The Primary Care Issue: Spine Doctor or Spin Doctor?

Reactions I have seen to the proposition that chiropractors are primary care providers run anywhere from a rolling of the eyes, to guarded acceptance within a neuromusculoskeletal framework, to emphatic approbation. What light (instead of heat) can we add to this still-explosive topic, debates of which go back at least as far back to the profession's centennial in 1995?¹ This issue has to be taken seriously, if for no other reason than that skeptics looking from the outside - who don't know better - could be branding chiropractors as anything from spine doctors to spin doctors.

The problem begins with how you frame it, harking back to the classic quotation, "The answer lies within the question." This is because multiple definitions of "primary care" abound, so the outcome pretty much depends on which version you embrace. Consider the following widely divergent takes on primary care:

1. Barbara Starfield: First-contact, longitudinal, coordinated and comprehensive care, in which the practitioner should take care of the majority of problems without referral.²
2. Public Health Service Act: Services which require family medicine, internal medicine, pediatrics, obstetrics/gynecology, dentistry or mental health as provided by physicians or other health care professionals.³
3. Institute of Medicine: Emphasis upon accessibility, comprehensiveness, continuity and coordination.⁴
4. Alma Ata, USSR: Health for all [HFA] by the year 2000.⁵
5. Craig Nelson: Care that most persons need most of the time.⁶

Looking at these definitions, you realize chiropractors can state their case in some of these definitions, but make little headway in others.

To assess chiropractic primary care from a multiplicity of viewpoints (capacity, potential and perception by the public), 10 years ago the FCER awarded a grant funded by the National Chiropractic Mutual Insurance Company to a health consulting firm in many aspects similar to the RAND Corporation, but based in Cambridge, Mass. Its principal findings were both sobering and hopeful. The authors of a subcontracted project out of Cleveland Chiropractic College in Kansas City pointed out that, if the competence of chiropractors is ever to "enjoy a wider traditional covenant" including primary care, students as well as practitioners must obviously be able to document their competence in such pursuits - including their performance on validated examinations. Such was the undertaking in this study, which compared exam scores of students from three chiropractic colleges with those from a small cohort of medical students entering their residency programs.

Overall, medical students scored higher than chiropractic students in 19 out of 20 categories, except in musculoskeletal conditions, in which their (the medical students') performance was markedly inferior, confirming findings obtained recently by Freedman and Bernstein, in which orthopedic residents failed a validated competency examination in musculoskeletal evaluation.^7,8 In certain other areas (injuries and trauma, management of acute and chronic conditions, neurological conditions, and even infectious diseases to some extent) the performance of chiropractic students in at least some schools was not that inferior to the medical cohort. But in others areas (cardiovascular conditions, genitourinary conditions, and screening and prevention), the chiropractic scores were markedly poorer.⁹ Scores relative to screening and prevention are particularly distressing in that much of the chiropractic profession has attempted to position itself as experts in wellness and prevention. A problem with this comparison is the fact that chiropractic students in their final year have been matched against medical students entering their first year of residency, which means the latter group has benefited uniquely from more advanced training than their chiropractic counterparts and would thus be expected to perform at a higher level. It also underscores the unmistakable fact, cited elsewhere,¹⁰ that chiropractic programs must offer far more extensive and varied clinical exposure to their students if they are to be effective in the practice of primary care.

But the prominent and distinguishing characteristic of the chiropractor, as opposed to any other manual therapist, is both the training and the capability to be able to perform complete medical diagnoses in the examination of the patient, independently from any other health care professional. This assertion was supported by a second portion of the study conducted by Abt Associates, Inc. It reviewed both the capabilities of and barriers to the delivery of primary care by chiropractors, following a methodology of using both a multidisicplinary and an all-chiropractic panel that had previously been employed by RAND.^11-13 The Abt study concluded that with respect to a list of 53 primary care functions found to occur daily in medical offices, chiropractors are capable of issuing diagnoses in 92 percent of these activities and making therapeutic contributions in more than 50 percent of them.¹⁴ Clearly, there is room for interpretation as to the definitions of "primary care" and "therapeutic contributions," although it seems apparent that from the perspectives of both training and performance, chiropractors (compared to physical therapists) have the better potential to perform the complete evaluation and diagnosis of patients.

Thus, the need for chiropractors to distinguish their profession by utilizing their capacity to provide diagnoses has never been more acute. This has provided the starting point to review their abilities to perform in a primary care role, both supported and refuted by a modest body of literature which has been reviewed in this discussion. One distinction that must be kept in mind is how chiropractors are taught, as opposed to what they are allowed to practice in their diverse locations. In such areas as interpreting laboratory chemistry determinations from blood, urine and stool specimens, for example, ample opportunities exist to excel and even surpass their medical counterparts; however, various practice and antiphlebotomy laws act as unfortunate disincentives to performing this vital diagnostic service. These barriers to practice have been extensively reviewed by Gaumer, representing a third component of FCER's aforementioned project conducted by Abt Associates.¹⁵

Yet chiropractic primary care may yet endure. Consider these findings:

1. A rural health survey, for instance, indicates 41 percent of chiropractors provide first-contact care for over three-quarters of the patients in rural areas lacking medical or osteopathic doctors.¹⁶
2. Chiropractic physicians have reported a much greater rate of referral to non-chiropractic providers than non-chiropractic providers have to chiropractors.¹⁷
3. Chiropractors have functioned well within multidisciplinary settings, determining appropriate protocols and conditions for patient management.^18,19 Within the framework of a large health maintenance organization, chiropractic physicians were shown to be capable of initiating and coordinating care for patients with a broad spectrum of disease states, representing a wider variety of diagnostic presentations than commonly reported from chiropractic offices. Furthermore, they appeared to do so at substantially greater efficiency and lower cost than their medical counterparts.²⁰
4. Respondents to a random national survey of 753 U.S. chiropractors indicated a substantial number of practice characteristics associated with primary care. However, less than 20 percent included reports with their referrals.²¹

These are not grounds, however, to pop any champagne corks or issue any manifestos. For while a survey of practitioners listed in the National Directory of Chiropractic shows no less than 90.4 percent answering "yes" to the question, "Do you consider yourself a primary care practitioner?"²¹ patients do not see it that way. They see chiropractors largely for neuromusculoskelal conditions.^22,23 So, the burden of proof remains upon the chiropractic community to demonstrate that the cognitive as well as the manual contributions of qualified chiropractors are an essential component for arriving at meaningful, efficient and cost-effective solutions to the proliferation of neuromusculoskeletal problems in today's society. It depends upon the support of future research, largely through FCER, to validate the possibility that chiropractors may make substantial offerings to the primary care management of specific somatovisceral conditions, in addition to being able to achieve the ultimate goals of patient wellness and prevention that are already in the process of being embraced by allopathic medicine.²⁴ It also depends upon proper education and training of the chiropractic physician, as explicitly mandated by the Council on Chiropractic Education.²⁵ All of these measures are essential to avoid ever having to bear the onus of being a spin doctor, a role better left to a politician rather than a health care provider.

References

1. Chiropractic Centennial, Washington D.C., July 6-8, 1995.
2. Starfield B. In reply. Journal of the American Medical Association 1993;270(20):2434.
3. Budetti PP. Achieving a uniform federal primary care policy. Opportunities presented by national healthcare reform. Journal of the American Medical Association 1993;269(4):498-501.
4. Barondess JA. The future of generalism. Annals of Internal Medicine 1993;119(2):153-160.
5. Bryant JH, Zuberi RW, Thaver IH. Alta Ata and health for all by the year 2000. The roles of academic institutions. Infectious Diseases and Clinics, North America 1991;5(2):403-416.
6. Nelson CF. Chiropractic scope of practice. Journal of Manipulative and Physiological Therapeutics 1993;16(7):488-497.
7. Freedman KB, Bernstein J. Educational deficiencies in musculoskeletal medicine. Journal of Bone and Joint Surgery 2002;84-A(4):604-608.
8. Freedman KB, Bernstein J. The adequacy of medical school education in musculoskeletal medicine. Journal of Bone and Joint Surgery 1998;80-A(10):1421-1427.
9. Sandefur R, Febbo TA, Rupert RL. Assessment of knowledge of primary care activities in a sample of medical and chiropractic students. Journal of Manipulative and Physiological Therapeutics 2005;28(5):336-344.
10. Coulter I, Adams A, Coggan P, Wilkes M, Gonyea M. A comparative study of chiropractic and medical education. Alternative Therapies in Health and Medicine 1998;4(5):64-75.
11. Shekelle PG, Adams AH, Chassin MR, Hurwitz EL,et al. The Appropriateness of Spinal Manipulation for Low Back Pain: Indications and Ratings by a Multidisciplinary Expert Panel. Santa Monica, CA: 1991, RAND, monograph No. R-4025/2-CCR/FCER.
12. Shekelle PG, Adams AH, Chassin MR, Hurwitz EL, et al. The Appropriateness of Spinal Manipulation for Low Back Pain: Indications and Ratings by an All-Chiropractic Expert Panel. Santa Monica, CA: 1992, RAND, monograph No. R-4025/3-CCR/FCER.
13. Coulter ID, Hurwitz EL, Adams AH, Meeker WC, et al. The Appropriateness of Manipulation and Mobilization of the Cervical Spine. Santa Monica, CA: RAND, monograph No. MR-781-CCR.
14. Gaumer GL, Walker A, Su S. Chiropractic and a new taxonomy of primary care activities. Journal of Manipulative and Physiological Therapeutics 2001; 24(4):239-259.
15. Gaumer G, Koren A, Gemmen E. Barriers to expanding primary care roles for chiropractors: the role of chiropractic as primary care gatekeeper. Journal of Manipulative and Physiological Therapeutics 2002;25(7):427-449.
16. Callahan D, Cianciulli A. The Chiropractor as a Primary Health Care Provider in Rural, Health Professional Shortage Areas of the U.S. Des Moines, IA: Foundation for Chiropractic Education and Research. Publication No. 9452, 1994.
17. Mootz RD, Meeker WC. A survey of referral habits of American Back Society symposium attendees. Chiropractic Technique 1994;6(1):1-4.
18. Hurwitz E. The relative impact of chiropractic vs. medical management of low back pain on health status in a multidisciplinary group practice. Journal of Manipulative and Physiological Therapeutics 1994;17(2):74-82.
19. Triano JJ, Roley B. Chiropractic in the interdisciplinary team practice. Topics in Clinical Chiropractic 1994;1(4):58-66.
20. Sarnat RL, Winterstein JL. Clinical and cost-effectiveness of an integrative medicine IPA. Journal of Manipulative and Physiological Therapeutics 2004;27(5):336-347.
21. Hawk C, Dusio M. A survey of 492 chiropractors on primary care and prevention-related issues. Journal of Manipulative and Physiological Therapeutics 1995;18(2):57-64.
22. Lebouef-Yde C, Pedersen EN, Bryner P, Cosman D, et al. Self-reported nonmusculoskeletal responses to chiropractic intervention: a multination survey. Journal of Manipulative and Physiological Therapeutics 2005;28(5):294-302.
23. Coulter ID, Hurwitz EL, Adams AH, Genovese BJ, et al. Patients using chiropractic in North America: who are they in chiropractic care? Spine 2002;27:291-298.
24. Zerhouni E. Director of the National Institutes of Health at the Harvard School of Public Health, April 14, 2005, quoted in the Boston Globe, April 19, 2005, pp. D1, D4.
25. Council on Chiropractic Education. Standards for Doctor of Chiropractic Programs and Requirements for Institutional Status. Scottsdale, AZ, 2004, p. 14.