For the past decade or more, it appears clear that chiropractic has been relegated, especially by third-party payers, to a musculoskeletal subspecialty practice within the allopathic health care model. Indeed, Medicare recognizes manipulation of the spine only as a reimbursable procedure. Within the profession, some begrudgingly and others willingly accept this designation. Many more, however, practice according to traditional chiropractic tenets and current educational standards: those of naturally based primary care. The resulting, sometimes heated, primary care versus specialty care debate has prompted a growing number of chiropractic organizations to formulate and adopt position statements on primary care consistent with the missions and goals of each group.
Recognizing the potential influence of this issue on the future of chiropractic, and in an effort to advance the profession in Connecticut, the Connecticut Chiropractic Association's (CCA) board of directors authorized the formation of an ad hoc committee on chiropractic scope of practice in January 1999 to study the subject. The committee members were DCs: Gina Carucci; Matthew Funk; E. Paul Grimmeisen; Michael Gurney; and myself as chairperson.
The committee investigated the terms primary care; primary care provider (clinician, physician); neuromusculoskeletal care; neuromusculoskeletal care provider (clinician, physician); musculoskeletal care; and musculoskeletal care provider (clinician, physician) to determine which, if any, of these terms may include the practice of chiropractic.
The committee also performed a literature review and an in-depth analysis of several definitions of these terms in conjunction with an interpretation of specific sections of chapter 372 of the Connecticut General Statutes, comparing the legal description of chiropractic practice to the term definitions.
Two opinion surveys were conducted: one of Council on Chiropractic Education (CCE)-accredited chiropractic college presidents and leaders of chiropractic organizations worldwide; the other, of Connecticut-licensed doctors of chiropractic. Survey topics addressed definitions of primary care and primary care provider; the formulation of these terms; neuromusculoskeletal care and neuromusculoskeletal care provider; individual rights in selecting a primary care provider; and which types of practitioners should be considered primary care providers.
Mission statements of all CCE-accredited chiropractic colleges were reviewed, with particular attention paid to educational goals and the professional qualifications of graduates.
Based upon the committee's review and analysis of the information included in this project, the following position statement on primary care was presented for adoption by the CCA board of directors:
"The Connecticut-licensed Doctor of Chiropractic (DC) is a primary care provider by virtue of:
- Definition of chiropractic
- Primary care definition
- Education
- Licensure
- Intra-professional consensus."
The committee used the following rationale as a basis for the position statement:
Definition of chiropractic: The definition of chiropractic, established by the CCE and largely adopted by all CCE-accredited chiropractic colleges, adds support to the position that the DC qualifies as a primary care provider. "The application of science in chiropractic concerns itself with the relationship between structure, primarily the spine, and function, primarily coordinated by the nervous system, of the human body as that relationship may affect the restoration and preservation of health. Further, this application of science in chiropractic focuses on the inherent ability of the body to heal without the use of drugs or surgery. The purpose of chiropractic professional education is to provide the doctoral candidate with a core of knowledge in the basic and clinical sciences and related health subjects sufficient for the doctor of chiropractic to perform the professional obligations of a primary care clinician. As a gatekeeper for direct access to the health delivery system, the doctor of chiropractic's responsibilities as a primary care clinician include wellness promotion, health assessment, diagnosis, and the chiropractic management of the patient's health care needs. When indicated, the doctor of chiropractic consults with, co-manages, or refers to other health care providers. The accreditation criteria indicate the minimum education expected to be received in the accredited programs and institutions that train students as primary health care providers."1
Primary care definition: The literature review produced several detailed definitions of primary care and/or primary care provider; however, no accurate descriptions of neuromusculoskeletal care or musculoskeletal care were found.
These definitions have undergone periodic refinement over the last 30+ years as a result of ongoing study by government agencies, academic and allopathic groups, insurance associations, philanthropic interests, private industry and individuals.2,5-10 Health care consumers have contributed little, and the chiropractic profession has not been invited to participate in any group study involving formulation of the definitions. Thus, without input from the health care consumer or active involvement of the chiropractic profession, virtually all the definitions appear limited to the allopathic model of health care.
Throughout the development of these definitions, several terms and phrases were cited that some might think would disqualify DCs from providing primary care. The following were of particular interest:
"Medicine": Webster's New World Dictionary of the American Language defines medicine as "...the science and art of diagnosing, treating, curing, and preventing disease, relieving pain, and improving and preserving health..."4 While some DCs argue that chiropractic does not seek to diagnose, treat, cure, prevent, or is even interested in addressing disease, the mission statements and curricula of most CCE-accredited chiropractic colleges clearly demonstrate that DCs are being trained to address the diagnosis, treatment, cure and prevention of disease and other conditions adversely affecting human health. It appears obvious that, by definition and by observation of the present-day health care environment, the term medicine is not exclusive to the allopathic discipline, but may apply to all branches of the healing arts. Since this term was used in the earliest definition of primary care,7 it has been suggested that the phrase "health care" replace "medicine." The most contemporary and comprehensive definition from the Institute of Medicine (IOM) does not make the distinction of practicing "medicine."2 "Comprehensiveness": Barbara Starfield, MD, MPH, in the Journal of Medical Education, examines this term at length. She points out that the provider need not render a broad range of services, but rather recognize problems presented by the patient, give explicit notification of the services provided in the facility, and arrange for appropriate patient care.9
"Widest possible range of common conditions": According to the IOM, this phrase connotes the provider act as a patient advocate. A full range of patient concerns are addressed and managed in the primary care practice, the scope of which includes acute care, chronic care, early detection and prevention, and coordination of referrals. To manage the patient throughout the scope implies that the clinician would "...direct or control the use of..." health care services.2
All of the aforementioned qualities are typical of chiropractic care and, in the context of chiropractic practice, none of the terms and phrases disqualifies the DC from providing primary care.
Education - Upon review of the mission statements of all CCE-accredited chiropractic colleges, the committee found that these institutions strive to train students in all aspects of primary care. As mentioned earlier, college curricula include professional training in primary care.
Licensure - The chiropractic scope of practice found in Sec. 20-28 of the General Statutes of Connecticut also adds credence to the concept of the DC providing primary care. According to this section, whole body examination, analysis, diagnosis and treatment are included within the parameters of chiropractic practice in the state of Connecticut.3
Intra professional consensus - The consensus among chiropractic college presidents, chiropractic organization leaders and Connecticut-licensed doctors of chiropractic was that the DC is qualified to provide primary care. Most considered any definition of primary care invalid if the chiropractic profession was not involved in its formulation. The overwhelming majority felt that patients should retain the ultimate choice in determining who should be their primary care providers.
Additional consideration was given to the concepts:
Development of chiropractic: Historically the chiropractic profession, by virtue of its separate and distinct attitude and its naturally based paradigm of health care, evolved independently from allopathic medicine, while simultaneously not functioning as mutually exclusive. As such, it has made every effort to establish itself as a first-contact health care discipline capable of addressing the total health care needs of the patient, recognizing that providers from all disciplines serve important positions on the health care team. Freedom of choice: In a free society, the individual must retain the right to make informed decisions. This is especially true when making personal health care choices. With a variety of disciplines from which to choose for primary care needs, in doing so, one is exercising the individual liberty of self-determination, the very essence of the principles upon which this country was built!
The committee also offered several suggestions for using the position statement on primary care to help fulfill the CCA's mission and objectives in the areas of public, government, insurance, industrial/commercial and inter professional relations.
At the October 1999 meeting of the CCA board of directors, the ad hoc committee presented its findings. The board unanimously adopted the position statement on primary care as presented.
This position statement reaffirms that chiropractic in Connecticut should be considered an independent primary health care profession focusing on comprehensive care of patients as they relate to their environment, rather than simply treatment of symptom complexes. It asserts that the individual DC, though a practitioner of a naturally based discipline, is willing to accept responsibility for coordination of patient care by integrating, through appropriate referral, whatever treatment is deemed necessary for the benefit of the patient. For the CCA and its members, the position statement signals unity of purpose, establishes an identity in the health care industry, and marks the direction of progress for the profession.
References
- Council on Chiropractic Education, Commission on Accreditation. Standards for Chiropractic Programs and Institutions, January 1999; 5.
- Donaldson MS, Yordy KD, Lolir KN, Vanselow NA. Primary Care: America's Health in a New Era. Institute of Medicine, Washington, DC: National Academy Press, 1996: 31.
- General Statutes of Connecticut. State of Connecticut, January 1999; 7: Title 20:34-40.
- Guralnik D B. Webster's New World Dictionary of the American Language. The World Publishing Company, Second College Edition, New York and Cleveland, 1970.
- Hibbard, RN, Nutting PA. Research in primary care: a national priority. In: Grady ML. Conference Proceedings Primary Care Research: Theory and Methods. U.S. Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research, September 1991, 1-4.
- Kranz, KC. An overview of primary care concepts. Topics Clin Chiro 1995;2(1):55-65.
- Millis J S (chairman). The graduate education of physicians. Report of the Citizens Commission on Graduate Medical Education. Chicago: American Medical Association, 1966.
- NCQA, Book III HEDIS 3.0/1998. Measurement Specifications. National Committee for Quality Assurance, Washington, D.C., 1998: 87.
- Starfield B. Measuring the attainment of primary care. J Med Educ 1979;54:361-369.
- World Health Organization. Primary health care. Alma Ata 1978. Geneva, World Health Organization.
