The Medical View of Chiropractic

Despite the advances chiropractic has made in the health care arena, a certain level of animosity lingers between elements of the medical and chiropractic professions. From a chiropractic perspective, the American Medical Association (AMA) played a major role in fostering this animosity. Most chiropractors know all too well that the AMA considered chiropractors part of an "unscientific cult" for most of the 20^th century. In 1967, the AMA Judicial Council issued an opinion holding that it was unethical for a physician to "associate professionally" with chiropractors, which included making referrals of patients to chiropractors; accepting referrals from chiropractors; providing diagnostic, laboratory, or radiology services for chiropractors; teaching chiropractors; or practicing together in any form. Not until 1980 did the AMA revise its Principles of Medical Ethics to allow physicians to "be free to choose whom to serve, with whom to associate, and the environment in which to provide medical services."¹

In the almost 26 years since the AMA revised its ethical code to allow medical doctors and doctors of chiropractic to associate without fear of retribution, there is little doubt that the professional relationship between MDs and DCs has improved to some degree. Despite this progress, only scant research has been published examining this relationship. How does the typical American medical physician feel about the average American doctor of chiropractic? What types of professional relationships do medical doctors and doctors of osteopathy have with chiropractors? How comfortable are they referring patients to, or accepting referrals from, a DC? And do they feel the same way toward their fellow physicians as they do chiropractors?

To answer these and other questions, researchers from Palmer College of Chiropractic, Western States Chiropractic College and the University of Iowa College of Public Health mailed a brief survey to every actively practicing primary care physician in the state of Iowa. The results of the survey, published in a recent issue of"BioMed Central: Complementary and Alternative Medicine, provide new insights into the practice of patient referral and the attitudes of physicians toward chiropractors.²

The original survey was mailed to 1,561 practicing medical doctors and osteopaths throughout Iowa, with two follow-ups sent to nonrespondents. Along with general questions regarding patient referrals and recommendations, the survey included specific questions as to whether the doctors referred patients to (or accepted referrals from) chiropractors, along with whether their patients had asked for information on chiropractic or asked to be referred to a chiropractor. A total of 513 primary care physicians (404 medical doctors and 109 osteopaths) returned the survey and were included in the final analysis.

Referral Patterns Between Medical Doctors, Osteopaths and Chiropractors

• Eighty-one percent of DOs and 87 percent of MDs reported that their patients had asked them for information about chiropractic; approximately 75 percent of all primary care physicians reported having patients who requested a referral.
• Sixty-five percent of DOs and 64 percent of MDs reported that they had recommended a patient see a chiropractor for care. However, only 29 percent of MDs (and 24 percent of DOs) had ever formally referred a patient to a chiropractor for evaluation or treatment.
• The vast majority of physicians (87 percent) preferred that their patients contact a chiropractor on their own, rather than initiating a formal referral themselves. This finding stood almost in direct contrast to the initiation of referrals between primary care physicians. Both MDs (99 percent) and DOs (98 percent) preferred overwhelmingly to initiate a formal referral to another primary care physician, rather than having the patient make initial contact with the doctor.
• While many primary care physicians seemed hesitant to make a formal referral to a chiropractor, a surprising number of MDs chose not to accept referrals from a DC. While more than 82 percent of DOs accepted referrals from chiropractors, only 55 percent of MDs followed suit.

Referral Patterns to Other Primary Care Physicians and Chiropractors

• Ninety-nine percent of the primary care providers responded that they would initiate a patient referral to another primary care provider (PCP). However, only 12 percent said that they would initiate a referral to a chiropractor.
• When referring a patient to another PCP, 95 percent of MDs and DOs included a case report (at least some of the time). When referring a patient to a chiropractor, only 73 percent of MDs and DOs included the report.
• Only 77 percent of PCPs who had accepted a referral from a chiropractor sent follow-up clinical information about the patient to the chiropractor, whereas 97 percent of PCPs who had accepted a referral from another primary care physician sent follow-up clinical information back to the referring physician.

Referral Patterns to Chiropractors Based on Gender, Practice and Specialty

• PCPs who operated out of a private practice were twice as likely to recommend that one of their patients see a chiropractor compared to primary care physicians in other practice settings. They were also 83 percent more likely to accept a referral from a DC, and 58 percent more likely to refer a patient to a chiropractor for evaluation or treatment. The authors of the survey suggested these findings were due to the fact that private-practice PCPs "are not subject to the peer review or pressure in large institutional settings."
• Medical doctors were 73 percent less likely than osteopaths to have accepted a referral from a chiropractor.
• Male physicians were 67 percent more likely to accept a referral from a DC than were female physicians.
• Doctors who specialized in internal medicine were 37 percent less likely to recommend a patient see a chiropractor, and 20 percent less likely to have ever referred a patient to a DC for evaluation or treatment, than doctors of other specialties.

Findings and Implications

According to this survey, a majority of actively practicing primary care physicians were willing to recommend that patients consult a chiropractor, yet they were hesitant to take the additional step of making a formal referral to a specific practitioner. In fact, most primary care physicians preferred that patients contact a chiropractor on their own.

Given the effectiveness of chiropractic care in the treatment of myriad health conditions, and the advances the chiropractic profession has made in the health care field over the past quarter-century, why are a significant number of physicians seemingly unwilling or unable to create formal professional relationships with chiropractors? The authors of the survey offered several possible explanations, including:

• Ignorance. According to the authors, "Some of the PCPs in our study mentioned that they do not know enough about chiropractic to have an opinion, or do not view chiropractic as a legitimate health profession."
• Competition. Some medical doctors and osteopaths may consider alternative health care providers "a threat to their practices." As such, they may be hesitant to establish professional relationships with potential competitors.
• Legal issues. Primary care physicians, like most health care providers, are wary of potential malpractice lawsuits, and may seek to avoid professional relationships that they feel expose them to greater risk of litigation.

"Our study adds precision to understanding the referral patterns of PCPs," the authors wrote. "A vast majority of PCPs seem to enjoy very good intraprofessional relationships. However, it is clear that there is a major communication problem in interprofessional relationships with chiropractors." Such a problem, they believe, could have potentially harmful consequences with regard to patient safety, leading to breaks in the coordination and continuity of care.

To prevent such breaks from occurring, the authors recommended that more research be conducted with the purpose of understanding the negative issues that result from poor interprofessional communication. Specifically, they suggested that future studies investigate the use of educational interventions to improve the standards of documentation and information-sharing between medical doctors, osteopaths and chiropractors, which could raise the level of communication while improving standards of care among both professions.

As the authors concluded:

"PCPs enjoy very good professional relationships with other PCPs. However, the lack of direct formalized referral relationships between PCPs and chiropractors has implications for efficiency, continuity, quality, and patient safety in the health care delivery system. Further research must focus on identifying facilitators and barriers of developing positive relationships between PCPs and chiropractors."

A complete version of the article, "Referral Patterns and Attitudes of Primary Care Physicians Towards Chiropractors," is available online at www.biomedcentral.com/content/pdf/1472-6882-6-5.pdf.

References

1. Wardwell WI. Chiropractic: History and Evolution of a New Profession. St. Louis: Mosby, 1992, pp. 162-164, 171.
2. Greene BR, Smith M, Allareddy V, Haas M. Referral patterns and attitudes of primary care physicians towards chiropractors. BMC Complementary and Alternative Medicine 2006;6(5): Published March 1, 2006.