The DCM: Chiropractic Primary Care, Part II

The announcement of Western States Chiropractic College's plans to implement a new degree program leading to a Doctor of Chiropractic Medicine (DCM) in the June 3, 1994 issue of Dynamic Chiropractic, has stimulated a flood of telephone calls and letters about the program. Although the predictable objections were raised, the great majority of the letters and calls received are positive and reflect interest in a chiropractic option for primary-care delivery. We would like to take this opportunity to continue the dialogue, address some of the questions raised, and offer a brief explanation of issues pertinent to the DCM.

Predictably, the most frequent objection raised to the DCM program is the inclusion of pharmaceutical privileges. Opponents contend that a chiropractor with prescription writing privileges is no longer a chiropractor, but rather an osteopathic physician. The logic of this statement is at best elusive, especially in light of the fact that chiropractic has no intention of surrendering any of its core values. The decision to include one aspect of allopathic medicine -- pharmaceutical privileges -- deserves explanation. The aim of the DCM program is to create a new type of health-care provider: a chiropractor competent to serve not only in a first contact, portal-of-entry role, but also as a primary-care physician with expanded skills in the diagnosis and treatment of common health problems from a conservative perspective.¹

Although most pronouncements emanating from the profession's leadership define chiropractic as drugless, numerous states claim over-the-counter drugs (OTCs), botanicals, and homeopathic remedies within their practice acts. A recent survey establishes that 77.1 percent of U.S. states and Canadian provinces include homeopathic preparations within their scopes of practice; 83 percent include botanical therapy; and 58 percent include over-the-counter drugs.² Many chiropractors use surrogate prescription writers when faced with a patient needing analgesics or anti-inflammatories. Many chiropractors and their families use, or at some point in their lives, have used medication. To claim we are a drugless profession is clearly misleading. Rather, we should take a position positing chiropractic as the profession with a conservative stance: "drugs prescribed only when conservatively appropriate and only when clearly in the best interest of the patient."

More to the point, the DCM program is not about drugs. They are a minor, although when indicated a necessary, component of primary-care delivery. Unless one honestly believes that medication in any form has absolutely no place in the health care delivery system, one must accept that the DCM graduate has a role in delivering primary care. The DCM will provide the legal authority needed for a chiropractor to offer primary care and to function on the same basis as other primary-care providers. Without the legal authority to prescribe, we do not have the authority to discontinue or modify drug use. In other words, the ability to prescribe allows prescription, proscription, or alteration of a patient's medication -- measures essential for total clinical authority -- and most importantly, allows the chiropractic physician to decide whatever treatment is truly in the best interest of the patient.

Adjustment of the spine is the core of chiropractic; similarly, it will be the core of chiropractic medicine. Although some osteopathic physicians include osteopathic manipulation within their treatment protocols, it is not routinely their first mode of intervention. For the DCM, adjustment will be the central component of health-care delivery. As a primary-care provider however, the DCM will have additional treatment modalities available, increasing cost effectiveness by eliminating costly referrals.

Another concern is that the chiropractor who enters the DCM program would not be able to deliver primary care after one additional year of training, and even if competency was attained, the power structure of the medical profession would never allow a chiropractor to serve as a primary-care provider. In regard to the first concern, it is undeniable that the current DC has -- and the DCM will have to an even greater extent -- an education comparable to medical school graduates and exceeding that of nurse practitioners and physician assistants currently providing primary care, some autonomously. What the current DC graduate lacks is broad-scope clinical training. Competency in basic primary-care provision, including minor surgery, can be achieved in one year of intensive training in a primary-care setting and minimum classroom education. Today's chiropractic college graduate is a competent diagnostician of primary-care conditions, but lacks the legal authority and the opportunity to offer definitive treatment of these conditions.

In regard to the concern that the medical profession will never allow chiropractors to practice primary care, we would be unrealistic to think no opposition will arise. The reality is that graduate of medical schools are consistently opting for specialty training rather than primary-care delivery, creating an increasingly expanding void that must be filled. George Lundberg in a 1993 JAMA article notes: "the percentage of physicians graduating form U.S. medical schools who are declaring generalist fields [general practitioners, family physicians, general internists, general pediatricians, and some obstetrician-gynecologist and emergency medicine subspecialists] has drastically declined during the last decade, from 36 percent of the graduating class in 1982 to only 14 percent in 1992."³ In the same article, Dr. Lundberg suggests: "simply allow primary care to be provided by those physicians currently in the field. ... Let the remainder of care be given by nurse practitioners, physician's assistants, homeopath, naprapaths, chiropractors, and other non-allopathic physicians providers."⁴ The government's aggressive efforts over the past 20 years to encourage graduates of medical schools to go into primary care as well as attempts to force medical schools to produce more primary-care physicians have been unsuccessful.⁵ According to the graduation questionnaire of the Association of American Medical Colleges (AAMC), interest in primary care has fallen from 36 percent of graduates in 1982 to 22.5 percent in 1989.^6,7 In 1989 only 11.7 percent of all medical school graduates planned careers in family practice, 6 percent in general internal medicine, and 4.8 percent in general pediatrics.⁸

Two new professions have been created within the past two or three decades to help meet the need for primary care providers -- the physician assistant, who care for patients under the license of an MD or DO and the nurse practitioner, who in many states has prescription writing and hospital admitting authority. Accreditation of educational programs, state practice act authority, liability coverage and third-party reimbursement have been achieved by these two primary-health care professions by effective and cohesive political action over the past 20 years. Adding the DCM to the accepted list of primary-care providers will depend on assuring that the accreditation and legislative processes are not subjected to the influence of a dogmatic belief system. The DCM curriculum, which builds on the competencies in basic science, clinical diagnosis, and patient management gained in four years of rigorous study in the DC program, is a rational approach to the creation of a conservative primary-care provider.

Finally, we must address the term primary care. Some have argued that the chiropractor is currently a primary-care provider, making the DCM redundant and unnecessary. Most claim that the chiropractor has evolved from a generalist role in the health-care delivery system to being strictly a musculoskeletal specialist. We would argue that the profession can easily encompass two types of chiropractors: a musculoskeletal specialist and a generalist who delivers musculoskeletal and primary care.

Whether citing Barbara Starfield's Primary Care: Concept, Evaluation, and Policy, a publication of the PEW foundation, definitions offered in state statutes, or lists of the most commonly presented and treated conditions reported by the U.S. Department of Health and Human Services, primary care focuses not only on diagnosis but also on the ability to provide definitive treatment, with referral only in complicated cases. We are currently not reimbursed by third-party payers for treating most primary-care conditions, even though we can argue our belief in chiropractic's effectiveness for treating these conditions. The DCM program is an attempt to offer the chiropractic profession a component in which conservative primary care can legitimately be offered as an alternative to that currently offered by allopathic medicine, and with desirable cost-effectiveness and risk-benefit ratios.

The DCM program is not an attempt to alter what exists currently within the profession, but rather a move to add a new dimension. We believe the majority of graduates from Western States Chiropractic College will continue to hold only the degree DC and will offer their patients traditional and effective chiropractic care. Graduates holding the DCM degree, however, will be able to deliver not only traditional chiropractic care but also primary care. Both types of graduates will understand the physician's role in assisting the body to regain and maintain its natural health state. Their inclusion in chiropractic can only strengthen the profession, enhance our credibility, and provide more comprehensive quality health care to chiropractic patients.

References

1. Western States Chiropractic College White Paper (draft), March, 1994.

    

2. L Lamm, E Wegner, D Collord. Chiropractic scope of practice: What the law allows: Update 1993. JMPT (forthcoming).

    

3. G Lundberg, R Lamm. Solving our primary care crisis by retaining specialist to gain specific primary care competencies. Journal of the American Medical Association, 270(3):380, July, 21, 1993.

    

4. Ibid.

    

5. R Rosenblatt, M Whitcomb, T Cullen, D Lishner, G Hart. The effect of federal grants on medical schools' production of primary care physicians. American Journal of Public Health, 83(3):322-328, March 1993.

    

6. 1982 Graduation Questionnaire. Washington D.C., Association of American Medical Colleges, 1982.

    

7. 1989 Graduation Questionnaire. Washington D.C., Association of American Medical Colleges, 1989.

    

8. J Colwill. Where have all the primary care applicants gone? New England Journal of Medicine, 326(6):387-393, Feb. 6, 1992.