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Look at the Possibilities

Dear Editor:

Your editorial, "First, Do No Harm: Do Things the Hard Way" [April 9 DC] is thoughtful, relevant and totally off the mark regarding chiropractic, drugs and what is happening in New Mexico, which your words point to. It is off the mark because the argument you and many others continue to make is one that has reduced the heart of the matter to an unproductive, elementary distinction.

The two sides to your coin are drugs and no drugs. They are also drugs = MDs and no drugs = DCs. That is the overly simplistic argument I was taught as I entered the chiropractic world in school and as a professional. It seemed quite reasonable at the time; until I took the time to look into it more deeply and, I will assert, more intelligently.

Concomitant with that argument is the assumption that what keeps chiropractic separate and distinct from medicine is that our profession doesn't use drugs. While this may be part of the equation for some (and not true anymore), I say that the true distinction is the chiropractic science of spinal dysfunction and the art of the chiropractic adjustment to positively influence health. To me, this is far more fundamental than the fact that our profession does not use drugs in its treatment regimen.

In fact, that distinction really requires a further distinction. The more complete and functional truth is that our profession does not promote or condone the use of drugs as the first intervention in any treatment regimen. That's a more valid and real-world distinction than the unrealistic view that fundamentalists continue to proselytize.

Now here's another distinction. Are there any chiropractors out there who oppose the advanced-practice reality in New Mexico and our attempts at legislating primary care, who give vitamins to their patients? Well, guess what. You are giving them drugs. Look at the definition from Wikipedia: "Drug – A drug, broadly speaking, is any substance that, when absorbed into the body of a living organism, alters normal bodily function. In pharmacology, a drug is 'a chemical substance used in the treatment, cure, prevention, or diagnosis of disease or used to otherwise enhance physical or mental well-being.'"

Here's the definition from the Merriam Webster Dictionary: a substance used as a medication or in the preparation of medication according to the Food, Drug, and Cosmetic Act (1) : a substance recognized in an official pharmacopoeia or formulary (2) : a substance intended for use in the diagnosis, cure, mitigation, treatment, or prevention of disease (3): a substance other than food intended to affect the structure or function of the body.

How about this definition from the FDA: "How does the law define a drug? The FD&C Act defines drugs, in part, by their intended use, as 'articles intended for use in the diagnosis, cure, mitigation, treatment, or prevention of disease' and 'articles (other than food) intended to affect the structure or any function of the body of man or other animals' [FD&C Act, sec. 201(g)(1)]."

Oh, I know you mean prescription drugs. But since our profession insists on being dogmatic, let's look at what we are really saying. Don, you say that "embracing drugs as a health choice is dishonest to who we are as a profession." No one in New Mexico and no one who supports what we are doing in New Mexico embraces drugs as a health choice. The only dishonesty is to one who finds no other way to define our profession except dogmatically. 

We as chiropractors embrace natural healing and the use of the chiropractic adjustment to further natural healing. In light of that and using it as a foundation, we are willing to see how the use of certain drugs in the right place at the right time can enhance the results that we get with chiropractic. The argument that we are becoming physicians who are using drugs as a first-line of intervention is very far from the truth and shows me that you and others are not listening to what we are saying.

You appear to be saying that we'd rather be medical doctors, give up chiropractic and use drugs instead. Have you ever asked any of us if this is true? Guess what? It isn't. That's not what we are interested in. You and others think that to use any drug in practice is so contrary to chiropractic philosophy that the only way to reconcile the two is to denigrate chiropractic. If you and others consider yourselves forward thinkers, you will begin to understand that chiropractic can be an evolving art and science, and that our patients would rather receive a drug from someone who is anti-drug than from someone whose sole basis for practice is drugs and nothing else.

Have a hard time understanding how someone who is anti-drug can provide drugs to their patients? The only thing in the way of "getting that" is the dogmatic belief that the two are antithetical. They are not. If you can embrace that concept, though, you can then begin to see that only with prescriptive authority can any chiropractor take people off drugs and replace them with healthier alternatives. By not being able to do that, we isolate ourselves. Has our profession grown in the past few decades? Has chiropractic college enrollment been up or down? Have more people come to see us collectively than in years past? I think you know the answers to those questions.

I suggest that you and others stop continuing to frame this profession as a religion and look at the possibilities that, as intelligent physicians, we can make available to our patients. I can embrace the chiropractic philosophy about how health works in our bodies and how the adjustment affects it, and assist my patients with the careful and judicious use of certain drugs as secondary treatment.
My patients do not care that I do not adhere to an arbitrary fundamental chiropractic philosophy. They didn't come to me for that, nor do they know anything about it unless I have indoctrinated them. They know that as a chiropractor, I provide adjustive work, and that's what they want.  Those who I have also provided biopuncture and prolotherapy to in situations that did not respond to chiropractic are eternally grateful that I have been able to help them without their having to go elsewhere.

So, your simplistic definition of the distinctions between chiropractic and medicine is what is holding this profession back from providing more comprehensive care to our patients. I know that you and a lot of others want to be so right about the way we have been trained. The world begins to reshape itself when you stop being right and start looking at possibilities. It's OK if chiropractic redefines itself on an ongoing basis. That's what a healthy profession does – and that's what our patients want, whether you know it and like it or not.

Stephen Perlstein, DC,
APC, FAADEP, DAAPM
Santa Fe, N.M.

"Our Authority in the Health Care System Is Vanishing"

Dear Editor:

This letter is sent in response to Robert Merrihew's letter [May 6 DC] asking fellow DCs to share their thoughts regarding the future of chiropractic. Recall that Merrihew was responding to ICA president Dr. Gary Walsemann's comments concerning New Mexico's scope of practice. Here are my opinions...

The DC scope of practice is plenty liberal. In most states, I'm guessing the allowed scope of practice is far more liberal than any current chiropractic fee schedules devised by specific insurance plans. It seems to this Oregon chiropractor, who actually could be licensed in this state to practice obstetrics and minor surgery, that the problem is limited "scope of payment" rather than limited "scope of practice."

We appear to have lost our primary care provider status where it counts most: insurance reimbursement. This limited scope of payment has degraded the chiropractor to an underpaid technician who is allowed X number of "back crackings" per patient per year for a quixotic condition called "subluxation." To make matters worse, we are often classified as "specialists" with regard to co-payments. These higher co-payments, as you may have noticed, are not infrequently higher than approved charges for chiropractic services.

Our authority in the health care system is vanishing. As a result, our credibility is deteriorating and our rightful position as a primary care provider is being filled by medical practitioners including physician assistants and nurse practitioners who work from the same liberal fee schedules as their MD / DO superiors. In addition, physical therapists continue their heyday, seeing a wide range of patients and receiving handsome compensation for their ministrations.

In many states, PTs have successfully lobbied for "practice without referral," giving them direct access to patients and almost unrestricted insurance reimbursement. Many of the conditions PTs treat fall clearly within the scope of chiropractic; however, they may not be problems for which spinal manipulation is the indicated treatment. If an insurance plan pays only for a limited number of chiropractic spinal manipulations, as many do, policyholders begin to believe that spinal manipulation is the limit of our skill, scope and expertise. Prospective patients in turn take their non-spine-related health problems elsewhere, where their insurance is useful.

I can see our credibility and success as a profession disappearing simultaneously with diminishing health plan allowances for services we should be providing, including physical examinations, lifestyle counseling, exercise instruction, prevention, etc. I do not believe that our credibility and success as a profession will be restored by adding allopathy to our license to practice.

Just from an economic standpoint, consider the addition of pharmaceutical prescriptive services to your scope and imagine trying to fund the professional liability insurance premiums necessary to cover your newfound allopathic love affair using the fee schedules we are working from now. It won't make good business sense. We will become a magnet for uninsured drug-seeking patients and our credibility will slip further into the abyss. When PTs and or primary care providers learn the manual techniques and skills of the DC, we will no longer be needed.

Chiropractors enjoyed great success in years past without pharmaceuticals in our scope of practice. I don't see it as an integral part of our future success as a profession. Reasonable DC inclusion in health plans, along with fair and equitable payment for quality services, is what will make this profession prosper again. Restoring our authority is the answer. In order for chiropractic as a profession to be successful in the future, prospective patients will have to be able to choose well-trained, highly credentialed DCs who act as portals of entry into the health care system, carefully examining, clearly documenting and treating those who fall within our drugless scope of chiropractic practice and referring those who need medical or other forms of care.

John Donovan, DC
The Dalles, Ore.

Dynamic Chiropractic encourages letters to the editor to discuss any issue relevant to the profession, including response to articles that appeared in a previous issue of the publication. All letters should be e-mailed to editorial@mpamedia.com with "Letter to the Editor" in the subject field. Please include your full name, degree(s), and the city and state in which you practice. Submission represents acknowledgement that your letter may appear in a future issue of DC, but does not guarantee publication. We receive considerable correspondence and endeavor to publish as many perspectives as possible.