The Chiropractor as General Practitioner and Primary Gatekeeper: Do We Have What It Takes?

Two recent articles published in Dynamic Chiropractic, one by Publisher/Editor Donald M. Petersen, "Are You the GP of Tomorrow?" (January 15, 1992 issue); and the other by Marino Passero, DC, chairman of the CCE's Commission on Accreditation, "The Chiropractor as Health Care Manager" (January 1, 1993 issue), have discussed the possible opportunity that exists in the health care world for the chiropractic physician to become the general practitioner of the future, the first level of contact in the evaluation of various health problems.

As someone who has been involved in undergraduate and postgraduate chiropractic education, I feel compelled to contribute my perspective on this idea. The notion of the chiropractic physician being recognized as the "family doctor" and as the first practitioner consulted when a health problem arises is truly an intriguing one. However, I must say, as Joseph Keating, PhD has pointed out ("DC," October 23, 1992), that our education and training have a very long way to go before we are anywhere close to having the level of diagnostic competence to be able to adequately fill that role.

There are some key areas in which the education of our students is seriously lacking. The first and most important is in the area of patient exposure. Compared to all other health care providers, the extent of our clinical experience, specifically regarding exposure to patients who are truly sick, is inadequate. Most chiropractic interns spend their 9-15 month internship working like mad to recruit many of their family and friends as "patients" to meet their minimum requirements. Perhaps along the way they may see one or two people who have a real health problem beyond just a stiff neck or sore back. For the most part, the clinical experience involves dealing with relatively healthy people. Experience in seeing and being involved in, with close supervision, the work-up of truly sick patients is at the heart of developing the diagnostic abilities required to handle the evaluation of physical ailments at the primary care level. To think that our current deficiency in this area can be compensated for with "additional diagnostic course work," as Mr. Petersen suggests, is naive.

One cannot learn diagnosis and differential diagnosis by listening to someone talk about it, or worse (and this is usually the case in chiropractic schools in my experience), having someone simply list the signs and symptoms of various disorders so that they can be memorized and regurgitated come test time. The most highly motivated students are forced to attempt to compensate by additional reading and outside seminars, but their learning is stunted by the absence of opportunity for the development of clinical diagnostic expertise.

Second, the chiropractic schools need topnotch instructors teaching in the clinics. Too often, the doctors who are involved in the education of the "future GPs" are recent graduates who have seen exactly 25 (the current CCE minimum requirement for graduation) more patients than the incoming interns. And these 25, of course, were mostly healthy people. The clinic staff is usually underpaid and overworked, so that attracting the top minds in the profession for full-time clinical faculty is virtually impossible. In medicine, the brightest people in the profession can usually be found in the teaching facilities. This is because these facilities attract them with salaries, opportunities, and respect commensurate with their knowledge, ability, and expertise. In chiropractic, we discourage the top people in the profession from pursuing careers in education. The few who have (and there are some excellent clinicians in chiropractic education), have done so out of love for the profession, rather than personal opportunity.

Finally, as with the well-known saying about leading a horse to water, one cannot force students to learn if they choose not to. All too often, students in chiropractic college already have or at some time develop the notion that there is little or nothing that they need to be "successful" in chiropractic besides an ability to crack backs and a strong "philosophy." They usually are fed this idea by some "mentor" who has influenced them early on in their education and has pumped them up with the concept that as long as they believe in innate, that all else will follow. This, of course, is attractive to some people because attending regular chiropractic pep rallies is a whole lot easier than the intense studying and pursuit of clinical experience that is required to become a truly excellent chiropractic physician. As this clinical experience is not provided by the school, it is not difficult to understand why many tend to seek the easy way out.

In practice, chiropractors can currently get away with lack of clinical competence, especially if they are good salesmen, because the public usually cannot discern competent chiropractors from those who are incompetent. In addition, people have typically gone to chiropractors as a last resort, after they have seen a plethora of medical specialists and all the differential diagnostic work-ups have been done for them. As primary care practitioners, we will not have that luxury. Certainly, there are some highly self-motivated students who are able to avoid this trap and develop into topnotch doctors. They obtain their clinical training "on the job," where they may attempt to learn as much as they can from the sick patients whom they encounter in practice. I have seen many of these go-getters, but unfortunately, they are in the minority.

Before we as a profession can truly take a place as primary care general practitioners and "gatekeepers," we must completely revamp the clinical training that we provide for our students. The clinical experience must be one of constant exposure to patients with real health problems being handled by or under the supervision of experienced chiropractic physicians who are among the top in their field. In order to attract these top people, a career in chiropractic clinical education must be made into an attractive option, with a respectable level of pay, challenging clinical stimulation and opportunity to pursue scholarly work. Also, the clinical internship has got to last far longer than 9-15 months and must become viewed by the student as an exciting opportunity to develop clinical excellence rather than something that one must simply "get through." The excitement generated by this offset the need for more "philosophy" (which in most cases simply mean enthusiasm about one's work) that is iterated by so many chiropractic students.

It is often noted that our education, as measured by hours spent on various subjects such as anatomy, physiology, and diagnosis is equal to or superior to that of medical school. This is true. As a result, we are capable of producing learned, educated doctors of chiropractic. But this is only a part of the formula that is necessary to help mold students into primary care physicians who are capable of being at the front line in the evaluation of health disorders.

I feel that the idea of the chiropractor as general practitioner and primary gatekeeper (as well as the idea of chiropractic specialists) is a very exciting one, and there currently are a number of chiropractic physicians who have the diagnostic skills to fill that role. The potential certainly exists for this profession to develop itself in that direction. But surely Dr. Passero, as chairman of the CCE's Commission on Accreditation, must be fully aware of the severe limitations in the clinical training of our future DCs. Until they are dealt with, we are a long way from being qualified to call ourselves primary "family" gatekeepers.

Donald R. Murphy, DC
Westerly, Rhode Island