Primary Spine Care: Addressing Concerns & Criticisms

The Dec. 1, 2013 issue of Dynamic Chiropractic included an article describing the implementation of a training program for primary spine practitioners (PSP) within a metropolitan region and supported by a large BC/BS plan. The role of the PSP had been described previously in an article in Chiropractic & Manual Therapies and several other DC articles. Over the past year, we have listened carefully to a number of concerns and criticisms about the PSP role for chiropractic physicians, and respond as follows:

1. Breaking Down Limits

The PSP role is not limiting; on the contrary, it breaks down limits. Spine-related disorders (SRDs) cost society more than $90 billion in direct costs and at least that much in indirect costs every year. Any group that can help solve the epidemic of disability and costs related to SRDs will be highly valued by society.

Chiropractors currently see approximately 7.5 percent of the population, while virtually 100 percent of the population experiences SRDs at some point in life, with many suffering from chronic and recurrent problems. Thus, chiropractors who move into the role of society's primary care practitioner for spine problems can expect to see a dramatic increase in the number of patients who seek their services.

2. Prepared to Serve

DCs are currently the professionals who, by virtue of their education, have the best background to be trained to serve in the PSP role (i.e., require the least amount of additional skill-enhancement training). Critically important is the fact that the public currently sees the chiropractic profession as "doctors of back and neck pain," although the vast majority of patients who see chiropractors do so for SRDs.

3. Primary Care Teamwork

The PSP is a key member of the primary care team. In many states, chiropractors are considered physicians. The PSP role reinforces this physician status. The PSP requires the knowledge and skills to take a comprehensive history and examination, develop a differential diagnosis and treatment plan, manage the majority of patients with SRDs, and refer for testing and consultation when necessary. In addition, as a primary care practitioner for spine problems, the PSP is responsible for coordinating the activities of all personnel involved in the care of the SRD patient.

4. Leading the Way in Wellness

High-quality primary spine care focuses on health and wellness. While the primary reason a patient may see a PSP is for help with a spine problem, the PSP recognizes that an SRD is a biopsychosocial phenomenon involving the whole person. In many cases, psychological factors can play the strongest role in perpetuating the problem, necessitating the PSP to address these factors in the context of the management of the somatic factors.

In addition, chronic SRDs are often just one aspect of a wider pattern of ill health that includes obesity, metabolic syndrome, diabetes, and cardiovascular risk factors. As such, the PSP will often be called upon to help address issues such as diet, weight loss, smoking cessation and exercise.

5. More Than Spine Care

While spine problems are the focus of the PSP, it is essential that the practitioner be competent to evaluate and manage all manner of non-spine musculoskeletal conditions. For example, the differential diagnosis and management of patients with sacroiliac joint problems often must include evaluation of the hip joint. In many patients with difficulty walking due to lumbar spine stenosis, knee pain contributes to the walking problem. This necessitates the PSP being competent in diagnosing and managing the knee problem along with the stenosis. The PSP recognizes that SRDs do not necessarily occur in isolation. Again, treating the patient as a whole person is essential to good primary spine care.

Embracing the PSP role will allow DCs to gain the trust of the public, allowing each DC to leverage that trust in branching off into whatever area of practice they choose – sports injuries, extremity disorders, nutrition or even primary health care. That said, we must start where the public currently sees us and has some measure of trust with us.

Adopting the PSP model as a professional identity makes tremendous sense for all the reasons enumerated above, and creates wonderful opportunities for chiropractors who pursue serving in this role. The PSP role becomes our foundational identity – not the total definition of who we are, but the foundation of who we are: physician-level health care providers whose focus is on spine-related disorders (but whose ultimate goals center on the health and wellness of our patients), and are also skilled in the evaluation and management of many other non-spine-related health conditions.

Authors' note: Those familiar with the biography of Scott Haldeman, DC, PhD, MD, should read the last chapter, an autobiographical chapter, describing the opportunities available to the chiropractic profession should we embrace the PSP role.

Resources

• Ventura JM. "Advancing the Primary Care Spine Practitioner." Dynamic Chiropractic, Dec. 1, 2013.
• Hawk C, et al. Prevalence of nonmusculoskeletal complaints in chiropractic practice: report from a practice-based research program. J Manip Physio Ther, 2001;24:157.
• Hurwitz E, et al. Use of chiropractic services from 1985 through 1991 in the United States and Canada. Am J Public Health, 1998;88(5):771.
• Murphy D, et al. The establishment of a primary spine practitioner and its benefits to health care reform in the United States. Chiro and Manual Ther, 2011;19(17).
• Philips R. The Journey of Scott Haldeman DC, PhD, MD, Spine Care Specialist and Researcher: Forging International, Interdisciplinary Cooperation. National Chiropractic Mutual Holding Company, 2009.