The Chiropractic Journal, July 2000
by Michel Tetrault, D.C.
There has been a notable increase in the number of chiropractors throughout the world in the past 10 years. In 2000, there are 81,000 chiropractors compared with 65,000 in 1989.
There has also been an increase in the number of chiropractic schools outside of the United States, from 5 in 1989 to 17 in 2000. This, in part, will account for the increase in the number of D.C.s practicing outside the USA to 12,000. (There are 69,000 D.C.s in the U.S. at present, or 85% of the world’s D.C. population.)
The past decade has also seen a significant change in the American health care industry.
Chiropractic has made some headway as a leader in alternative health care. It has also experienced the HMO squeeze and the PPO effects on the average chiropractic practice. Most D.C.s state their practices are seeing half to two-thirds of the people they were servicing 10 years ago.
It comes as no surprise that there is a growing interest for chiropractors to want to practice outside the United States. There are several reasons for this growing trend, as well as a real need to help these doctors prepare for a successful transition.
The prospects of establishing a practice in a foreign country is not as simple as moving to another city or state. Besides the similar challenges of setting up an office and moving the family, the D.C. who wants to relocate to another country will encounter several additional challenges.
There is the physical move and the local customs to establish a new business. The licensing requirements are notably different from country to country, and notably different from the USA. Plus, there are language and socio-economic realities that also present quite a challenge.
Naturally, everyone with an interest in practicing abroad needs to know the legal requirements for setting up a practice in a foreign country. This will depend on the legal status of the profession in that country. Here are the four scenarios:
- Full legal recognition of the chiropractic profession.
- No legislation protecting the D.C. title or defining the scope of practice but lawful to practice once a title or degree has been verified and the doctor sets up a lawful business.
- No requirements other than setting up a lawful business.
- Chiropractic is illegal and chiropractors are on their own.
Note: All countries require an approved resident or working visa first.
Let’s look at each of these scenarios more closely.
1) FULLY LEGAL. There are about 35 countries which have gone through the legislative process to define the scope of practice and where most protect the title “chiropractor, D.C., or its equivalent Bachelor degrees.”
These countries are: Australia, Belgium, Bolivia, Canada, Cayman Islands, Costa Rica, Cyprus, Denmark, Fiji, Finland, Hong Kong, Iceland, Iran, Jamaica, Jordan, Lebanon, Liechtenstein, Mexico, Nambia, New Zealand, Netherlands, Norway, Panama, Puerto Rico, Saint Kitts & Nevis, Saudi Arabia, South Africa, Sweden, Switzerland, Trinidad & Tobago, United Arab Emirates, United Kingdom, United States, Virgin Islands-U.S., and Zimbabwe. You can obtain a license to practice in these countries by making application, passing boards (most) and taking a practical exam. You will have to inquire as to the specific requirements of your country of interest.
2) SOMEWHAT LEGAL. The following countries have accepted the chiropractic diploma as qualification to practice chiropractic: Greece, Italy, Israel, Libya, Germany, Chile, Venezuela, Bolivia, Ecuador, Peru, Argentina, Columbia, Philippines, Singapore, Malaysia, Taiwan, Thailand, Japan, Korea, Dominican Republic, Jamaica, and the Bahamas.
However, the actual license or certificate is not necessarily for chiropractic. It is more frequently issued for a natural healer, drugless practitioner or even a physical therapist or massage therapist.
3) NOT ILLEGAL. When it is otherwise not illegal to practice chiropractic (as it is in countries with Napoleonic Laws) and there is no official recognition of the profession, there are no laws to prevent you from practicing chiropractic. In fact, the Commonwealth countries are governed by “Common Law” which makes it legal to practice your profession.
Once you meet the resident or work visa requirements, meaning that you can legally live and work in the country, all that is required is that you set up your practice by meeting all the local laws that apply to any business.
There are many countries that require citizenship in order to own a clinic, therefore you could only work in another D.C.’s office. There are disadvantages though. It is very difficult to run a regular practice. You have virtually no access to x-rays, ordering lab tests or other procedures that are under other providers’ regulations.
This tends to be handled by establishing a close working relationship with a local medical doctor. It is recommended that you visit every* chiropractor in the country to discover what he or she has learned about what is or is not permitted. (*Not everybody shares the same views.)
4) ILLEGAL (but somewhat tolerated). When it is illegal to practice chiropractic, the laws usually prevent anyone other than an M.D. to treat people. There are several countries (for example, in Eastern Europe) where M.D.s have become D.C.s and limit their practice to chiropractic.
France and Spain have seen slower growth because of this difficulty. There are only 80 D.C.s in Spain and 360 D.C.s in France (because there is a school in Paris). It is a risk, but that does not seem to deter those who are there. As Europe enters unprecedented economic cooperation, it will be interesting to see how antiquated medical dominated laws will crumble as new trade laws permit D.C.s equal access within the unified European nations.
Belgium capitalized on the growing need facing governments to acknowledge the many “complementary and alternative medical” providers in their country. This is also how Israel and the Philippines are finding their governments extending an invitation whereby chiropractors can define their profession, for regulatory purposes.
If this is done right, it can be an excellent first step. The key is to lobby for a full scope of chiropractic recognition without compromising or selling the profession short down the road. The important fact to remember here is that chiropractors are the most educated of the majority of the “alternative or traditional” providers.
This turns out to be our strength. In 1913, California was recognized under the “Drugless Practitioner’s” Act, which later became the Chiropractic Board. When we are the strongest or more educated group, we tend to dominate the “drugless” practitioners.
In 1999, the Chiropractic Diplomatic Corps established a Foreign Service Registry where more than 250 D.C.s have registered from eight different countries. 95% are from the USA, 72% are graduates of subluxation-based schools, while only 20% have six or more years experience.
It’s also interesting to note that just 23% are interested in establishing a permanent practice. Everyone else is more interested in “spreading the word” and/or desires to experience different cultures. While this may be noble and a good personal growth experience, the long term benefits to these foreign communities leaves much to be desired. We don’t see the profession, nor these communities, benefiting from a working vacation type of practice.
A suitable compromise would be to urge those D.C.s who see themselves committed to only a temporary stay, to plan on remaining for five to six years, then transitioning their practice to another doctor. This way the community continues to benefit from a permanent clinic and a five-to-six year stay will make the exchange a win-win situation.
Another option is to set up a long term cooperative between a small number of D.C.s who can rotate with each other’s clinics, one of these clinics being in the United States.
We like to support and encourage D.C.s to “get right” in their hearts and minds before practicing abroad and prefer to see them moving permanently to the country of their choice. One of the main motivators for this kind of thinking is that it takes just as much time, energy and money to see a chiropractor establish a foreign practice for one year as for a lifetime (you figure out the math).
In conclusion, there are excellent opportunities for chiropractors to practice abroad. Take an honest survey of yourself. Ask friends and family to help you get a realistic view of your strengths and weaknesses:
- Do you see yourself as a pioneer?
- Do you see yourself as a solid practitioner who can adapt in a foreign culture?
- Can you learn another language?
- Can you be happy living under different physical standards?
You’ll be better able to make a decision about setting up a foreign practice the more you’re able to learn about yourself and about other cultures. There is a self- evaluation quiz on the Chiropractic Diplomatic Corps’ website (TOPIC #12) that may be of interest.
Those of you who immigrated to North America have to ask yourselves different questions. Why are you not back home, building the profession in the culture and language of your heritage? Are you going to leave it up to foreigners (albeit well meaning) to decide how chiropractic is to develop in your homeland?
The future growth of chiropractic will be in non-English speaking countries. There are six billion people on this planet. Taking into account economic and socio-cultural factors, there are an estimated 372,000 chiropractors needed to service those people who can afford the care, today.
Right now we are only caring for 21% of our potential patients. If you practice in California or Florida, you know first hand what it’s like to practice where there is a saturation of chiropractors. Think it’s getting crowded in America and harder to practice? Think again. Think differently. Think: “Do I have the right stuff to practice abroad?”