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We Need More Training to Prescribe

Dear Editor:

My colleague, Dr. Tim Levin, submitted a letter to the editor in the June 15, 2013 issue of DC with the title, "We Are the Most Overtrained Profession in the Country." In his letter, Dr. Levin argues in favor of doctors of chiropractic having prescription rights. While I agree with Dr. Levin that the chiropractic profession should push for prescription rights, I have to respectfully disagree with his comment, "I think that chiropractors coming out of school today are well-educated." He goes on to state, "It seems like we are the most overtrained profession in the country for what we are trained to do."

In addition to a full-time chiropractic practice, I am also involved in education. I am a faculty associate at Arizona State University in the kinesiology program, teaching exercise physiology and functional anatomy & kinesiology to undergraduate pre-health-care profession students. My office is also an internship site for seniors in the ASU kinesiology program and for senior chiropractic students. I have been dealing with pre-chiropractic students, current chiropractic students and new chiropractic graduates for my entire career. I have also employed several newly graduated associate doctors of chiropractic in my private practice.

What Dr. Levin, and numerous others in our profession, fail to understand is that it is the lack of training chiropractic students receive that will prevent us from having prescription rights as a profession. Medical doctors, doctors of osteopathy, physical therapists,nurse practitioners and physician assistants are better trained and educated than chiropractic students are. These other professions require a bachelor's degree and an admission test (MCAT, GRE) for admission. The only chiropractic college that requires a bachelor's degree is National University of Health Sciences. No chiropractic college requires an entrance examination. It takes more education to get into law school than chiropractic school.

Once in chiropractic college, classroom education is not a problem. I believe our teaching faculties of DCs, DACBRs and PhDs are excellent. It is the lack of clinical education, experience and training that is an issue for our profession. Our students graduate with a miniscule amount of clinical training and experience in comparison to other health care graduate-school programs. Added to that, nearly every MD or DO does some type of residency after graduation, providing them with more clinical experience than our graduates, who have limited / no access to such a residency.

I have never met a new chiropractic graduate in 18 years of practice who was competent at physical examination, diagnosis and manipulation. Our students are not adequately trained to provide the services within our current scope of practice, let alone trained to add prescription rights to our scope of practice.

In order to have prescription rights for our profession, chiropractic has to prove that its education and training requirements compare with any other health care profession with prescription rights. Our admissions standards must be the equal of the medical and osteopathic professions. Our clinical education and training must be on par with our classroom education, and post-graduate residencies must become standard. Other health care profession students laugh when I tell about the admission requirements and clinical training of chiropractic students, and I don't blame them.

So, I am baffled by Dr. Levin's statement, "We are the most overtrained profession in the country for what we are trained to do." What we should be trained to do is the same thing any health care professional should be trained to do: make life-or-death diagnostic and treatment decisions for our patients.

I recently ordered a contrast lumbar spine MRI examination for a patient with lower back pain and found an intradural cystic enhancing mass (a schwannoma). I consulted with the radiologist who read the film and referred the patient to a neurosurgeon at Barrow's Neurological Institute, where the tumor was removed and the patient is now doing well. This patient had been in pain for over a year and had seen several DCs who failed to diagnose his condition.

Diagnosing this type of condition, ordering the proper advanced imaging, consulting with other health care professionals, making the proper referrals to specialists, saving people's lives … this is what doctors of chiropractic should be trained to do, and no one can be overtrained to do that.

If we can add prescription rights to our scope of practice, I am all for it, and I applaud Dr. Levin for speaking out on the subject. But it will require raising our admissions standards and expanding our clinical training. Our profession will need more training to get prescription rights, not less.

Steven Brown, DC, Dipl. Med. Ac. (IAMA)
Tempe, Ariz.

Editor's Note: The following two letters to the editor address Dr. Thomas Klapp's three-part article series, "The Case Against Drugs in Chiropractic." Part 3 begins on page 28 of this issue.

We Must Become the Preferred Natural Primary-Care Source

Dear Editor:

I'd like to offer a different perspective on the inclusion of pharmaceuticals in chiropractic practice. To begin an article regarding the inclusion of pharmaceuticals in chiropractic practice by referring to those of us seeking to advance our scope as "pharma-practors" implies that we would bypass everything that we know and love about our profession, and ignores our stated desire to use manipulation and functional medicine as primary care and pharmaceuticals as a last resort.

Dr. Klapp states that we must have "full inclusion" as chiropractic primary care providers, which begs the question: What does "full inclusion" mean to Dr. Klapp? If our current status with Medicare seems perfectly fine ... then he must remain satisfied with getting reimbursed for only a fraction of what we can do.

Regarding remembering why we were separately licensed in the first place, chiropractic began in an era when allopathic medicine relied on such things as treatment with mercury, arsenic,cocaine, and strong "purges." Medicine has advanced considerably since that time, but Dr. Klapp feels that chiropractic should be embalmed and forever entombed as the profession dedicated to finding and correcting subluxations.
To suggest that chiropractors seeking to expand our scope wish to "ultimately destroy chiropractic" is ridiculous in the extreme; the only way to save our profession is to bring it into the 21st century as the preferred natural primary-care source.

With regard to the moral argument for drugs: There certainly is a moral argument to be made for chiropractic to be the primary care of choice with some pharmaceuticals in our arsenal; patients are much less likely to be led down a pill-strewn path by a physician skilled in manual and functional medicine than by a provider whose only education is the chemistry-driven allopathic model.

With regard to the idea that one must have prescriptive rights to be a primary care physician: Dr. Klapp, whether you agree in principle or you don't, our ability to counsel patients regarding their meds, and to suggest treatment via manipulation and natural medicines, depends on our having prescriptive rights Without those rights, we cannot fully function as primary care physicians. Period.

With regard to states' rights to determine our scope: States do have the right to legislate scope, but we need to all agree on basic parameters for practice, including a formulary. To have such division within the profession and from state to state makes us look unprofessional and disorganized.

With regard to Dr. Klapp's statement that those suggesting a wider scope insist their patients need drugs to get out of pain, I would ask that he poll members of the advanced-practice community to find out just how many of them have utilized the muscle relaxants in their formulary. He would receive answers ranging from "never" to "very few times." And with prescriptive authority, if we encounter a patient using pain meds, it gives us the ability to counsel and assist them in reducing their dependence on those very harmful substances.

The position of those seeking a wide scope is and always has been to have the widest scope,the biggest umbrella that we can manage, and then each physician can treat in the manner they feel best serves the patient. Allopathic medicine has done this successfully for decades. It's time that we take a look at what is working and mobilize it to our greatest benefit.

Cathlynn Groh, DC, APC
Sante Fe, N.M.

Allow Doctor and Patient to Agree on Treatment Choice

Dear Editor:

Dr. Klapp wants all advanced-practice chiropractors to step back in time and not include any benefits patients may gain from our new skills and knowledge. By adding remedies like homeopathic and herbs, we can shift patients away from prescription medicines and even over-the-counter medicines at the pharmacy.

I ask all my patients with back or neck pain what they are taking to lessen the pain levels. Eighty to 90 percent answer that they are taking a NSAID or a prescription muscle relaxant before seeing me for help. Now the conversation is open for discussion with our patients about other choices for treatment. It is not to be imposed on all patients.

We always need to have judgment regarding our choices of treatment, whether it is an adjustment, a modality or even a nutritional supplement. We need to allow the doctor and the patient to agree on the treatment of choice.

Harold Steinberg, DC, APC, DACBN
Sante Fe, N.M.