Editor's note: Below is Dr. Cox's unexpurgated letter of Aug. 13, 1996 to Dynamic Chiropractic, responding to contentions from the German Chiropractor's Association that he is teaching German MDs to adjust. His letter is then followed by a letter of response from Dr. Ingrid White, vice president of the German Chiropractors' Association.
Dr. Cox's Response
The July 29, 1996 article stating the German Chiropractors' Association claims that I am teaching MDs to adjust for money is a serious charge and error. I have never invited an MD to my clinic or lecture to be taught how to adjust.
I have never lectured in Germany and have never asked or authorized someone else to teach my technique in Germany. I presented two lectures in Europe, both sponsored by chiropractic groups: in the Netherlands by the Netherlands Chiropractic Association to about 150 chiropractors; in Schaffhausen, Switzerland, to 60 to 70 chiropractors, by National College of Chiropractic. At these two lectures, a total of nine other-than-chiropractic practitioners attended, according to Dr. Ingrid White, vice president of the German Chiropractors' Association: three in the Netherlands and six (three of whom Dr. White said were MDs) in Switzerland. I had nothing to do with their presence and did not know or screen the attendees by professional degree. In Switzerland, I did meet a doctor from Italy who held the dual degrees of MD and DC and commonly worked with orthopedists as well as a neurosurgeon who attended the lecture.
Ten years ago, at the invitation of the Netherlands Chiropractic Association, I gave a lecture on the mechanism and diagnosis of low back pain that included technic demonstration, as I was asked to do. The Netherlands Chiropractic Association registered the attendees. Apparently, according to Dr. White, three MDs, perhaps from Germany attended. As far as the money goes, I was paid travel expenses and an honorarium by the Netherlands Chiropractic Association. To insinuate that I taught MDs in Germany for money is not true. I had nothing to do with who attended and the MDs did not pay me, the Netherlands Chiropractic Association did.
Two years ago, with the sponsorship of the National College of Chiropractic and many requests by European chiropractors, I gave a similar lecture in Switzerland to the one I gave for the Netherlands Association and have given for over 30 years now on the mechanism, diagnosis and demonstration of technic for the care of low back pain. According to Dr. White, three MDs attended in a total attendance of about 60 to 70 doctors of chiropractic; one or more were from Germany. I did not register attendees, and again I was paid travel expenses and an honorarium which was in turn given in total to National College of Chiropractic for research study as were all of my honoraria in 1994. Therefore, I was not only not in control of the attendees, but donated my pay for the lecture to research. I had nothing to do with screening their attendees, and they did not pay me.
The controversy in this matter stems from a German MD attending these two lectures. In Germany, I understand there is no licensing act for chiropractors and many types of practitioners, and I understand even laymen practice manipulation. Dr. White claims that the Zenith table dealer who furnished the instruments for my lecture registered the MDs or other non-chiropractors. The lecture was held in Switzerland because the Zenith dealer is there, and he helped procure the hospital amphitheater in Schaffhausen, Switzerland as the venue, and assisted National College of Chiropractic in registering the attendees, about 60 to 70 chiropractors. I am very sensitive to protecting chiropractic ethics. A solution to this dilemma of lecturing in countries where chiropractic is not licensed, for me, will be that whenever speaking in such a foreign country, the lecture will be co-sponsored by the chiropractic organization or college of chiropractic of that country with the National College of Chiropractic, and they would select or reject attendees. I urge all lecturers to do the same. I feel licensing chiropractic in foreign countries is vital, however, to insure standards of practice.
I have never taught an MD in my clinic or lecture in the United States to adjust the spine. I have demonstrated my technic before MDs at conferences such as the American Back Society, Challenge of the Lumbar Spine, and other conventions. These demonstrations occur in breakout sessions in which lecturers show the treatment they lectured on. That means surgeons show surgical techniques, physical therapists show their therapies, and chiropractors show our procedures. All do so without hesitation and in the spirit of demonstration, not of teaching someone to be proficient in the procedure shown. Demonstrating is different from teaching.
Demonstration versus Teaching -- Teaching chiropractic technic is the job of our colleges. It is a five year study. This education is dominant to be able to capably perform spinal adjustments. My demonstration of technic is that -- it shows how the technic is applied. Teaching it requires more intense study; an optional 36 hour certification course in Cox Distraction Adjusting followed by written and practical testing is offered by National College of Chiropractic for interested chiropractors to gain proficiency. This is the definitive teaching course for my distraction adjusting procedures. No MD has been so certified.
However, medical doctors do lecture and teach chiropractors regularly. It is common to attend chiropractic seminars with medical doctors on the program. Knowledge becomes wisdom through study and application. Sharing knowledge is a two way street. Our profession no longer lives in the singular role in the healing arts. We are part of the entire healing arts profession and are only recognized as such due to long years of educational, judicial and legislative battles.
I know of no MD who has attended my lecture and gone on to practice manipulation. Fear of MDs stealing what we are skilled to perform seems to me to reflect a lack of confidence in our public and professional acceptance and ability. Research and study will lead to greater public and professional acceptance and understanding of our healing contribution.
Understanding promotes referral -- Isolationism of chiropractic is not progressive. Referral from other healing arts to us demands understanding. The great benefits of the chiropractic adjustment are much better known and respected today. So often I hear DCs say MDs do not refer patients back to them, or refer at all; that is because they do not understand what we do. In the managed care environment, we must function in the health care delivery system -- that demands interdisciplinary study and understanding and referral. Interdisciplinary study fosters this cooperation, resulting in superb patient care.
Another way of looking at interdisciplinary study is this -- I have seen surgical procedures performed, but I do not feel trained to perform them. MDs are not proficient by seeing a demonstration of chiropractic technic to perform it. Chiropractic adjusting is foreign to the philosophy and practice of MDs.
Further, in the U.S., the largest group of performers of spinal manipulation other than chiropractors is physical therapists, not medical doctors.
Now and in the future, cooperation in the US between MDs and DCs must continue and flourish. Collaborative research studies conducted at chiropractic and medical colleges into chiropractic adjustment procedures will continue like the three federally funded ones currently underway at National College of Chiropractic with Loyola Medical School and LACC and Western States with medical schools. The National College of Chiropractic Research Department received a federal grant in October, 1994 to research the biomechanics of distraction manipulation. The only way this grant proposal would even be considered was if a medical school and its medical doctor researchers were to be involved in its research. This stipulation was the same for the other two grants received by chiropractic colleges named above. Our profession needs to expand its awareness of this and not maintain isolationism of our great healing art form. It is becoming increasingly common to see chiropractors in interdisciplinary study and practice with other health providers.
In summary, I did not invite German MDs or non-chiropractors to attend and learn how to adjust. They attended lectures sponsored by organizations who had contracted me to speak. I had no control over the attendees and in the 1994 lecture received no honorarium. I demonstrated my technic in the lectures as well as presented didactics of the mechanism and diagnosis of low back pain.
The solution to this problem of lecturing in countries where chiropractic is not licensed, to me, is that the lecture be co-sponsored by the chiropractic organization or college of chiropractic of that country with National College of Chiropractic. That organization would screen and determine who could attend and be responsible for the audience composition. I would be willing to come to Germany for Dr. White and the German Chiropractic Association to implement this concept of co-sponsorship to the world.
Finally, my response to the newly posed question, "Should We Teach MDs Adjusting Techniques?" is "No." However, we should inform, educate and encourage MDs to understand what we do -- including demonstration -- so that we may work more comfortably and confidently together, knowing and understanding the research and science behind what we each do.
Thank you for the opportunity to factually show that I did not invite MDs to learn to manipulate. The damaging headline of Dynamic Chiropractic mislead the profession to believe that I am actually teaching MDs to adjust and that is not true.
Sincerely,
James M. Cox, DC, DACBR
Dr. White's Response Dr. Cox makes some strong statements of intent and also of opinion which coincide with our requests of (1) no more teaching non-chiropractors in a workshop-type technique courses and (2) screening of attendees by national chiropractic organizations or chiropractic colleges. (The Netherlands Chiropractors' Association [NCA] started asking for proof of having graduated from a chiropractic college after the incident we had previously mentioned.) We (the GCA) are quite happy with his statements.
In his last letter there were a few factual errors which need to be corrected, but will not make a difference in the "outcome" of this issue. The NCA lecture was in April 1989, not 10 years. The NCA had been told the three Germans in question were chiropractors. At that time, Dr. Blaauw (then NCA president) told me they had been registered as such by the Swiss representative of Zenith/Cox tables. The six non-chiropractors in Switzerland two years ago were three MDs, one health practitioner (lay medical practitioner) and two physiotherapists. One of the physiotherapists was Italian, and the other five non-chiropractors were German. According to Dr. Kemski (I was not there in person), she believes there were non-chiropractors in attendance, but she could only ascertain the names and professions of these six.
We are also of the opinion that the chiropractic profession cannot live in "splendid isolation." However, our interaction cannot be by teaching non-chiropractors chiropractic techniques. Apparently that is not the only GCA opinion, but also the European Chiropractic Union (ECU) opinion. In its policy decision of 1984, updated in 1994, the ECU states:
4.1 "The Board of Education proposes that each National Association member includes the ability to discipline individual members for teaching chiropractic to non-chiropractors within its Code of Ethics."
We have no quarrel with multiple degree holders in chiropractic technique seminars, as long as one such degree is the DC or B.Sc.(AECC).
Dr. Cox speaks about collaborative studies at chiropractic and medical colleges. We are in favor of interdisciplinary study, research, and practice. But here it has been the case that MDs have gladly learned from chiropractors while DCs are not welcomed by the organizations of manual medicine.
Again, we are happy to see that Dr. Cox's statements have changed from his previous letters to this last one of August 13, 1996.
Ingrid E. White, DC
German Chiropractors' Association
