Restoring Trust in Chiropractic Licensure: State Boards Should Prioritize Institutional Competency Over NBCE Part IV
Originally published: 2025-03-28
At the heart of professional licensure is a simple but powerful premise: states license individuals, not private corporations. Yet in the chiropractic profession, that line has been dangerously blurred. Nowhere is this more evident than in the continued, and increasingly indefensible, reliance on NBCE Part IV—a centralized, costly, and controversial examination that has become a barrier to licensure, not a guarantor of competence.
State chiropractic regulatory boards must recognize that their duty is to protect the public, not to protect the NBCE's testing monopoly. The time has come to abandon the use of NBCE Part IV as a requirement for licensure and instead accept the clinical competency determinations made by the chiropractic institutions authorized to confer the Doctor of Chiropractic degree.
The Problem with NBCE Part IV
When it was introduced, NBCE Part IV was marketed as a high-stakes, objective measure of clinical skills. In practice, however, it has evolved into an expensive, logistically burdensome, and opaque process that neither reflects the real-world skills chiropractors need nor improves public safety.
The problems with Part IV are well-documented:
Centralization: The exam has now been consolidated to a single site in Greeley, Colorado, requiring students from across the country to incur significant travel and lodging costs, often exceeding $1,500, on top of already exorbitant exam fees.
Delays and Bottlenecks: With testing slots limited to a few windows each year, students face unnecessary delays in licensure and practice, especially those who fail by narrow margins and must wait months to retest.
Lack of Transparency: The NBCE does not provide meaningful feedback or access to performance breakdowns, raising serious questions about due process and fairness.
Redundancy: All accredited chiropractic programs already include rigorous clinical internships and exit assessments, overseen by faculty and institutional review boards. Part IV duplicates this process—at great cost and little additional value.
Institutional Competency Assessment is the Gold Standard
Chiropractic colleges and programs undergo comprehensive institutional and programmatic accreditation, including oversight of their clinical training and assessment. These institutions:
Train students in patient-centered care using real patients under supervised clinical rotations.
Require case management, technique proficiency, diagnostic reasoning, and professionalism as conditions for graduation.
Conduct formal exit exams and clinical evaluations in compliance with their educational mission and accreditation requirements.
No single weekend exam can match the depth and longitudinal integrity of these evaluations. Trusting chiropractic colleges to certify their own graduates is not only reasonable—it is consistent with how most licensed health professions operate, including medicine, dentistry, and nursing.
Federalism and State Authority
The continued use of NBCE Part IV is an abdication of state authority to a private, unaccountable corporation. There is no statutory requirement—federal or otherwise—that compels state boards to use NBCE exams. This is a policy choice, not a legal obligation.
States have the power—and the responsibility—to determine what constitutes clinical competence. That power should reside with educational institutions, whose missions are to educate and graduate safe, competent practitioners—not with a private testing body with no direct patient care role, no academic oversight, and no public accountability.
Legal and Political Risks of Maintaining the Status Quo
States that continue to require NBCE Part IV despite credible alternatives open themselves to a range of legal and policy challenges:
Restraint of Trade Claims: The artificial bottleneck and monopoly control could be viewed as anti-competitive.
Due Process Violations: The lack of meaningful feedback, transparency, or appeal rights creates exposure under administrative law.
Political Fallout: As more students speak out against the burdens of Part IV, state boards risk appearing captured by special interests rather than public-minded stewards of licensure.
A Call for Reform
State chiropractic boards should:
Immediately remove NBCE Part IV as a licensure requirement.
Recognize institutional certification of clinical competency as sufficient evidence of practice readiness.
Develop state-specific standards for verifying institutional assessment quality, in cooperation with accredited chiropractic programs.
Provide a pathway for appeal or secondary review for applicants whose schools are not recognized or who have been denied a diploma.
Conclusion
Part IV testing no longer serves the profession, the public, or the students. It is a relic of a time when institutions were not trusted to oversee clinical competence—a time that has long passed. Chiropractic colleges today are robust, accredited, and fully capable of determining who is prepared to enter practice.
State boards must stop outsourcing their regulatory responsibility and trust the very institutions they authorize to educate tomorrow’s chiropractors. The profession, and the public, will be stronger for it.
Now is the time to act.
