characteristics (age, number of patients per week, hours worked per week) were similar to the larger ACORN project sample. However, the low response rate indicated that the final study sample was unlikely to be truly representative of the study population and the low number of participants made association testing unsuitable. Conclusion and recommendations The low response rate and small study sample in this study made any substantive analysis inappropriate. For these reasons, the study was not concluded. However, the potential reasons for the low response from this large database of volunteer research participants are of interest and need to be investigated. Clearly, it is necessary to engage this population better to explore sensitive issues such as personality inventories and different practice profiles in the interest of effective health care delivery and patient safety

Similarities and differences of a selection of key accreditation standards between chiropractic councils on education: A systematic review

Background Councils of Chiropractic Education (CCE) indirectly influence patient care and safety through their role of ensuring the standards of training delivered by chiropractic educational institutions. This is achieved by a process of accreditation where CCEs define and assess graduate competencies and educational standards. A previous study comparing CCE graduate competencies found variations between the CCE jurisdictions. It was proffered that variations in standards may potentially compromise patient care and safety and also inter-jurisdictional mutual recognition. This study continues the examination of CCEs by looking for similarities and differences in CCE accreditation standards. There were two purposes of this review. The first was to compare the accreditation standards, domains of accreditation standards, and components of the domains of accreditation standards as represented by the domains of "Mission, goals, vision, objectives", "Resources", "Faculty/Academic staff", "Educational program/curriculum". In addition, we compared the accreditation standards between CCEs and those of the widely accepted medical accreditation standards of the World Federation of Medical Education (WFME), in order to search for deficiencies and opportunities for improvements in these standards. The second purpose was to make recommendations, if significant deficiencies or variations were found. Method We undertook a systematic review of the similarities and differences between five CCEs' definitions of an accreditation standard and the descriptive lists of accreditation standards they have adopted. CCE selection criteria and data selection method were undertaken in a systematic manner. This information was tabulated for a comparative analysis and took place in April 2016. Results Only two CCEs had a definition of the term "accreditation / educational standard". At the domain level there was considerably more similarities than differences. The differences became more apparent when the comparisons were made at the component level. These included intended purposes of the mission statement, standards for faculty staff, requirements for clinical training by students, program budgetary autonomy and transparency, the inclusion of chiropractic philosophy and history, and which subjects should be taught in basic, behavioural and clinical sciences. Conclusions A series of recommendations were made. These included the need for an increased clarity of the required basic and clinical science subjects, teaching clinic student requirements, and faculty staff qualifications. These are proposed with the intention of creating uniform and high quality international accreditation standards for chiropractic education. Future research should compare the levels of CCEs inspection standards and processes to see if similarities and differences exist also there

How comprehensively is evidence-based practice represented in councils on chiropractic education (CCE) educational standards: A systematic audit

Background The incorporation of evidence-based practice (EBP) is widely recognised as a necessary process for entry-level health professional training. Accreditation documents reflect the practice standards of health professions. No previous study has assessed the extent to which EBP has been taken up by chiropractic regulatory/licencing authorities, known as Councils on Chiropractic Education (CCEs), around the world. The purposes of this study were to examine CCEs' educational standards for signs of a positive and negative approach to EBP as indicated by the prevalence and use of the words evidence, research, subluxation and vitalism, and to make recommendations if significant deficiencies were found. Method We undertook a systematic audit of the educational standard documents of the various CCEs. CCEs were selected on the basis of the World Health Organisation. Two investigators identified the occurrences of terms explicitly related to EBP: evidence, evidence-based, research, subluxation and vitalism. This information was tabulated for comparative purposes. The date of the study was March 2016. Results Occurrences of the term evidence, as it related to EBP, was highest in the CCE-Europe (n = 6), followed by CCE-Australia (n = 2), and CCE-USA (n = 1). None were found in the CCE-International or CCE-Canada documents. The term research appeared most frequently in the CCE-Europe documents (n = 43), followed by CCE-USA (n-32), CCE-Australia (n = 29), CCE-Canada (n = 9) and CCE-International (n = 8). The term subluxation was found only once (CCE-USA) and vitalism did not appear in any educational standard documents. Conclusions Accreditation bodies are powerfully positioned to act as a driver for education providers to give greater priority to embedding EBP into entry-level programs and shaping future directions within the profession. Terminology relating explicitly to EBP appears to be lacking in the educational standard documentation of CCEs. Therefore, future revisions of accreditation standards should address lack of terminology

The relationship between intolerance of uncertainty in chiropractic students and their treatment intervention choices

Background: Psychological factors, such as intolerance of uncertainty (IU), have been shown to impact on the quality of medical care. However, this psychological measure has not been studied in the chiropractic profession. Our objective was to investigate if higher levels of IU in chiropractic students were related to poor choices of management in specific clinical scenarios. Also, we sought to investigate if levels of IU were related to students' intentions to adopt a prescriptive chiropractic technique system and evaluate their levels of self-belief. Method: Between October and November of 2016, students from two Australian chiropractic programs (N = 444) answered a questionnaire on measures of IU levels, patient case scenarios for neck and low back pain, and questions about self-ratings of their future chiropractic abilities and perceived need for the adoption of a chiropractic technique system. Associations were tested by the IU score and the therapeutic choices relating to a) a neck pain case scenario, b) a low back pain scenario, c) various technique systems, and d) the self-rated competence level treating the IU score both as a continuous and a categorical variable. Results: There was an overall response rate of 53%. Those students who were high in levels of IU were significantly more likely to make incorrect clinical decisions than those with normal or low levels of IU for the neck pain case scenario. No differences were found on the low back pain scenario, on preferences to use a technique system in the future, or on predicted self-rating of competence after graduation. Conclusions: Psychological factors, such as IU, may have an impact on chiropractic students' clinical decisions. However, it does not impact on all aspects of practice. This finding has implications for chiropractic educators, especially when dealing with neck pain. However, it may be relevant to continue the search for specific personality profiles in relation to various favourable and unfavourable practice patterns, as it is unknown whether these dynamics are important for other aspects of chiropractic education

A perspective on Chiropractic Councils on Education accreditation standards and processes from the inside: A narrative description of expert opinion, part 1: Themes

Background The aim of this study was to report on key informant opinions of Councils on Chiropractic Education (CCE) regarding recent research findings reporting on improving accreditation standards and processes for chiropractic programs (CPs). Methods This qualitative study employed in-depth semi-structured interviews with key experienced personnel from the five CCEs in June and July of 2018. The interviews consisted of open-ended questions on a range of issues surrounding accreditation, graduate competency standards and processes. All interviews were audio-recorded, and transcribed verbatim. The transcripts were analysed to develop codes and themes using thematic analysis techniques assisted by NVivo coding software. The study followed the COREQ guidelines for qualitative studies. Results Six themes were isolated from the interview transcripts; they were: professional differences; keep it in the family; to focus on outcomes or be prescriptive?; more resources please; inter-profession integration; and CPs making ends meet. Most respondents saw a need for CCEs standards and processes to improve interdisciplinarity while at the same time preserving the 'uniqueness' of chiropractic. Additionally, informants viewed CCEs as carrying out their functions with limited resources while simultaneously dealing with vocal disparate interest groups. Diverse views were observed on how CCEs should go about their business of assessing chiropractic programs for accreditation and re-accreditation. Conclusions An overarching confounder for positive changes in CCE accreditation standards and processes is the inability to clearly define basic and fundamental terms such as 'chiropractic' and its resultant scope of practice. This is said to be because of vocal, diverse and disparate interest groups within the chiropractic profession. Silence or nebulous definitions negotiated in order to allow a diversity of chiropractic practice to co-exist, appears to have complicated and hindered the activities of CCEs. Recommendations are made including an adoption of an evidence-based approach to accreditation standards and processes and the use of expertise from other health professions. Further, the focus of attention should be moved away from professional interests and toward that of protection of the public and the patient

Leading and higher twists in the proton polarized structure function at large Bjorken x

A phenomenological parameterization of the proton polarized structure function has been developed for x > 0.02 using deep inelastic data up to ~ 50 (GeV/c)**2 as well as available experimental results on both photo- and electro-production of proton resonances. According to the new parameterization the generalized Drell-Hearn-Gerasimov sum rule is predicted to have a zero-crossing point at Q**2 = 0.16 +/- 0.04 (GeV/c)**2. Then, low-order polarized Nachtmann moments have been estimated and their Q**2-behavior has been investigated in terms of leading and higher twists for Q**2 > 1 (GeV/c)**2. The leading twist has been treated at NLO in the strong coupling constant and the effects of higher orders of the perturbative series have been estimated using soft-gluon resummation techniques. In case of the first moment higher-twist effects are found to be quite small for Q**2 > 1 (GeV/c)**2, and the singlet axial charge has been determined to be a0[10 (GeV/c)**2] = 0.16 +/- 0.09. In case of higher order moments, which are sensitive to the large-x region, higher-twist effects are significantly reduced by the introduction of soft gluon contributions, but they are still relevant at Q**2 ~ few (GeV/c)**2 at variance with the case of the unpolarized transverse structure function of the proton. Our finding suggests that spin-dependent correlations among partons may have more impact than spin-independent ones. As a byproduct, it is also shown that the Bloom-Gilman local duality is strongly violated in the region of polarized electroproduction of the Delta(1232) resonance.Comment: revised version to appear in Phys. Rev. D; extended discussion on the generalized DHG sum rul

High-precision molecular dynamics simulation of UO2-PuO2: Anion self-diffusion in UO2

Our series of articles is devoted to high-precision molecular dynamics simulation of mixed actinide-oxide (MOX) fuel in the approximation of rigid ions and pair interactions (RIPI) using high-performance graphics processors (GPU). In this article we study self-diffusion mechanisms of oxygen anions in uranium dioxide (UO2) with the ten recent and widely used sets of interatomic pair potentials (SPP) under periodic (PBC) and isolated (IBC) boundary conditions. Wide range of measured diffusion coefficients (from 10^-3 cm^2/s at melting point down to 10^-12 cm^2/s at 1400 K) made possible a direct comparison (without extrapolation) of the simulation results with the experimental data, which have been known only at low temperatures (T < 1500 K). A highly detailed (with the temperature step of 1 K) calculation of the diffusion coefficient allowed us to plot temperature dependences of the diffusion activation energy and its derivative, both of which show a wide (~1000 K) superionic transition region confirming the broad lambda-peaks of heat capacity obtained by us earlier. It is shown that regardless of SPP the anion self-diffusion in model crystals without surface or artificially embedded defects goes on via exchange mechanism, rather than interstitial or vacancy mechanisms suggested by the previous works. The activation energy of exchange diffusion turned out to coincide with the anti-Frenkel defect formation energy calculated by the lattice statics.Comment: 18 pages, 11 figures, 5 table

Horizontal Branch Stars: The Interplay between Observations and Theory, and Insights into the Formation of the Galaxy

We review HB stars in a broad astrophysical context, including both variable and non-variable stars. A reassessment of the Oosterhoff dichotomy is presented, which provides unprecedented detail regarding its origin and systematics. We show that the Oosterhoff dichotomy and the distribution of globular clusters (GCs) in the HB morphology-metallicity plane both exclude, with high statistical significance, the possibility that the Galactic halo may have formed from the accretion of dwarf galaxies resembling present-day Milky Way satellites such as Fornax, Sagittarius, and the LMC. A rediscussion of the second-parameter problem is presented. A technique is proposed to estimate the HB types of extragalactic GCs on the basis of integrated far-UV photometry. The relationship between the absolute V magnitude of the HB at the RR Lyrae level and metallicity, as obtained on the basis of trigonometric parallax measurements for the star RR Lyrae, is also revisited, giving a distance modulus to the LMC of (m-M)_0 = 18.44+/-0.11. RR Lyrae period change rates are studied. Finally, the conductive opacities used in evolutionary calculations of low-mass stars are investigated. [ABRIDGED]Comment: 56 pages, 22 figures. Invited review, to appear in Astrophysics and Space Scienc