Recently, I read on the International Federation of Chiropractors and Organizations (IFCO) website that "Danny Knowles led a charge at recent board meeting to better define what chiropractic is and what chiropractors do in his state." The IFCO stated that the Colorado Chiropractic Association approved new standards of care. After reading the Colorado Chiropractic Practice Act, I doubted a responsible chiropractic association such as the CCA could have approved such standards.
It is my opinion that the new standards of care eliminate the need to make a diagnosis prior to chiropractic treatment. I teach diagnosis is the key to successful treatment. In addition, it is the legal and ethical to gain informed consent, which requires a diagnosis prior to treatment.
Unfortunately, my research found some evidence of these drastic changes. An email communication from a member of the Colorado Chiropractic Association confirmed that the new standards of care were passed at a CCA meeting on Sept. 11, 2015. Dr. Knowles, editor of the Circle of Docs, a social network of chiropractors, posted "Colorado Chiropractic Association Approves the Chiropractic Practice Act" on the Circle of Docs website,1 noting, "The following motions were passed by the Colorado Chiropractic Association as official positions as a result of the efforts of its members":
"Whereas addressing subluxations and spinal adjustments are central to The Colorado chiropractic practice act. The Colorado Chiropractic Association considers it standard practice and an acceptable standard of care for practitioners to choose to deliver care solely for the location analysis and correction of spinal subluxations in child and adult patients, regardless of whether symptoms are present. Subluxations are in and of themselves a detriment to one's health. [Italics added]
"Whereas The Colorado Chiropractic Association is concerned with practitioners delivering quality chiropractic care, the CCA considers it standard practice and within the acceptable standard of care, as noted in recognized clinical practice guidelines, to take x-rays for the location and analysis of spinal subluxations when clinically indicated. Clinical indications include evidence of subluxation demonstrated by chiropractic examination, and is not limited to patients presenting with symptoms or a history of trauma.
"Whereas the Colorado chiropractic Association considers patient safety a priority, the Colorado Chiropractic Association considers it an acceptable and standard practice for chiropractic practitioners to deliver chiropractic care solely for the location analysis and correction of spinal subluxation and for practitioners to choose to focus their scope of practice to that practice objective when an informed consent is obtained from the healthcare consumer. [Italics added]
"Whereas the Colorado Chiropractic Association supports free-market competition in the healthcare marketplace, the Colorado Chiropractic Association supports chiropractic practitioners and their patient's right to lawfully contract privately for professional services, and is opposed to regulatory agencies interfering with the ability of chiropractors to enter into lawful contracts for the provision of professional services.
"Whereas multiple health care professions including dentistry and medicine utilize open office design concepts. The Colorado Chiropractic Association considers it standard practice and within the acceptable standard of care to deliver chiropractic care in an open adjusting room setting as long as provisions are made to respect requests for patient privacy and the chiropractor complies with HIPAA privacy regulations.
"Thank you to the IFCO for their incredible effort and support."
If the Colorado Chiropractic Association membership and leadership intend to provide evidence-based, patient-centered care based upon the state statutes, chiropractors are required to diagnose and analyze patients for human ailments. The practice act does not permit chiropractors the opportunity to avoid the responsibility to diagnose the reason for a patient's ailment. Article 33 specifically states that chiropractic includes the diagnosing and analyzing of human ailments, and seeks the elimination of the abnormal functioning of the human nervous system. According to Article 33: Chiropractors, Part 1: General Provisions (1.7):
"'Chiropractic' means that branch of the healing arts that is based on the premise that disease is attributable to the abnormal functioning of the human nervous system. It includes the diagnosing and analyzing of human ailments and seeks the elimination of the abnormal functioning of the human nervous system by the adjustment or manipulation, by hand or instrument, of the articulations and adjacent tissue of the human body, particularly the spinal column, and the use as indicated of procedures that facilitate the adjustment or manipulation and make it more effective and the use of sanitary, hygienic, nutritional, and physical remedial measures for the promotion, maintenance, and restoration of health, the prevention of disease, and the treatment of human ailments."[Italics added]
The Colorado Chiropractic Practice Act requires chiropractic schools/colleges to teach chiropractic students to perform a diagnosis. In fact, the law states that training chiropractors to diagnose is a minimum educational requirement. Without the performance of a differential diagnosis, how would a chiropractor know when to treat a patient or refer them to another health care provider?
§ 12-33-111. Licensure – minimum education requirements. Group 6: Diagnosis (to include, but not be limited to, physical, clinical, laboratory, and all other recognized diagnostic procedures), pediatrics, dermatology, syphilology, psychiatry, and X-ray.
Yet, based upon the new standards of care, it appears that a chiropractor may limit scope of practice to analyzing the spine for subluxation only, which would eliminate the requirement to make a diagnosis prior to treatment: "The Colorado Chiropractic Association considers it standard practice and an acceptable standard of care for practitioners to choose to deliver care solely for the location analysis and correction of spinal subluxations in child and adult patients ... and to choose to focus their scope of practice to that practice objective." [Italics added]
This year, I was interviewing a patient with a chief concern of low back pain. She appeared to be unkempt, confused and agitated, and was a poor historian. I noticed the fingers of her left hand were in a constant state of flexion. Immediately, I suspected a stroke. She admitted to a recent episode of severe headaches, which had caused her to visit the emergency room. According to the patient, the ER doctor had examined her for a heart attack and found no signs of such a condition.
When I advised her that she was presenting with signs and symptoms of a stroke, she became quite aggravated with me. At that time, I sent an instant message to one of our primary care providers, advising her that this patient did not need a chiropractic examination for lower back pain, but medical care for a stroke. The primary care provider, who agreed with my diagnosis, immediately prescribed appropriate medical care for the patient.
Fortunately, I have the luxury of working within a community health center staffed by medical doctors and advanced-practice registered nurses (APRNs) trained to provide primary care. What would have happened to this patient if I were in a private practice and had elected not perform a diagnosis, but instead searched for subluxations?
Dr. Michael Kohler wrote in a previous issue of DC that the legal definition of the chiropractic standard of care may vary slightly from state to state, but the essential concept is: "What a (licensed) prudent, competent doctor of chiropractic in the same region would do in the same or similar circumstances."2
The American Chiropractic Association claims doctors of chiropractic are educated as primary-contact health care providers, with an emphasis on diagnosis and treatment of conditions related to the musculoskeletal system (the muscles, ligaments and joints of the spine and extremities) and the nerves that supply them. Educational requirements for doctors of chiropractic are among the most stringent of any of the health care professions.3
It appears the above CCA standards of care do not protect the public, but permit chiropractors to determine whether a diagnosis is necessary prior to treatment of a patient with a chiropractic intervention. This type of irresponsible behavior by chiropractors should not be considered appropriate based upon a trade organization's standards of care. The Colorado Chiropractic Board of Examiners is appointed by the governor to protect the public. It is time for the board to denounce the CCA standards of care.
According to the CCA's Code of Ethics, the association does not condone any illegal and/or unethical activities. Officers and members found guilty of such activities shall be subject to board disciplinary action, as outlined in the association's policies and bylaws.4 It appears the officers and members of the CCA should immediately rescind the CCA's most recent standards of care, which subject chiropractic patients in Colorado to dangerous and negligent doctor-centric behavior, and appear to be both illegal and unethical.
References
Editor's Note: Contact the author with questions and comments via email at jlehman@bridgeport.edu.
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