Exploring the evolution of chiropractic assistants and what it should become

We know how chiropractic and the chiropractor have evolved, but what about the other professional within this great union—the chiropractic assistant (CA)? Is it an earned title of academia, a technical vocation, or simply used to designate an individual who works for a chiropractor?

Even to those who have worked in chiropractic offices for years, the definition of a CA and when the title is earned, is debatable. More than 20 years ago, when I first took a job working for a chiropractor, I was given the CA title, but I did not know at that time what the name implied or what the position required. Being a CA, or becoming one, is is a career, a vocation, and a dedication. A CA is not what you are when you come into the profession, but what you become because of the profession.

I can still remember the feeling of inadequacy during those first few months. I was a one-CA office, with no one to train me except the doctor. He was a recent graduate who had no idea how to run an office. Those first years consisted of the blind leading the blind and an awful lot of luck. The only thing we did correct was attending all the seminars we could afford. Like many CAs in those days, my basic training came from Jim Parker, DC, and his multitude of expert speakers. And, if truth be told, my learning came from making every mistake in the book. From making up CPT codes and assigning ICD-9 codes to leaving patients waiting in the reception room if they did not have a scheduled appointment—I did it all.

How Far Have We Come?
Have we evolved as a profession? The answer is yes and, unfortunately, no. Temporary individuals who are seeking more pay and better benefits typically fill positions. The true professional CA who makes a career out of his or her knowledge is a rare find. Long hours, low pay, under-appreciation, no benefits or retirement, are all culprits that have robbed the best and brightest from our union. Unfortunately, there are still too many offices who believe that our positions can be filled with the next smiling face who walks through the door. One doctor once told me, “If they can smile while they are flipping hamburgers for a living, I can make them a CA.” My response was: Sure, if you want them to make hamburger out of your business.

Perhaps the designation of being a CA is not descriptive enough. One office I called did not even know they were CAs. When I asked to speak to the CA, I was told, “We don’t have any here.” Maybe what we need is a more distinguished title. Hospitals have administrators and doctors’ offices have head nurses. Even the title of medical assistant (MA) has a different meaning from receptionist in most offices. MA indicates academically trained individuals who made a vocational choice to receive training before applying for a position.

Which brings me back to the original question: What is a CA? If working for a chiropractor makes an individual a CA, what does training make a CA? We are facing an identity crisis due to the lack of more structured education. Our on-the-job-training expertise depends on who does the training.

State the Facts
A few states have laws, rules and regulations regarding the registration, certification, and licensure of CAs, but most states have none. Here are some of the states that do:

• Arizona requires CAs to have formal training and annual renewal of certification. Currently, the Arizona Board of Chiropractic Examiners registers approximately 2,500 CAs annually.

• Florida has a required 208-hour course. After passing a test after the 2-year course, individuals earn the title, Certified Chiropractic Physician Assistant (CCPA). This course is required by the Florida Board of Chiropractic Medicine and sponsored by Cleveland Chiropractic College. CCPAs can do almost anything except adjust and diagnose. Taking x-rays requires a separate certification.

• Maine requires a 100-hour course and passing a test before individuals can be designated CAs. However, they can get a job with chiropractors and have the title, temporary assistant, as long as they show proof of a high school diploma and enrollment in the CA class. Maine CAs must also submit to a background check.

• Mississippi requires 6 hours of CA continuing education (CE) each year and has a rule that the board shall be authorized to establish educational qualifications and CE requirements for CAs who participate in direct patient care. They also charge a $50 fee CA registration.

• Nevada calls CAs certified, but there is no formal education requirement and technically they are registered under the doctor’s license.

• New Mexico has a Board rule for the minimum education requirement for a CA, which is a high school diploma or equivalent with a minimum of 3 months of supervised on-the-job training. There is no standard of educational requirements or protocol.

• Oregon licenses CAs and awards the title of Certified Chiropractic Assistant (CCA). Initial training requirements consist of 6-hours of instruction, concluding with a test. Two DC professors from Western States Chiropractic College notifies the Oregon Board of Chiropractic Examiners (OBCE) of all students who have completed the course. There is also a 6-hour CE requirement.

• North Carolina offers two beginning and one advanced CA course per year, and awardw two titles, Certified CA and Advanced Certified CA.

• Tennessee requires certification for CAs who work with therapy and take x-rays.

• Texas requires CAs who take x-rays to be registered with the Texas Board of Chiropractic Examiners under the DC’s license and to take CE hours each year.

Most states have some requirements of education and registration or certification when it comes to taking x-rays or performing clinical duties. And, most states offer CA training classes, either through the state association, CA associations, or those sponsored by chiropractic colleges, or other management groups. However, there is no national standard for CA education and no qualification for instructors. Plus, with the new rules of training under HIPAA, all states fall short in training front desk and insurance personnel; two areas where HIPAA violations are likely to occur.

Book Learning
From an academic standpoint, one would expect CA training to be offered at all chiropractic colleges. The first formal CA class graduated from Palmer Chiropractic College on June 15, 1968, and today, Palmer still offers three levels of CA training, including an associates degree for chiropractic technicians (CT). Cleveland, Los Angeles Chiropractic College, University of Bridgeport, and Texas Chiropractic College have all offered CA courses through their postgraduate divisions, and Parker College offers CA training online.

However, for an individual outside the profession, finding a career as a CA would be a challenge. Usually, CA or CT courses are not found at most community colleges or technical schools. There is at least one college in Wisconsin, Moraine Park Technical College, that offers a 2-year associates degree as a CT.

The bulk of CA training today is offered in seminar format by former CAs who have turned their talents and knowledge into educating others. These individuals have worked in an office and recognize the need for more education and a qualified workforce. Pat Atanas, Sherry Hodge, Susan Hoy, and Rose Jacobs are nationally known speakers, who have lectured for several years. Some trainers have their own businesses, while others align themselves with management groups or chiropractic colleges.

One of the longest running CA training courses is offered in Texas. Kathy Jones, cofounder of the National Academy of Chiropractic Assistants (NACA) [of which Soyring is a cofounder], continues to teach the CA Certification course, now into its 13th year. This program is offered to beginning and advanced CAs. The 4-month course not only offers front desk and insurance training, but also back-office physiotherapy, anatomy, policies, and procedures, and has recently added HIPAA regulations.

Debra Southard, President of Chiropractic Educational Network (CEN), has been at the forefront of CA training since 1989. Today, in conjunction with Cleveland, CEN offers a proactive approach to ensuring quality CA education. CEN and Cleveland offer classes in approximately 15 different states, including those taught in Florida and North Carolina. CEN offers technical courses as well as administrative procedural classes.

“States are now adding CA certification requirements, [which] will provide the [CA] profession with more recognition because new standards, such as HIPAA, require a higher level of training,” Southard said. “CAs need to be more functional in the office, allowing the doctor to concentrate on treatment of patients. More importantly, CAs will ensure quality care and patient safety as they have a full understanding of chiropractic care, ethics, protocols, and procedures. An educated CA is the make-it or break-it link to a successful office. My goal is to align all qualified CA instructors and standardize the educational requirements for CAs. I hope this will be the year that CAs emerge into an entity that is seen as a true profession,” Southard adds.

In most states, the law does not legislate what CAs are, the Boards of Chiropractic Examiners do not regulate it, and the associations do not bylaw it—what CA means remains a debate. CP

Ces Soyring, CA, is cofounder of the National Academy of Chiropractic Assistants (www.naca-online.com) and a chiropractic consultant. She can be reached at: 888-218-7757 or via email: naca_csoyring@yahoo.com.