The challenge to chiropractors caring for childrens' spinal problems continues. In a recent issue of Woman's Day, a revival of the old cases portrayed in the Wall Street Journal and on the "20/20" current affairs program was presented. For those chiropractic doctors who care for a lot of childrens' spines, this may seem to be an affront to their good work and in direct contrast to the enthusiasm of the childrens' parents. As one eminent medical doctor stated, "You know that you're making an impact when they start criticizing you."
Despite what is being published in the news media, chiropractic care for children is receiving wider acceptance, not only from parents but increasingly from medical pediatricians. Chiropractors throughout the US are reporting an increase in referrals from pediatricians. The reason for this increasing acceptance at what might be called the "grassroots level" appears to be the result of greater communication and understanding by medical doctors of the anatomical and physiological rationale used to explain the effects of the spinal adjustment.
A classic example of this increasing cooperation is that of an East coast chiropractor who sent copies of a journal article explaining the chiropractic hypothesis for the treatment of otitis media to all the pediatricians in his area. Several months later he reported that six of the pediatricians had taken him to lunch and that he was starting to receive referrals of children with chronic earaches, particularly where tympanostomy tube insertion was being considered. The chiropractor was naturally very proud of his efforts and reported that not one of the children he had treated had needed to have the tubes inserted.
Several months ago, I was contacted by a chiropractor who was having difficulty with being paid for treatment of a child who was insured with a particular insurance company. After suggesting some references which the chiropractor might use to support his claim, I subsequently received a phone call from the medical director of the insurance company. The medical director had several concerns, firstly about a chiropractor's knowledge and ability to accurately identify a child's problems and secondly, about the safety of chiropractic treatment for children. Not far into the discussion, I realized that the medical director had little understanding of chiropractic education and training, and even less about our chiropractic license requirements and scope of practice. Now at this point, let me say that I consider this doctor's concerns to be quite appropriate for someone who has little knowledge of what we do, and a major responsibility to his organization for appropriate standards of care and management of insured patients. After discussing the situation for 15 to 20 minutes, I suggested to the medical director that I should put some information into the mail for his consideration.
The following is the letter I forwarded.
Dear Doctor,
The opportunity to speak with you recently was greatly appreciated. I share your concerns that patient safety should be of utmost importance in the clinical setting. In addressing your concern for patient safety, when a child is under the care of a chiropractor, I will comment on three aspects: those of training, scope of practice, and safety.
Firstly, to address one of your concerns, chiropractors do receive extensive training in the recognition of pathology. While it is true that they may not have the extensive postgraduate skills of a specialist pediatrician, their training is designed to give them skills somewhat equivalent to those of a general medical practitioner. Training in the basic degree program includes anatomy (648 hrs.), physiology (363 hrs.), chemistry/physics (360 hrs.), pathology (552 hrs.), physical diagnosis (480 hrs.) and a further 360 hours in the specialties of EENT, obstetrics, dermatology, geriatrics, pediatrics, and clinical psychology.
By scope of practice, the chiropractor's license carries with it the responsibility of a portal of entry provider. In keeping with this responsibility, chiropractic curricula are designed such that a major part of the chiropractor's training is an emphasis on the development of skills to identify those conditions which can be treated by the chiropractor alone, from those conditions which should be managed in conjunction with another health care specialist and importantly, those conditions which need immediate referral. When evaluating patients, chiropractors therefore are trained to identify and diagnose conditions which clearly are beyond their scope of practice to treat. Chiropractic licensing authorities take a dim view of any chiropractor who fails to uphold the primary care standards dictated by the license. In this regard, failure to appropriately diagnose a patient's condition subjects the doctor to state licensing board action, possible license suspension and malpractice charges.
In regard to the issue of safety, chiropractors have been treating children for many years. It has only been in the last decade however that a concerted effort has been made to ensure that the chiropractor's pediatric knowledge-base is equivalent to that of the medical general practitioner. Some chiropractors place great emphasis on the importance of spinal care for children in their practice while others, possibly the majority, treat small numbers of children, principally at the parent's request. The fact that in the past decade, only a handful of claims have been made against chiropractors resulting from the treatment of pediatric patients, suggests that chiropractors' standard of training is appropriate and safe.
As discussed, I have included with this letter several journal articles which address the issue of the chiropractor's involvement in the care and management of the pediatric patient. Also included, is a copy of a typical syllabus for a pediatrics class as taught in chiropractic programs throughout the US. After graduation, chiropractors may undertake additional training in pediatrics by attending a diplomate program in pediatrics which consists of an additional 300 hours of training.
Although the chiropractic profession has yet to develop strict guidelines in the form of standards of care for the treatment of children, management protocols and treatment schedules, which are generally quite conservative, are taught at both undergraduate and postgraduate levels. I ask that your organization consider offering primary care provider and/or co-management privileges to chiropractors for the treatment of pediatric patients.
I look forward to your reply.
Some weeks later, I received a call from the medical director advising that those privileges had been granted. As a footnote to the conversation, the doctor stated that two advisory board members who were rather conservative pediatricians, after having read this information, had decided to send some of their patients to chiropractors, especially those with chronic ear infections.
In my travels, most of the pediatricians that I have met have the same goals that I do: to get children well and to keep them that way. So we both have a common therapeutic goal, and a common concern for patient well-being and safety, our only differences being in our methods of treatment. I do what I do because it is what I was taught in chiropractic school and believe to be the best approach; likewise the pediatrician does what he knows best, that which he was taught in medical school.
From small beginnings with honest and open communication, chiropractors can play an important role in bringing better quality health care to children. It all can start at a local level.
Peter Fysh, DC
San Jose, California
Editor's Note: Dr. Fysh conducts pediatric seminars. He may be contacted at 1-800-999-7337.
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