(We) "... failed to utilize the available evidence, and missed an excellent opportunity."
Dear Editor:
A recent article in Dynamic Chiropractic on otitis media really caught my attention, especially in light of its historical context. ("DC" July 15, Interesting Quotes, "The Limited Benefits of Antibiotics for Otitis Media" p. 12.) According to the article, Research Activities, a publication of the Agency for Health Care Policy and Research, describes an analysis of 27 studies conducted between 1966 and 1993 on the effectiveness of treating otitis media in children with antibiotics. Only 1 in 9 with acute otitis media and 1 in 6 with otitis media with effusion benefit from antibiotic therapy, and the improvement only lasts about one month. In light of the potential adverse side effects and the $3.5 billion dollar cost of treating pediatric otitis media in the United States with antibiotics, the APHA now recommends that children three and under be given a course of conservative therapy for 3-6 months before antibiotics are used.
Do you recall any of the specifics of the anti-chiropractic slam in the Wall Street Journal last year? Most of us recall the ugly tone of the propaganda piece, but it is worth reminding you that the article was about the supposed dangers of taking your children to see a chiropractor, and how chiropractors were targeting pediatric patients as a market to be exploited. The "centerpiece" of the smear was an account of a child who was said to be irreparably harmed by not receiving antibiotics immediately for otitis media, because the parents had used a chiropractor instead of a "real" doctor. The response from our profession was immediate and reflexive, and for the most part apologetic.
When I first read of the AHCPR study in "DC," I felt smugly content with the outcome. Not only was the drugless approach to pediatric otitis media the best to begin with, the literature to support the drugless approach already existed in the medical record. Then I noticed that the research spanned over a quarter century, and I realized that the chiropractic profession had made a slip. The medical community should have been (and probably was) aware of the lack of truth in the Wall Street Journal article. Sadly, we should have been. While it is true that no published literature review of this subject was available at the time, we as a profession should have taken the time to review it ourselves. Had we done so, our response at the time would have been far more compelling. Those of us who claim to be evidence-based failed to utilize the available evidence, and missed an excellent opportunity. Let us (and our national organizations) learn a lesson from this for the future.
Robert Ward
Associated Student Body President
Los Angeles College of Chiropractic
Some sold "their future for 12 cents a share"
Dear Editor:
Today I received my September 1, 1994 issue and read, with great dismay, that CliniCorp, Inc., has decided to put MDs into their chiropractic clinics "to survive." About one year ago, my brother was "pitched to" by CliniCorp to have them buy his clinic in exchange for stock in the company. After we carefully analyzed the situation, my brother and I both felt that CliniCorp did not have a handle on how a chiropractic office works. It was obvious to us that centralized billing would not work, as there was no mechanism to account for the nuances of the system. For example, we have found that certain insurance companies and certain adjustors in particular, notoriously "lose" chiropractic bills. Billing, in those cases, must be done by return receipt certified mail. How can a central office follow something like that? Also, there was no way to allow "Mrs. Jones" to pay only $5 per month on her deductible, when the central office computer only knows to bill her $250 up front. Also, once the doctor cedes control to a central office, how does that doctor control problems that arise?
Another problem with CliniCorp's original model was that there was very little incentive left for the doctor to produce. His fortunes were left to the mercy of the company. His own individual effort made very little difference to his financial bottom line. So the fact that CliniCorp is facing hard times does not surprise us. It is too bad for the doctors who sold their future for 12 cents a share.
What concerns me the most, however, is the fact that CliniCorp has concluded that they must install MDs and become primary care medical facilities to survive. There are now seminars, given by respected chiropractic consultants, who say that you must become a "Rehab" clinic with MDs and PTs if you wish to survive the '90s. What they are really saying is that you need the clout of the MD license to get paid and to get into the managed care system.
As the 34-year-old son of a long time chiropractor, I have grown up with the profession. I lived through the drive for acceptance in the 1960s, the insurance equality battles of the 1970s, the Wilk trial which concluded in the 1980s and now, the battle with managed care and the Clintons. If, after all of this, we have to "kiss up" to the medical doctor to make a living, then we should turn in our licenses right now and sell shoes.
My family of chiropractors has stayed away from the dogmatic infighting of the "straight" versus the "mixer." Live and let live has been our way of thinking. We have even used physical therapy where it benefitted the patient, to the dismay of some of our "straight" friends. But this trend toward "medicalization" of the profession in the name of getting paid is where we draw the line. After carefully examining what is happening to our profession and in health care in general, it would appear that our energies would be better spent in trying to pass a law that would guarantee access to our offices. This, along with a companion law that would guarantee fair payment from whatever health care system emerges, is our best hope. Hiring MDs so that you can bill under their name, and becoming a pseudo-medical facility is professional suicide. Prostituting yourself by doing bogus insurance reviews for a mere $100 or $200 also causes professional cannibalization. While both of these money-making tactics may provide the chiropractor with a short-term financial gain, the long term damage to the profession is irreversible. Yes, I know that the consultant selling the seminar will rationalize that hiring MDs and PTs is the way to integrate into health care of the '90s by providing a "full service" facility. But the truth is just that ... it's a mere rationalization. Certainly society has far too many medical facilities already. The real, underlying reason that chiropractors are advised to hire MDs is so that they can get better paid under the MD license. That is where this chiropractor draws the line.
It is up to our leadership to provide the drive for the laws that our patients need to guarantee true chiropractic access. If our leadership sells out to pressure from government, the insurance industry, and from the medical profession, we will be expected to get patients better in two visits, after being referred by an MD, and only for those patients who have not gotten better at the insurance or medically owned PT center. The time is now to stand up and for what you believe in, namely the chiropractic principle, and not to transpose yourself into a pseudo-medical facility that will be gone once the medical profession gets full control.
Bernard D. Newman, DC
Pittsburgh, Pennsylvania
Insurance Does Not Have to Be "A Horror Story" Dear Editor:
As an individual providing insurance and financial services to a number of various professional practitioners, I would like to add more emphasis and perhaps some guidance relative to Dr. David P. Gilkey's "An Insurance Horror Story" published August 12, 1994.
Purchasing insurance should be handled in a similar fashion as purchasing any other commodity. You may not be able to feel it, smell it or touch it, but it is as much a commodity as is a car. A $10,000 care will take you from A to B as would a $50,000 car and you may not be impressed with the fact that it is more attractive or has a better stereo, but if you are in a serious accident, there is a difference.
As in the case of a car, cost may not be all inclusive, but it should be part of the thought process. You can't expect to get an equivalent car for half the cost and you can't expect to get an equivalent policy for half the cost. By and large, as in all products, you get what you pay for.
My suggestion is that Dr. Gilkey fell victim to the singly most important item about disability insurance. The definition of disability. His agent gave him the "if I couldn't treat patients, I was covered" definition but the policy most likely stated that "Total Disability" was requirement as well as bring unable to work in any occupation related to his "education and training." I have studied a number of companies and found that definition is clearly stated in both proposals and policies. However, what is clear to me as an insurance professional may not be clear to the purchaser.
This now brings focus to the second most important item. Choose your agent as you would your chiropractic physician. Rely on references, experience, specialty, and "vibes." If all look good but you don't feel "comfortable" with your relationship, find another agent. Do not expect the agent to put in writing their definition of the policy, they are prohibited from re-wording the policy language in any way.
Obviously there is more that could be discussed relative to disability coverage but my experience suggests that I have revealed the two most important items. I hope it will be helpful to your readers.
Carl R. Piserchia, MBA
Norwalk, Connecticut
"Smart" Wins in the Information Age Dear Editor:
Both Paul and Alan Tuthill should be commended on their insightful article, "Chiropractic and the Information Age" (August 12, 1994). The potential gains that can be made by the chiropractic profession through harnessing the power of today's technical tools is tremendous. The challenge, however, is that in the information age, "fast and first" don't always win. The winners in today's world of information management are those who are the smartest. "Smartest" implies those who make the tools of technology work for them. Chiropractic knows what goals it wants to achieve as a profession. The smart chiropractor will choose the tools that best help him/her achieve these goals.
The danger of being "first and fast" in the world of technology is that the tools are changing at an amazingly rapid rate. Mike Causey of Computer Sciences Corporation (CSC), one of the world's largest system integrators, says that a "professional bulletin board system (BBS) is just one component of a greater system which integrates hardward, software, telecommunications, and operational procedures that requires thorough planning before implementation."
Here are some of the "smart" questions that need to be answered before chiropractic rushes out to be first and fast in order to ensure that the tools you choose today will be right for tommorrow's jobs:
Hardware
- How much and what kind of hardware do you need initially to support your expected usage?
- Where will it be located? Do you have the space and power?
- How will you respond to growth?
- How will you handle service upgrades?
- What will it cost?
Software - What is the right combination of: Operating System, Network Operating System, Bulletin Board Software, Data Base Management System, User Interface, Communications (both data and fax) Utilities?
- How will it be integrated to best serve chiropractic?
- How will you respond to the changing needs of your users?
- How will you handle service upgrades?
- What will it cost?
Operations - What will be your hours of operations?
- How will you handle routine backup and recovery?
- What are your long-term requirements for archives?
- How will you track and charge back for usage? Or is it free? Can you afford to offer it free?
- Who will staff it? What kind of training will be needed?
- Will you need user's and operations manuals? Who will write them?
- What will it cost?
In addition to the issues above, chiropractic must take a look at where they want to go to get their information. Can the profession afford to have all 50 states starting up their own systems or would you rather have access to all information through one system? These are questions that need to be answered before chiropractic races out to attempt to be on the "cutting edge of technology." By thinking smart, chiropractic can gain the edge through technology ... without getting cut.
Shaun P. Callahan
Chiro-Serve, Inc.
Annapolis, Maryland
"The medical profession already has enough incompetence to fill everyone's gut."
Dear Editor:
The creation of the doctor of chiropractic medicine (DCM) degree is a noble attempt by some of our more progressive thinkers to propel the chiropractic profession into mainstream health care. While the DCM degree theoretically benefits both the chiropractic physician and the patient, the practical application and training of a chiropractic primary care professional by this route may be substandard and inadequate.
As a chiropractor and third year medical student I have had a unique opportunity to evaluate the bias expounded by both medicine and chiropractic. (Even as a medical student I continue as a fervent advocate of holistic applications to maintain health and alleviate sickness.) Chiropractic education is not pathology oriented nor is it biochemically emphasized. The chiropractic profession must realize that just because one institution declares itself as "medically ordained" does not instantly (and ethically) transform its graduates onto competent medical practitioners ready to treat the ills of the world with drugs and surgery.
Clearly, Dr. Dallas' article reflects the desires of a great many DCs who perceive that the addition of drugs and surgery to their scope of practice will enhance the chiropractic physician's image, increase public acceptance, and bolster sagging incomes. In the face of major health care reform, Western States College of Chiropractic has selected the most logical solution, but I believe this program cannot produce clinicians competent to cover a broad spectrum primary care area with the current chiropractic curriculum and a one-year medical-like internship.
Surgery and pharmacology are complex issues. To gain expertise the student of medicine must learn to use surgery and pharmacology over a long period of time beginning from the first year of medical school to the last day of residency. This is much like the student of chiropractic. To become skillful, chiropractic manipulation is taught from day one (spinal biomechanics) to the end of the clinical externship before graduation. Medicine and chiropractic require respective extensive educational backgrounds to become proficient. Simply, medical education is not conducive to mastering osseous manipulation, and chiropractic education is not conducive to mastering medicine.
Dr. Dallas describes in detail the new realm of chiropractic education at Western States College of Chiropractic but does not touch on one very significant issue -- the quality of the DCM degree. We must remember that the unsuspecting patient might be the recipient of medical incompetence perpetrated by an ill-trained doctor of chiropractic medicine. The medical profession already has enough incompetence to fill everyone's gut. Why do we want to place this burden on the chiropractic profession?
C. Wilson, DC
3rd year medical student
710 S. Park Road
Hollywood, Florida 33021
Dr. Amaro Responds to Criticism of DCs Practicing Acupuncture Dear Editor:
The August 12, 1994 issue of "DC" printed a letter to the editor from a David Orman AP, MTOM, of Annandale, Virginia that challenged my August 20, column "Warning: This Article Is Not For The Weak Of Heart." In that letter, Mr. Orman attacked the acupuncture education currently being received by DCs. He stated, in a nutshell, that we as DCs are not qualified to practice or to include this work within our scope of practice.
Mr. Orman's primary reason was that we are doing patients a disservice because "these 100-200 hour programs pale in comparison to the 2,800 hour oriental medical school training ..."
Mr. Orman stated: "Many states do not require chiropractors or medical doctors to test for competency with acupuncture. Acupuncturists on the other hand are required to pass a state and/or national examination for licensure." Then, in his next paragraph, he mentions Florida and the fact that "virtually every health care practitioner advertises, 'acupuncture services'..."
First off, the Department of Professional Regulations, under the direction of the governor's office of the state of Florida, regulates the practice of acupuncture by chiropractic physicians through state board administered examination and documentation of a 100-hour program in acupuncture conducted by the Council on Chiropractic Education's certification program. The legislators in Florida obviously see no problem with this "certification."
What Mr. Orman forgets or doesn't know is that chiropractic physicians attend four years of college which as anyone reading this knows is equivalent to the best medical schools the U.S. has to offer.
Allow me to quote the number of hours and subject matter offered in a typical acupuncture program regarding subjects we as chiropractic physicians have already studied and been examined.
| General Biology | 42 hours |
| General Chemistry | 42 hours |
| Organic Chemistry | 42 hours |
| Biochemistry | 42 hours |
| General Physics/Biophysics | 42 hours |
| Human Anatomy | 112 hours |
| Physiology I & II | |
| Pathology | 42 hours |
| Western Nutrition | 28 hours |
| Counseling and Communication | 14 hours |
| General Psychology | 28 hours |
| |
| Medical History | 28 hours |
| Western Medical Terminology | 14 hours |
| |
| Western Clinical Sciences | 105 hours |
| Survey of Health Professions | 14 hours |
| Western Pharmacology | 14 hours |
| Cardiopulmonary Resuscitation | 7 hours |
| |
| Laws, Ethics & Practice Management | 35 hours |
| Observation Internship | 100 hours |
| Practice Internship | 700 hours |
| |
| Total | 1,409 hours |
I have taken these subjects and hour figures directly from the curriculum page of one of acupuncture's more notable schools. The other 18 catalogues of acupuncture schools I have in my possession are of a similar nature.
Mr. Orman needs to be reminded we don't have to retake these subjects and when it comes to the academics of acupuncture and nutritional therapy it becomes very obvious this critic doesn't know what he's talking about.
John A. Amaro, DC, FIACA, Dipl.Ac.
Carefree, Arizona
