An Overview of the Process Leading to the Resolution
Gerard Clum, D.C., president of Life Chiropractic College West (1992 ICA Chiropractor of the Year) wrote what I feel is perhaps the most critical yet ultimately supportive article regarding the Mercy Guidelines.1 Dr. Clum states that while there are many weaknesses with the Guidelines, "The good news is that the profession will now have something to improve upon." While this may sound like hollow or worthless praise, those who fully understand the Guidelines understand that this is a very reasonable criticism and does not weaken or invalidate its recommendations. Dr. Clum concluded his criticism of the Mercy Guidelines: "Your participation in the process is our only line of recourse. Do your homework, and become involved in a constructive, meaningful way. Your help is needed."
The CCA Continues the Consensus Process
At the May 1992 CCA Board of Directors Meeting, then CCA President Willard D. Smith, D.C., appointed the Mercy Conference Review Committee. I was appointed as committee chairman along with DCs Jo English, Bob Friday, John Hannan, and Russell Smith. Because we anticipated that the document would be lengthy and complex, each committee member was allowed to select several other CCA members to help in the analysis.
Since the Mercy document was not available at the time our committee was formed, we began reviewing articles about the document, including statements or resolutions created by a veritable alphabet soup of organizations: ACA, ICA, FSCO, FCLB, KCS (Kentucky Chiropractic Society), and FCA (Florida Chiropractic Association). Additionally, we read reprints from chiropractic newspapers and magazines: Dynamic Chiropractic, Clinical Chiropractic, and The Chiropractic Journal.
In spite of all the rumors, claims, counterclaims and resolutions from these organizations and publications regarding the Guidelines, the CCA's Mercy Conference Review Committee refrained from formally endorsing or rejecting the Guidelines as we felt this was clearly unfair and short sighted to make conclusions based on speculation regarding a document the profession had not yet seen. We agreed to make our formal recommendations regarding the Guidelines only when the document had been released to the profession and when the committee had the opportunity to fully study the processes and recommendations of the Guidelines.
By October 1992, one of the infamous "For Review Only" draft copies of the Mercy document was made available to the committee. This was one of many draft copies circulating which had fueled the conclusions by the various organizations noted above.
At that point, I reviewed the document and was able to assign sections to my committee members so that when the official document came out, we could immediately begin our review. Each committee member was required to read the "General Disclaimer," a "Letter of Transmittal," "Acknowledgements," "Prefaces" (four), "History of the Commission," "Introduction to the Guide and Use of the Guidelines," the "Epilogue," and all "Appendices." Each committee member and their subcommittee helpers were then asked to do an in-depth review of two to three chapters (depending on the relative size of the chapters), as well as to generally review the entire document.
When the Mercy Guidelines were finally made available to the profession at large, it became apparent that in spite of our methodical approach to reviewing the document, the chiropractic public needed an avenue to express its thoughts and concerns regarding the document and its conclusions. The CCA then arranged and publicized two open public hearings for members and nonmembers. One was held in Los Angeles, the other in Santa Clara. We also solicited written input from those who could not attend either hearing. These public hearings were not intended to teach people about the document nor to change anyone's mind regarding it. Rather, they were designed to allow doctors of chiropractic and interested parties to comment on the consensus process in general or the Guidelines and its recommendations.
Each public hearing began with a brief presentation by a DC who had been involved in some manner with the Mercy Conference itself. In Southern California, Kurt Hegetschweiler, D.C., (an observer at the Mercy Center Conference) gave a brief overview of the consensus process from his perspective. In the Northern California public hearing, Robert Mootz, D.C., of Palmer College of Chiropractic West (an actual contributor and partial author of one the sections in the Guidelines) gave a similar presentation of the process and its structure. Neither of these doctors were there to sell or convince DCs or the audience of the value of the proceedings or the document. Their presentations were essentially informational.
Subsequent to these brief presentations, I played a videotaped lecture by Scott Haldeman, D.C., Ph.D., M.D. This was taped at the Congress of Chiropractic State Associations in Palm Springs, California in November. Dr. Haldeman is the primary architect of the Mercy document and is a proponent and supporter of it. CCA chose to show his lecture not so much because of his support of the document, but because the lecture focuses primarily on the rationale and structure of the consensus process in general. We felt this was extremely important for the profession to understand because the consensus process itself is relatively new; understanding this process and the reasons it is applied in health care is an essential foundation to understanding the significance of the Guidelines. The information Dr. Haldeman presented in this videotape lecture is, to my knowledge, not contained in any written information I have regarding the Guidelines.
Given the controversy that existed in the chiropractic press regarding the Mercy Conference, we expected a large and vocal turnout at both public hearings and a flood of written comments. Surprisingly, the turnout at both public hearings, in spite of what we felt was adequate notice, was quite small. More surprising perhaps was the fact that there were few significant negative comments. The written comments were even more surprising. CCA received perhaps only ten written comments regarding the Mercy Conference. While all of the comments were negative in tone, it is important to note that perhaps eight of the letters, although they were from different chiropractic doctors throughout the state, were essentially word-for-word copies of one another. It was actually humorous reading the letters, particularly since one criticism made was that the Mercy Guidelines had a "cookbook fashion" regarding treatment. I cannot think of anything more cookbook than the carbon copy criticisms received.
Of course there were legitimate criticisms made of the document, both in public hearings, in some of the letters, and by our own committee and subcommittee members. These criticisms will be forwarded to Dynamic Chiropractic, as that publication's Editor Don Petersen has agreed to act as a clearing house for information which will be utilized in a future and perhaps second edition of the Mercy Guidelines.
The Recommendation
After our thorough review of the document analysis of the written comments by other associations and publications, and after assessing the responses of those who chose to attend our public hearings and write the association with their concerns, the committee reached a general consensus that the Mercy Guidelines set reasonable parameters for the chiropractic profession.
The committee then crafted a resolution which, while endorsing the document, the consensus process in general, and the Mercy Guidelines in particular, points out many conclusions that we feel are important and must be considered. Before completing a final resolution, the committee presented its recommendations to the CCA Executive Committee and to the legal counsel. Minor modifications were made and ultimately the document was accepted at the February 1993 meeting of the CCA Board of Directors by unanimous vote of all 32 voting directors.
The Mercy Guidelines are thorough, but certainly not perfect. The process by which the CCA undertook to evaluate the document was also quite thorough, although I am sure that it was not perfect either. I think it serves as a good model for other organizations who are contemplating studying this document. It allows for a levelheaded analysis of the document as well as honestly allowing the consensus process to continue.
Reference:
1. Clum, G: The Mercy Center Conference: What does it mean to you? The Journal of Clinical Chiropractic 2:3, July 1992.
I. The Guidelines for Chiropractic Quality Assurance and Practice Parameters (Guidelines), which represent the written proceedings of the Mercy Center Consensus Conference, have been presented to the CCA Board of Directors for consideration.
II. The consensus process used in preparing the Guidelines has been widely applied in other health care disciplines and is generally accepted as being an appropriate method for development of practice parameters. It is understood that this process is ongoing and that revisions to the conclusions of the Guidelines and to the consensus process itself will occur over time.
III. The authors of and contributors to the Guidelines represent a broad spectrum of practicing chiropractic doctors, including practitioners of diverse philosophical and practical backgrounds, as well as a minority (one-third) of researchers and/or educators, all of whom hold DC degrees.
IV. The Guidelines represent practice parameters, not standards of care. They were developed as guidelines to improve patient care and to address the AHCPR's request for the development of practice parameters. It is understood that AHCPR considers the development of these kinds of guidelines to be an important component in the formation of national health care policies. To date, no other profession has presented such comprehensive parameters to AHCPR.
V. The Guidelines do not purport to set forth standardized treatment schedules or approaches. The Guidelines must be considered as a whole document to be properly understood. When viewed otherwise, portions can be taken out of context and used in a misleading or inappropriate manner. The Guidelines may provide some assistance to third-party payers in the evaluation of care, but cannot be solely relied upon in making such decisions. Many factors must be considered in determining clinical necessity, and the ultimate determination as to clinical necessity and the propriety of a specific procedure must be made by the practitioner in light of each patient's individual circumstances and conditions.
VI. No particular method, practice style or technique is endorsed or condemned by the Guidelines as being appropriate or inappropriate in all circumstances or at all times. Certain techniques and procedures may not presently quality for positive categorization; however, future documentation and scientific validation of such techniques and procedures may result in a shift in rating and/or consensus level. Practitioners who employ such techniques or procedures are encouraged to support continued investigation to provide further scientific documentation as to the use of such techniques in clinical practice.
VII. The suggested clinical goals of the Guidelines, in particular that patient management results in documented improvement, apply to all practicing chiropractic doctors regardless of whether one's practice is based on a model of symptomatic care or a nonsymptomatic, subluxation-based model. Patient care, in all forms, has as its goal either the improvement or elimination of a condition and/or the enhancement of an individual's health and well-being, which developments, if documented, can be shown to have occurred over a reasonable period of time.
VIII. The Guidelines are not static but rather serve as the basis for research and assessment of relevant clinical data. Such undertakings will lead to modification and/or revision of the Guidelines' current statements and conclusions through a continuation of the consensus process.
IX: The CCA appreciates the efforts of all sponsors and participants who have contributed to the development and distribution of the Guidelines.
Recommendation: In consideration of the above, the CCA Board of Directors endorses the process and recommendations of the Guidelines for Chiropractic Quality Assurance and Practice Parameters, subject to the qualifications below, as being reasonable general parameters for the chiropractic profession in consideration of the present state of scientific evidence. The CCA takes exception to any provision in the Guidelines that may be in conflict with laws regulating the practice of chiropractic in the state of California. Further, in endorsing the process and recommendations of the Guidelines, it is understood that appropriate chiropractic practice may include various responses to particular clinical problems, and that adherence to any particular guideline is voluntary. In this regard, the ultimate judgment regarding a clinical decision is the responsibility of the particular practitioner in consideration of the patient's condition and the particular circumstances of the case.
Whereas: the Mercy Center Conference Document entitled Guidelines for Chiropractic Quality Assurance and Standards of Practice (hereafter referred to as "the Document") has come before the Board of the New York Chiropractic Council for consideration as to endorsement or other disposition, and
Whereas: the Board of the New York Chiropractic Council has given the Document priority attention, discussion and study since our Board Chairman, Dr. William Remling returned from participating in the Mercy conference and
Whereas: this Board of the New York Chiropractic Council has conferred with its legal council, Mr. James Hogan as well as the International Chiropractors Association, and
Whereas: the National Association of Chiropractic Attorneys, finds that portions of the Document would create serious and substantial problems for the chiropractic profession, and
Whereas: apart from concerns with respect to the profession at large, the Board of the New York Chiropractic Council acknowledges serious concerns relative to clinical goals and practice concepts of our members as well as other members of the profession, and
Whereas: the Document attempts to address several procedures not routinely taught in a majority of CCE approved colleges, and
Whereas: the Document has not been reviewed by a substantial portion of the profession prior to its printing and circulation, and
Whereas: the structure of the Mercy Center Conference was designed so as not to enable any modifications or amendment of the Document in its current form,
Therefore be it resolved that the Board of New York Chiropractic Council does not accept, endorse, approve or otherwise sanction the Document produced by the Mercy Center Conference."
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