The Structural Care Model vs. The Biochemical Care Model

In attempting to try and categorize the different methods of chiropractic practice, certainly one of the major differentiating factors would be those practicing in a structural (or musculoskeletal) care model and those using more of a biochemical care model.

The musculoskeletal doctors would include anyone primarily using adjustments, manipulation, PT, exercise, massage, etc as the main treatment intervention. In the biochemical category we would find those primarily providing treatment using supplements, dietary advice, detox protocols, weight loss, and possibly drugs—although for this article, I am not going to include drug therapy as part of that category because it represents so few chiropractic practices.

So, which method of care is superior?

Or maybe the questions should be, "which method of care is more appropriate for a chiropractor to deliver"? Maybe practices should consider offering a little bit of both? How do we even go about answering such questions? Well, let's take a look!

History

The Structural Care Model certainly seems to be at the root of traditional chiropractic. The story of D.D. Palmer's first adjustment was certainly one of a structural intervention. And if we look at B.J.'s development of chiropractic we see definite focus on spinal/structural care but there are enough mentions of nutrition in his writings to know that B.J. appreciated the role of proper biochemistry in human health.

Chiropractic also has a long tradition of nutrition as a modality. There were very significant developments in the field of nutrition made by chiropractors. This is a significant part of our history.

History: EVEN

Philosophically

I am by no means an expert on chiropractic philosophy, however, I feel well versed enough in basic chiropractic philosophy, chiropractic history and practice to engage in a discussion of it. I think that any chiropractor could agree that structural care can have a profound effect on overall health, and influence biochemical indicators of health such as blood chemistry.

Also, an understanding of neurology or, simply the "safety pin cycle" would lead one to conclude that biochemical factors within the body can lead to structural problems such as subluxation. Into this latter idea would fall the aspect of chiropractic philosophy which suggests that trauma, toxins, and auto-suggestion are the root cause of subluxation. With these factors in mind, there seems to be an intimate relationship between the application of either structural or biochemical care with musculoskeletal health and proper body biochemistry.

In simple terms, it seems that the innate intelligence of the body could have a difficult, or maybe impossible task of healing the body, if the biochemistry of the body is too far gone. I believe that this would fall into the "limitation of matter" clause of chiropractic philosophy. And, of course, it would apply in reverse—a body with perfect biochemistry could cease to function or, at least function properly, with a severe enough subluxation of the spine.

So, that leads us to the question of whether or not it is the job of the chiropractor to help a patient handle his "limitation of matter" through a biochemical intervention, such as nutrition. There seems to be two logical answers to this question which lead us into the legal and ethical sections of this discussion.

Philosophically: SLIGHT ADVANTAGE STRUCTURAL BASED PRACTICE

(I say slight only because we are chiropractors. There is certainly nothing philosophically wrong with a nutrition bases practice)

Legally

A chiropractor can offer any type of care which falls under his scope of practice. So there is not advantage either way with regard to the law.

However, some practices that are providing biochemical care are also accused of practicing medicine without a license. I'm not suggesting that they are in fact practicing medicine without a license. But this type of practice has more exposure to problems with the medical board and chiropractic board, just by the very nature of what they offer, in terms of care. Therefore, it is very important to really know your laws, and what you are doing if you choose to practice in this manner.

Legal: ADVANTAGE STRUCTURAL PRACTICE

Ethically

Second, if the chiropractor becomes aware of a condition which adversely effects the patient, or limits the effectiveness of the structural care he is providing the patient, the chiropractor should inform the patient and either provide a solution, or guidance—or referral to someone or someplace who can provide a solution.

So, can a chiropractor provide biochemical care, such as nutrition? Well, he sure can as long as what he offers is in accordance with his scope of practice.

Should a chiropractor provide care with an emphasis on a biochemical model or structural model—well, it's up to him, as long as he's following the law. That leads us to the question of, "Which is better?"

Well, since I can imagine a patient encounter where either structural care or a biochemical intervention would be more appropriate and more helpful to the patient, I guess I'd have to say that it depends on the patient and the situation. I guess we could surmise that from the patient's perspective, a chiropractor who offers both types of care would be ideal.

This would allow the chiropractor to use whichever treatment protocol best matched the patient's condition or situation. In many cases, I can imagine that both would be appropriate for an individual patient.

[pb]Ethical Aspects: EVEN

Financially

From a financial standpoint, there are super successful practices which use either (or both) models. The key point which makes either one financially workable is the fact that there can be demand for both services. So, the success or failure of a particular clinic is not dependent on which of the two types of care is offered.However, there are some differences between the two types of care, with regard to demand.

Most offices which practice along the biochemical model, enjoy the fact that patients often arrive to their office with a significant and known health problem—for example fatigue or allergies. Or, the patient arrives with a known abnormal physiological indicator, such as high cholesterol. These two factors can change the playing field for a practice. The fact that the patient is aware of their abnormal condition and/or has been educated to be aware of physiological indicator such as high cholesterol makes it easier for the doctor to get a higher degree of compliance with recommendations.
The challenge can come in when the doctor has to help the patient understand the difference between a drug therapy (which is often easier and cheaper for the patient) and more natural alternatives (which are often harder and more expensive than taking a pill). However, on the flip side, often the patient who arrives at a chiropractors office for help with a thyroid problem is already a failed medical case, or is enlightened enough to know that they do not want drugs-- not always, but often enough to comment.

The major challenge for the chiropractor offering nutritional care for organic problems, is getting enough new patients in the door. So few people think of going to a chiropractor for organic conditions. Also, the major thinking in society is that medical care is the only option for Type-O conditions.

If the chiropractor in this type of practice can make himself well known, and bring in plenty of new patients, and sell his services effectively, this practice can be outstanding. Once initially sold on the idea of the care being offered, patient compliance is not the major issue.

If we compare this to most structural practices, we find that one of the main difficulties in musculoskeletal practices is often patient compliance. Unless the care being offered is exclusively symptom relief the doctor can often be left frustrated, trying to get the patient to understand why they need care beyond pain relief.

Most patients are unaware that there is anything wrong with them outside the fact that some part of their body hurts. The drug industry has educated people into believing that the problem is the pain. Therefore, the doctor who understands that the patient's chronic back pain and degeneration is due to the chronic abnormal biomechanics finds himself with an uphill battle getting through to the patient. That is why this type of practice, to be successful, needs a very good patient education system—which may not be necessary in a practice focused on, let's say, weight loss.

Because musculoskeletal problems are the main driver of patients into chiropractic offices, and because many of these diagnoses are eligible for insurance coverage, the structural care practice that accepts insurance does enjoy an easier sales cycle. The fact that many people in society associate chiropractors with spinal problems, or injuries, acts as an advantage if viewed from the perspective that people with these problems often walk into a chiropractor's office, or will easily understand that a chiropractor's care would be appropriate for their condition. This is an advantage over the nutrition doctor who hangs his shingle hoping to see patients walk in with demanding care for their thyroid condition.

There are definite differences, between the structural practice and biochemically based practice when it comes to income potential. However, if the business is run well, and the emphasis is placed in the correct places, then either model can be financially successful.

Financial Advantage: EVEN

Let's Compare "Props"

By props I am referring to those tests which, in addition to giving the doctor data on what is wrong with the patient and how to proceed with treatment, also gives the doctor a tool with which to educate their patient on the condition found—and the need for care.

In the typical biochemical model, the practice can use lab testing. There is a huge advantage with lab testing that has been created by drug company advertising. Because of all the money poured into promoting these tests for the purpose of drug sales, the public has been trained to be very afraid of test results that are outside of normal. This creates an environment where there is very little need to do much education, outside of showing the results and presenting treatment options. The drug companies have done the hard work, in getting people to understand the significance of an abnormal test.

Most structurally based offices use x-rays, or orthopedic testing to gather data and educate the patient on conditions found. These diagnostic tools require much more in the way of explanation to the patient. Most patients do not understand normal, nor do they understand the significance of abnormal. These tools can be very effective at achieving compliance, if used correctly to get the patient to fully understand their condition. However, most doctors do not fully appreciate the level of communication required to really get enough data across to the patient, in order for the patient to understand their condition well enough to make a self-determined choice to proceed with care.

Here, I'd have to say that the advantage (although not insurmountable by any means) goes to the lab testing.

Props: ADVANTAGE BIOCHEMICAL MODEL

I think that it is fair to say that no chiropractor can go wrong in choosing either type of practice, or a combination of both, as long as he gives it his all, and keeps in mind what is best for the patient. It will be very interesting to see how chiropractic practice evolves over the next 10 years. I think it is safe to say that it will certainly include aspects of both models discussed in this article.

OVERALL: It's up to You!