Rather than approaching a response in a point-counterpoint fashion, I would like to address a series of perspectives in response to the misconceptions expressed in the latest article on the DCM issue ("The DCM: Chiropractic Primary Care, Round II," by William Dallas, DC, July 29). The assertions I make are as follows:
- The chiropractic profession is a drugless profession.
- The doctor of chiropractic can be a primary care provider.
- The movement of the chiropractic practitioner into drug therapy will alter the core practices and principles of the profession.
The concept that the chiropractic profession is an allopathic discipline as indicated in the July 29 article is distasteful and offensive to the great majority of chiropractors in the world. Dr. Dallas states: "To claim we are a drugless profession is clearly misleading." The misleading aspect of the discussion is the revisionist history involved in the argument as well as the distortion of the issues upon which the discussion is based.
Not a single state, province or nation requires that a DC be educated in the indications, applications and consequences of drug therapy. Not a single licensing board or registration body in the world examines candidates for chiropractic licensure in the area of drug therapy.1 The National Board of Chiropractic Examiners (NBCE) does not include testing material on drug therapy as a mode of practice.2 The Council on Chiropractic Education (CCE) mandates that the educational offerings of accredited institutions be "drugless."3
The evidence to support the "fact" that it is misleading to refer to the chiropractic profession as drugless lies in the supposed ability of chiropractors in three-quarters of the states to tell a patient to use Maalox or Preparation H, an ability and authority that 100 percent of the population possesses without any training whatsoever; an occurrence that neighbors offer each other, beauticians offer clients, and strangers hawk to us constantly in the media. The argument that chiropractic is not drugless is sealed with the astounding statement: "Many chiropractors and their families use or at some point in their lives used medication." Chiropractic is not a drugless profession because anesthesia and analgesics were used in the course of surgeries to correct my daughter's congenital anomalies! Or, chiropractic can not be considered a drugless profession because I receive novocaine at the dentist.
Revisionist history is the order of the day when the current (and factual) historical representatives no longer serve the needs of the reviser. To say chiropractic is a drug-based profession is in conflict with every aspect and component of professional life as a chiropractor.
The DCM concept is based on the assertion that the chiropractor is not a primary care provider, and further, the only way to survive under health care reform is to be a primary care physician. A distinction needs to be drawn between a primary care provider and a primary care physician. Further, it needs to be understood that while there may be significant documentation and agreement in health care as to what constitutes a primary care physician, there is no such agreement as to what constitutes a primary care provider.
It has been asserted by Dr. Dallas: "... 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..." While I am very proud of the depth and breadth of chiropractic education, such a statement is wanting for context. It must be remembered that the chiropractic graduate moves directly into a practice setting, while the medical school graduate moves into a residence setting which includes three years of graduate medical education. While medical school graduates and chiropractic college graduates may have education comparable in depth, they are very different in content and clinical emphasis. In particular, one must consider the impact of residency training of an allopathic physician.
The definition of primary care cited in Dr. Dallas' article, "primary care focuses not only on diagnosis buy also on the ability to provide definitive treatment with referral only in complicated cases," is not an accepted definition of primary care, rather it is the definition of "family practice," which represents an area of medical specialty. The extent to the utilization of pharmaceuticals is contraindicated within Dr. Dallas' article. At one point it states: "... the DCM program is not about drugs. They are a minor ... component." Later the true desires behind the curriculum are revealed: "... the ability to prescribe allows prescription, proscription or alteration of a patient's medication -- measures essential for total clinical authority." (Emphasis added) How can "total clinical authority" (i.e., obstetrics, surgery, emergency medicine, etc.) be viewed as an expansion of the role of the chiropractor to be a "generalist who delivers musculoskeletal and primary care?" The reality is the DCM is attempting to create an allopathic physician with an appreciation for chiropractic care.
The consideration that drug therapy is "a necessary component of primary care delivery" is countered within the article itself. The quote from the JAMA cited is revealing: "...but the remainder of (primary) care be given by ... chiropractors and other nonallopathic physicians providers."4 In this statement it is clear that the intent of the article is for chiropractors to provide primary care on a nonallopathic basis. This position was set forth almost one year before the announcement of the DCM concept.5
The final area I would like to explore relates to the paradigm alteration that a movement into pharmaceuticals represents. Pharmaceuticals are an excursion into the field of medicine. This is not a variation on a theme that could be construed to be a "scope matter." In this discussion the products, procedures, and rationale being advocated are inconsistent with a chiropractic approach to healing. The expansionist argument that physical therapy for example was supportive of an adjustment, while rejected by many, could at least be made. The argument has now gone beyond any issue of being supportive or complementary to chiropractic care. It is now a discussion of medicine, be it heavily oriented to physical procedures or not, it is no long a chiropractic discussion. A careful reading of "The DCM: Chiropractic Primary Care, Round II," reveals some very alarming perspectives. Already addressed is the assertion that the chiropractic profession is in fact a drug-based discipline. This is followed by the non sequitur that to be a primary provider, drug therapy is an essential requirement. In one statement it is professed that, "Adjustment of the spine is the core of chiropractic," and it goes on to read: "Although some osteopathic physicians include osteopathic manipulation within their treatment protocols it is not routinely their first mode of intervention." Spinal care was a significant portion of osteopathy at one time, and was taught at all osteopathic institutions. But today, since the advent of "measures essential for total clinical authority," osteopathy has relinquished any appreciation for the procedure that was once the core of osteopathic practice. Why do we assume we will be any different? Why do we assume that the seductive element of moving square into the realm of medicine would impact chiropractic less than it did osteopathy?
Consider the following as you contemplate the ability to travel both sides of the street: "The osteopathic profession continues to struggle with its identity problem. At one time its niche was manual medicine, but the profession was uncomfortable with it and that aspect has since been shouldered aside by chiropractic. Later osteopathy would point to its commitment to primary care and say that it was different from allopathic medicine...6 (emphasis added). Perhaps you might say we have a different philosophical perspective, a different tradition, a different history, but what our DCM colleagues seek is "accreditation and legislative processes not subjected to the influence of a dogmatic belief system." This statement assumes that currently accreditation and legislative processes are in fact subjected to a "dogmatic belief system." The comment also implies that the "accepted list of primary providers" are not subject to a "dogmatic belief system." If one considers David Eddy, MD, of Duke University to be anywhere near correct in stating, "only about 15 percent of medical interventions are supported by solid scientific evidence," then the great majority of medicine is based on belief.7
Many among us would agree that in the following statement chiropractic could easily be substituted for osteopathy:
"During the past 100 years prosperity of DOs meant doing well in practice, increasing their numbers and gaining acceptance from the American public."8
Regrettably some within our profession feel we must replicate the next step that osteopathy took:
"ironically the only way osteopathy could gain acceptance and credibility was by becoming more like allopathic medicine."9
We need not succumb to the irony of osteopathy's path. To do so will be destructive to our future and to our potential contribution to human kind. As you consider the oxymoron of chiropractic medicine consider the thoughts of Gevitz:
"...movements such as osteopathy, homeopathy, and eclecticism generally have a natural life cycle. They are conceived by a crisis in medical care; their youth is marked by broadening of their ideas; and their decline occurs when whatever distinctive notions they have as to patient management are allowed to wither. At this point, no longer having a compelling reason for existence, they die."10 (emphasis added)
Health care in the United States is in great turmoil. As the public demands clinical accountability and financial soundness of health care procedures, we will see the strength of chiropractic grow and allure of medicine decline. To make a change in the chiropractic profession that will be irreversible, out of fear of a system that may never come to fruition, is not progress, vision or leadership. The order of the day is to stay the course, tell our story, advocate our care, motivate out people and inspire our patients. Our brightest day is about to dawn!
- Official Directory Chiropractic Licensure and Practice Statistics, 1994-1995 edition. Greeley, Colorado. Federation of Chiropractic Licensing Boards, 1994.
- National Board of Chiropractic Examiners Candidates' Guide for Part I, Part II, and the Elective Physiotherapy Examinations, 5th edition. Greeley, Colorado. National Board of Chiropractic Examiners, 1989.
- Standards for Chiropractic Programs and Institutions. West Des Moines, Iowa. Council on Chiropractic Education, 1994.
- Lundberg GD, Lamin RD. Solving our primary care crisis by retraining specialists to gain specific primary care competencies (editorial). JAMA, 270:380-381, 1993.
- WSCC's doctor of chiropractic medicine program: training chiropractors to provide primary care. Dynamic Chiropractic, 12(12):1, 32, 1994.
- Meyer CT, Price A. Crisis in osteopathic medicine. Acad Med, 67(12):810-816, 1992.
- Smith R. Where is the wisdom...? The poverty of medical evidence (editorial). BMJ, 303:798-799, 1991.
- Meyer, CT.
- Meyer, CT.
- Gevitz N. The DOs: Osteopathic Medicine in America. Baltimore, Maryland. John Hopkins University Press, 1982.
