Spine Care: An Unlimited Opportunity for DCs

The American health care system is in crisis. We have an unsustainable growth in health care expenditures that will consume 20 percent of our gross domestic product within the next five years. Last year, this crisis culminated in passage of the Patient Protection and Affordable Care Act by Congress. Although parts of this act are currently being legally challenged, the health care reform train has left the station. The question is whether chiropractors are going to board this train, watch it pass by, or be run over by it.

There is a specific "subcrisis" within the broader health care crisis; the medical mismanagement of spine problems. Back and neck pain, as well as related disorders such as radiculopathy and cervicogenic headache, continue to be the most common reason for disability in American adults and the second most common condition for which patients seek medical care. Patients are faced with an environment in which a wide variety of practitioners offer a disparate array of diagnostic tests and treatments, many of which are completely unnecessary.

In addition, there is little or no coordination of services and no central resource to which patients can turn for guidance through the spine care maze. Spine surgery rates are higher in the U.S. than in any other nation in the world, inappropriate use of imaging and injections is rampant, and the number of Americans addicted to prescription pain medications is at an all-time high.

Primary Spine Care

Not only does this dysfunctional medical management of spine problems cause untold human suffering, but it is also extremely expensive. These runaway costs have created an enormous economic burden on taxpayers and employers. Our disjointed, disorganized and dysfunctional spine care "system" requires a primary-level physician who can serve as "primary care" for this group of patients – the primary spine care physician.

Someone has to step up and serve this primary spine care role. Who is this person going to be? The traditional primary care physician (PCP), who has minimal training in musculoskeletal diagnosis and management, is not the best choice. What is needed is a primary spine care physician who has the skills and willingness to embrace this role and become part of the solution to the enormous inefficiency, cost and poor outcomes we see in spine care.

Luck can be defined as when preparedness meets opportunity. Every crisis creates opportunities for those who are prepared. An unlimited opportunity awaits chiropractors who have the desire and skills to take on the role of primary spine care physician. Several of us have already assumed this role in our communities. We have seen first-hand the many benefits this role brings to patients and the health care system through appropriate primary spine care, which helps avoid the high costs and iatrogenesis of our current disjointed spine care "system." In addition, we have seen the personal and practice benefits the role of primary spine care physician brings:

• Sixty-plus new patients per month, the vast majority referred by medical doctors
• A highly successful and self-sustaining practice without the need for advertising or high-pressure sales
• High levels of patient satisfaction
• Serving as medical director of a hospital spine care program
• Invitations to speak at local medical conferences and hospital grand rounds
• Receiving referrals of many non-spine patients (extremity problems, facial pain, TMJ, dizziness, carpal tunnel syndrome and other NMS disorders) that results from having established credibility and respect in our core area of competence – primary care for spine-related disorders
• The option to address nonmusculoskeletal conditions that can promote musculoskeletal pain (metabolic syndrome, hyperlipidemia, irritable bowel syndrome, gluten sensitivity, hypothyroidism, vitamin D deficiency, obesity, dysmenorrhea, etc.)
• The opportunity to provide health promotion and wellness activities throughout a patient's lifetime

A Universal Problem in Need of a Solution

Yet some of our colleagues are quick to dismiss this huge opportunity, arguing that taking on the role of society's primary care spine physician is somehow "limiting" and "myopic." More than 80 percent of American adults will suffer from back pain at some point, and this condition tends to be episodic and recurrent. Add in neck pain and headaches and you are looking at nearly 100 percent of the population in need of primary spine care services.

Most of these patients are not receiving high-quality management and as a result, many are becoming chronic pain sufferers. A large percentage of these patients also suffer with diverse comorbidities that can be managed successfully by chiropractors. Billions of dollars are currently being poured into our health care system for the diagnosis and management of spine problems; much of it for unnecessary tests and inappropriate treatment. A primary spine care physician is desperately needed in health care. Given this, how could anyone consider a primary care role for a virtually universal condition (spine pain) to be "limiting" or "myopic"?

Necessary Skills and Attributes

The primary spine care physician can provide "one-stop shopping" for diagnosis, management and triage of all spine-related disorders. This physician must be able to manage the majority of patients with spine problems without the need for referral, and to understand the appropriate process of referral for diagnostic tests and/or invasive procedures. To play this role, the primary spine care physician must possess these skills and attributes:

• A broad-scope educational background in anatomy, physiology, pathology and diagnosis
• A strong broad-scope knowledge and training in differential diagnosis of disorders that can manifest as spine-related complaints
• The ability to order and interpret diagnostic tests such as MRI, CT, X-ray, EMG-NCV, and various metabolic tests
• Skills with a variety of nonsurgical treatments such as mobilization, manipulation, McKenzie, soft-tissue therapy, rehabilitative exercise, traction, and posture correction
• A keen understanding of the psychosocial factors that contribute to spine problems and chronic pain syndromes
• The ability to empower patients to care for themselves without overreliance on practitioner-driven treatments
• Knowledge in counseling patients about the benefits and risks of all treatment options for spine-related disorders, including both invasive and non-invasive procedures
• The ability to communicate and interact with other members of the health care team such as PCPs, surgeons, physical therapists, and psychologists
• The ability to serve as "captain of the spine care team"
• The ability to provide comprehensive lifestyle modifications for the myriad comorbidities associated with spinal pain, such as weight loss, posture education, diet and nutrition, smoking cessation, and the improvement of general fitness/exercise

A Perfect Opportunity

Chiropractors are well-positioned to move into the role of primary spine care physician for a number of reasons. First, we are the only health care profession with four years of graduate-level education focused on the spine and neuromusculoskeletal system. Second, chiropractors are already perceived by the general public as "doctors" and more specifically as "spine doctors." This gives us an automatic advantage toward gaining full cultural authority as primary spine care physicians. Third, DCs are trained in full-systems, broad-scope differential diagnosis and already have direct access to patients as portal-of-entry health care providers. And fourth, the philosophy of chiropractic – which emphasizes a natural, healthy lifestyle – is perfectly aligned with the current recognized approach to spine problems that considers the whole person.