Leadership in chiropractic education is in a challenging position these days, with any number of forces putting pressure on the schools that train doctors of chiropractic. The health care marketplace is in upheaval (trends in value-based compensation models, consolidation of delivery services in ACOs and ‘medical’ homes, etc.). Higher and professional education is under profound stress (distributed/distance learning, pressures on historical institutional hierarchies, millennial sensibilities about career choices, relentless increases in delivery costs, etc.). The wild and crazy world of the emerging consumer-focused health care marketplace is changing the nature of relationships right under providers’ feet (right-setting of the supply-demand dynamic in retail terms, developing decision-support tools, new-found independence and autonomy of roles, etc.).
With all this, nothing can–or should–be taken for granted. What’s the effect of all this on practicing doctors of chiropractic–and what might the schools do about it? I think there are three basic questions that need to be asked of–and by–all health care educators in these challenging times.
1. What are we training people to do? Service providers of any type operate in a marketplace. How the needs of the marketplace are perceived by the providers and how they then respond to try and address those needs directly affects whether they stay in business or not. The health care marketplace is under intense pressure, and ongoing change is inevitable. Provider roles will be under the same pressure to evolve to ensure they are relevant. If health professional educators use circular reasoning that answers this question only in terms of professional competencies, their graduates are going to be in for a rude awakening. Whole new skill sets need to be evaluated, reinforced, and supported that create the context for how the professional skills are made available and applied. Providers will need to extend themselves to become part of the context for care (how people seek it, the options they understand they have, the role they see themselves in, etc.) and potentially separate from the provision of care. In other words, if we only train people to do something instead of be something to health care consumers, we’ve limited their effectiveness.
2. How will we train them? The current costs of higher and professional education are unsustainable, increasingly exclusive and are fundamentally out of alignment with most compensation models after graduation. Increasing scrutiny of educational delivery methods is going to employ more and more supply chain values and metrics, and the ‘ivory tower’ cultural model of research, self development and teaching is not likely to be as prevalent in a generation as it is now. Economic forces aren’t the only ones at work; tremendous changes in social structures, distributed peer cohort efforts, communication norms and other contextual forces are going to force our ‘legacy’ educational model of butts in seats into an archaic position. Those who come up with alternative models of delivery, measurement, testing, financing and rewards will be the winners. Tenured track educators, fairly or not, will likely be among the losers.
3. Will leadership be characterized by disruptive emergence? In health care education, host cultures have historically paved the way for leaders to develop within the bounds of those cultures. Cultures capable of enforcing greater compliance than others find change more disruptive than cultures without the same capacity for rigid control and development. These days disruptive innovation is visible everywhere, including education, but the influence of disruption in education is muted in contrast to other industries because of the historical ability of the educational culture to exact behavioral compliance. An unintended consequence of efforts to maintain a tightly structured educational culture is that we may very likely force potential innovators to go elsewhere, because the innate creative forces that ‘find their way out’ of these individuals and groups won’t tolerate hostile cultures. They will seek other avenues for their creative–and disruptive–expression, and the benefits those energies create will accrue elsewhere.
Locally, Northwestern Health Sciences University is under new leadership, and the for-profit educational background of its new president must have been viewed as an asset by the school’s Board of Trustees. Sorting through the limited information coming out of the institution, it’s clear that quite a bit of disruptive change to the culture is in the works as new idealized or necessary efficiencies are sought and established. Whether those changes produce an improved ‘educational product’ or create a more efficient system and process of education remains to be seen. At the end of the day, if that product is not what the marketplace wants, those efforts will have been for naught.
Nationally, chiropractic programs will have to grapple with the near-inevitability of a two-tiered profession, given the mounting likelihood that state scope laws will begin to be revised and broaden the scope of chiropractic, with the effect of both diffusing and fogging its identity. How the schools navigate those challenging political waters will help determine how many schools are even around in twenty years. From where I sit, it’s hard not to see an inevitable culling, as it’s not clear that scope revisions are even something the marketplace wants. So investing in training programs based on an untested presumption of marketplace relevance is bound to leave some in untenable economic and recruiting positions.
Internationally, existing, emerging and future schools will not be exempt from these forces. What is likely is that many will get established while the health care marketplaces in host countries take shape and form, subject to each set of unique local circumstances. But regardless of the degree to which those countries’ health care systems mirror or differ from that of the US, the same intraprofessional stresses and tensions created because of our conflicted identity are likely to make it very challenging for necessary collaboration, and will most likely reprise the competition we saw earlier in the history of chiropractic. It’s not likely that this will be beneficial, but unless we come up with a new understanding of the benefits of collaboration, it’s probably unavoidable.
With all that said, what’s still powerfully true is that chiropractic offers the potential of immense benefit in health and healing. Whether its members focus exclusively on subluxation, structural balance and integrity, energetic homogeneity or optimal neurologic function, there are clearly connections between all versions of the chiropractic paradigm that have relevance. That the profession has survived and grown the point it has after 119 years of adverse internal and external forces is nothing short of remarkable. And the need for chiropractic has not lessened; imagining what benefits it might confer if our market penetration was well north of where it is today is an exciting and seductive prospect. So it’s going to be up to our schools to accurately assess the marketplace interests, needs, and opportunities–and then to align their efforts to produce a relevant graduate. We’ll see if they’re up to the job.