The Challenge of Chiropractic Integration

Integrated care has been defined as: "a discrete set of techniques and organizational models designed to create connectivity, alignment and collaboration within and between the cure and care sectors. ... The focus is on patients' needs as provided by an interdisciplinary team."¹ Meanwhile, according to Bell, "Using the term integrative medicine to refer to the merging of complementary and alternative medicine (CAM) with conventional biomedicine (combination medicine) is not integrative. Integrative medicine represents a higher-order system of systems of care that emphasize wellness and healing of the entire person as primary goals."²

The Arizona Center for Integrative Medicine recently proposed a model of integrative medicine that "provides care that is patient centered, healing-oriented, emphasizes the therapeutic relationship and uses therapeutic approaches originating from conventional and alternative medicine. Recommendations include creating financial incentives aligned with health promotion and prevention."³

The National Center for Complementary and Alternative Medicine (NCCAM) has defined CAM as a "group of diverse medical and health care systems, practices and products that are not presently considered to be part of conventional medicine" and put integrative medicine forward as a key component of its five-year strategic plan.⁴ Of note, the World Health Organization has estimated that CAM is first tried by a majority of the world's population for serious chronic or recurrent illness.⁵

Whether or not you agree with the label, the mainstream health care system includes chiropractic under the umbrella of CAM. That said, when patients come under the care of more than one health care provider at the same time, there should be a reasonable expectation that all providers are willing to participate in consultations and develop effective, evidence-based treatment plans. Sadly, this has not been the case with chiropractic care. Greene, et al., reported in one survey that 99 percent of 517 primary care physicians had strong referral relationships with their medical physician peers, but only 12 percent said that they would initiate a referral to a chiropractor. Physicians claimed that they did not understand enough about chiropractic to know which patients were eligible for chiropractic care and what treatments were available to them. Some physicians replied that they didn't view chiropractic as a legitimate health profession.

The underlying cause of these opinions appears to be a major credibility and communication problem in interprofessional relationships with chiropractors. The lack of any direct, formalized referral relationship between primary care physicians and doctors of chiropractic may contribute to some very serious negative implications for health care efficiency, quality, continuity of care, and safety in the delivery of patient-centered care.⁶

Up to 77 percent of patients do not inform their medical practitioner of their CAM use, primarily because of concerns about a negative response by the practitioner, but also because the patient felt that their medical doctor did not need to know and that the physician rarely even asked.⁷

Chiropractors have been excluded or marginalized by mainstream health care through regulatory restrictions and limited spheres of competence. There are also significant barriers to professional interaction and access to patient files, referral networks and diagnostic tests. All health care providers should improve communication and limit the use of esoteric terminology and specialized knowledge in order to minimize fragmentation of care and improve interprofessional referral relationships. There will continue to be opportunities to produce research evidence that support CAM therapies and the integration of chiropractic into future health care systems.^8,9

References

1. Kodner DL, Kyriacou CK. Fully integrated care for the frail elderly: two American models. Int J Integr Care, 2000;1:e08.
2. Bell IR, Caspi O, Schwartz GE, et al. Integrative medicine and systemic outcomes research: issues in the emergence of a new model for primary health care. Arch Intern Med, 2002 Aug 12-26;162(15):1781-2.
3. Maizes V, Rakel D, Niemiec C. Integrative medicine and patient-centered care. Explore, 2009 Sept-Oct;5(5):277-89.
4. National Center for Complementary and Alternative Medicine.Expanding Horizons of Healthcare: Five-Year Strategic Plan, 2001-2005.
5. World Health Organization. Traditional Medicine Strategy 2002-2005.
6. Greene BR, Smith M, Allareddy V, Haas M. Referral patterns and attitudes of primary care physicians towards chiropractors. BMC Complement Altern Med, 2006;6:5.
7. Robinson A, McGrail MR. Disclosure of CAM use to medical practitioners: a review of qualitative and quantitative studies.Compement Ther Med, 2004 June-Sept;12(2-3):90-8.
8. Allareddy V, Greene BR, Smith M, et al. Facilitators and barriers to improving interprofessional referral relationships between primary care physicians and chiropractors. J Ambul Care Manage, 2007 Oct-Dec;30(4):347-54.
9. Hollenberg D. Uncharted ground: patterns of professional interaction among complementary/alternative and biomedical practitioners in integrative health care settings. Soc Sci Med, 2006 Feb;62(3):731-44.