You asked a number of questions about chiropractors addressing licensure requirements, scope of practice, disciplinary action, malpractice coverage, continuing education requirements, and advertising.

SUMMARY

The practice of chiropractic focuses on the relationship between structure (primarily the spine) and function (as coordinated by the nervous system) and how that relationship affects the preservation and restoration of health. Chiropractors must be licensed in Connecticut. Licensure is based on educational requirements and passage of an examination that includes both written and practical components. The Department of Public Health (DPH) and the State Board of Chiropractic Examiners (the board) regulate chiropractic practice in the state.

State law defines the scope of practice of chiropractors, and requires them to maintain professional liability insurance and meet continuing education requirements in order to maintain licensure. The board may take disciplinary action against a chiropractor, following notice and a hearing, for violations of the law on chiropractic, incompetent or negligent conduct in the practice of chiropractic, fraud or material deception in practice, substance abuse and other reasons.

Chiropractors can advertise in the state. The law specifies the proper use of professional titles related to chiropractic practice and imposes penalties for violations.

DEFINITION OF CHIROPRACTIC

State law defines “practice of chiropractic” as:

“the practice of that branch of the healing arts consisting of the science of adjustment, manipulation and treatment of the human body in which vertebral subluxations and other malpositioned articulations and structures that may interfere with the normal generation, transmission and expression of nerve impulse between the brain, organs and tissue cells of the body, which may be a cause of disease, are adjusted, manipulated, or treated” (CGS § 20-24(a)).

A “subluxation” is a complex of functional, structural, and/or pathological changes that compromise neural integrity and may influence organ system function and growth.

The law considers the terms chiropractic, doctor of chiropractic, chiropractor, and chiropractic physician to be synonymous (§ 20-24(b)).

LICENSE REQUIREMENTS

Anyone practicing chiropractic in Connecticut must be licensed by DPH, with the advice and consent of the State Board of Chiropractic Examiners (§ 20-27(a)). The board has seven members, four who are practicing chiropractors and three who are public members (§ 20-25). The license fee is $ 450; the annual renewal fee is also $ 450 (§ 20-27(b)).

License Application

A person seeking to practice chiropractic in the state must apply on DPH forms (see attached). The applicant must provide a statement of the “educational advantages of the applicant, his experience in matters pertaining to a knowledge of the care of the sick, the length of time applied and the school in which he studied chiropractic, any collateral branch of study and the length of time engaged in clinical practice, and any diploma, certificate or degree which as been conferred upon such applicant” (§ 20-27(b)).

An applicant must present DPH with satisfactory evidence that he graduated (1) from an approved high school or has educational qualifications equivalent to those required for graduation before beginning chiropractic study and (2) with the degree of doctor of chiropractic from an accredited college of chiropractic and approved by the board with the consent of DPH (§ 20-27(b)). An “accredited chiropractic college” means an institution which at the time of the applicant’s graduation, either (1) was accredited by the Council on Chiropractic Education or other specialized accrediting agency recognized by the U. S. Department of Education or (2) if located outside the United States, is deemed by the council to meet its educational standards (§ 20-24(3)). The board must file annually with DPH a list of accredited chiropractic institutions it approved with the consent of DPH (§ 20-27(d)).

Each applicant, after July 1, 1960, must provide DPH with satisfactory evidence that before beginning chiropractic study, he completed at least two academic years or 60 semester hours of study leading to a baccalaureate degree in a higher education institution approved by the board with the consent of DPH. Before that date, different academic standards applied (see § 20-27(b)).

Examination Requirement

An applicant must pass an examination prescribed by DPH, with the advice and consent of the board, in order to receive a license. The examination has both written and practical components. DPH administers the examination under the board’s supervision. Passing scores are established by DPH with the board’s consent (§ 20-27(b)). A person passing the examination receives a license from DPH which states that the individual is qualified to practice chiropractic (§ 20-27(d)).

The subjects of the written examination are: anatomy, physiology, symptomatology, histology, vertebral palpation, principles of chiropractic and adjusting, chemistry, hygiene, pathology, dietetics, and diagnosis. The national board tests of the National Board of Chiropractic Examiners may be accepted as the written examination provided it includes physiotherapy (§ 20-28(a)).

The practical examination requires a demonstration of clinical competency in basic chiropractic principles and procedures, including orthopedics, neurology, diagnosis, x-ray, vertebral palpation, and adjustment (§ 20-28(a)).

Licensure Without Written Examination

DPH can grant a license without a written examination to any currently practicing, competent licensee from another state with licensure requirements substantially similar to, or higher than, Connecticut’s. The individual must (1) be a graduate of an accredited chiropractic school approved by the board with DPH’s consent, (2) present satisfactory evidence to DPH of completion of a two year academic course or 60 semester hours of study in a college or scientific school approved by the board with DPH’s consent, and (3) successfully pass the practical examination. The application fee for a license under these terms is also $ 450. A license cannot be issued to an applicant facing disciplinary action or who is the subject of an unresolved complaint in the other state (§ 20-27(c)).

SCOPE OF PRACTICE

The law allows a licensed chiropractor to:

1. practice chiropractic, as defined by law, but does not allow (a) prescribing for or administering to any person any medicine or drug included in material medica, except vitamins, or (b) performing surgery or practicing obstetrics or osteopathy;

2. examine, analyze, and diagnose the human living body and its diseases, and use for diagnostic purposes the x-ray or any other general examination method for diagnosis and analysis taught in any school or college of chiropractic that has been recognized and approved by the state board;

3. treat the human body by (a) manual, mechanical, electrical or natural methods, including acupuncture, (b) use of physical means, including light, heat, water, or exercise in preparation for chiropractic adjustment or manipulation, and (c) oral administration of foods, food concentrates, food extracts, or vitamins; and

4. administer first aid and, incidental to the care of the sick, advise and instruct patients in all matters pertaining to hygiene and sanitary measures as taught and approved by recognized chiropractic schools (§ 20-28(b)).

Exempt Activities

The law on chiropractic scope of practice specifies that it should not be construed as prohibiting a chiropractic student enrolled in an educational program in a regionally accredited chiropractic institution, approved by the board with the consent of DPH, from performing such work incidental to his course of study, if under the direct supervision of a licensed chiropractor (§ 20-28a).

DISCIPLINARY ACTION

The Chiropractic Board can take a number of disciplinary actions against a chiropractor for any of the following:

1. fraud or deception in obtaining a license;

2. alcohol or substance abuse;

3. violation of any provision of the chiropractic law and regulations;

4. fraud or material deception in the course of professional services and activities;

5. physical or mental illness, emotional disorder, or loss of motor skill, including deterioration through the aging process;

6. illegal, incompetent, or negligent conduct in the practice of chiropractic; or

7. failure to maintain professional liability insurance or other indemnity against liability for professional malpractice (§ 20-29).

DPH can order a licensee to undergo a reasonable physical or mental examination if his physical or mental capacity to practice safely is under investigation (§ 20-29).

Any chiropractor facing disciplinary action for any of the above reasons must be given a copy of the complaint and have a hearing before the board. The hearing must follow DPH regulations (§ 20-29).

The possible disciplinary actions that the board can take against a chiropractor include (1) suspending or revoking a license, (2) issuing a letter of reprimand to or censuring the licensee, (3) placing him on probation, (4) assessing a civil penalty up to $ 10,000, or (5) taking summary action against a licensee found guilty of a state or federal felony or subject to disciplinary action in another jurisdiction. The board may at any time within two years of such action, rescind it by a majority vote (§ 20-29). DPH can petition the Hartford-New Britain Superior Court to enforce such orders or actions (§ 20-29).

Disciplinary actions taken against chiropractors is public information. Information about a pending investigation would not be available to the public; information is not released about an investigation until it has been completed or closed, or until the statement of charges is issued. DPH issues a quarterly report (Regulatory Action Report) that lists enforcement actions taken against a variety of health care professionals and facilities. It is available at http: //www. dph. state. ct. us/rar_home. htm.

Patients seeking to make a complaint against a chiropractor can contact the State Board of Chiropractic Examiners at 410 Capitol Ave. , PO Box 340308, Hartford, Ct. 06134-0308; 860-509-7648. Also, complaints can be made to the DPH at its main number (860-509-8000), its Consumer Complaint Hotline at 800-842-0038 or the Practitioner Licensing and Investigations Unit at 860-509-7590.

MALPRACTICE COVERAGE

The law requires chiropractors who provide direct patient care services to maintain professional liability insurance or other indemnity against liability for professional malpractice. The amount of insurance or indemnity must be at least $ 500,000 per incident per individual, with an aggregate of at least $ 1. 5 million. Failure to obtain such coverage can result in a range of disciplinary actions against the chiropractor as discussed above. Each insurance company issuing professional liability coverage must provide DPH with a record of the names and addresses of cancellations and refusals to renew such policies and the reasons for such cancellations and refusals (§ 20-28b).

We contacted the Department of Insurance for information on malpractice claims and payments involving chiropractors. The department reported that it does not have any paid/incurred loss data specifically for chiropractors.

CONTINUING EDUCATION

The law requires chiropractors applying for license renewal to provide evidence of having participated in continuing education programs (§ 20-32(b); DPH Regs. §§ 20-32b-1 through 7). Each such licensee must complete at least 48 contact hours of qualifying continuing

education during each continuing education monitoring period. One contact hour is a minimum of 50 minutes of continuing education activity. A continuing education monitoring period means two consecutive license renewal periods beginning in an odd-numbered year.

Continuing education must be in areas related to the individual’s practice. Section 20-32b-4 of the chiropractic regulations identifies qualifying continuing education activities (see attached). DPH does not approve continuing education courses or pre-approve specific coursework for individual licensees, nor does it maintain a list of continuing education courses.

Each licensee must obtain a certificate of completion from the continuing education provider for all hours successfully completed and must retain the certificate for a minimum of three years after the end of the continuing education monitoring period. Upon the request of DPH, the licensee must submit the certificate to the department. A licensee failing to comply with the continuing education requirements, including failure to maintain proof of course completion, may be subject to disciplinary action, or a non-renewal of his license (Regs. § 20-32b-5).

A licensee applying for license renewal for the first time is exempt from continuing education requirements until his next registration period. A licensee not engaged in any active practice during a given monitoring period is exempt from the requirements upon the submission, before the expiration of the monitoring period, of a notarized application on a DPH form. The application must state that the licensee will not engage in any active practice until he has shown proof of meeting the continuing education requirements (Regs. § 20-32b-6).

USE OF NAMES AND TITLES; ADVERTISING; PENALTIES

The law prohibits any licensee from using the title “Doctor” or any abbreviation or synonym unless he holds the degree of doctor of chiropractic from a chartered chiropractic school or college. In that event, the title must be one that designates the licensee as a practitioner of chiropractic. A person may not practice as a chiropractor under any name other than the name of the chiropractor actually owning the practice or a corporate name containing the names of such chiropractors. Each licensed chiropractor must exhibit his name at the entrance of his place of business or on the office door (CGS § 20-32(a)).

The statutes do not address advertising by chiropractors. Advertising by chiropractors would only be problematic if a chiropractor was advertising services outside his scope of practice. It would also be inappropriate for an individual to advertise himself as a chiropractor if not licensed as such in Connecticut.

Any person, except a licensed physician or surgeon, who (1) practices or attempts to practice chiropractic, (2) buys, sells, or fraudulently obtains any diploma or license to practice chiropractic, whether recorded or not, (3) uses the title “Chiropractor,” “D. C. ” or any word or title to induce the belief that he is engaged in chiropractic practice without complying with the law’s requirements for practice, or (4) violates the provisions of the chiropractic law, is subject to a fine of up to $ 500, imprisonment up to five years, or both. Failure to renew a license in a timely manner is not a violation under this section of the law (§ 20-33).

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