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Don't Run Our Future Into the Ground

Dear Editor:

I just read "A Call for Higher Standards" by Dr. John W. O'Neal (DC, Feb. 24, letter to the editor) and agree with him wholeheartedly. As a student at Palmer College of Chiropractic, I find the attitudes of some of my fellow students quite disturbing. I think I've actually taken a step back in maturity level since leaving Kansas State University. It's as if I'm in high school again. How is the public supposed to entrust their health in chiropractors when the standards to get into school are so low? The medical profession is held to high standards; consider how challenging and competitive it is to get into school, much less become a doctor. Don't get me wrong: There are intelligent students who deserve to be here, but many do not, and they are the ones who cause the problems. Studying to become a doctor should not be considered a chore or an inconvenience - what did these people think they were in for when they enrolled in a professional school? Students miss class frequently and cram for tests, which we all know does not constitute learning the material. These students just want to pass with the bare minimum. Why would anyone try to get an "A," when all you need is a "C"?

Motivation and professionalism are needed to become the best. Students without such qualities would not be here if decent standards were required to matriculate to a chiropractic college. A grade point average of 2.5 in undergraduate work would be laughed at by a medical school; why does a chiropractic college open its arms wide to this type of candidate? True, a 2.5 GPA isn't so bad, but let's not kid ourselves, it is not doctor material. I feel colleges want to make money and get as many chiropractors out there as possible, just to compete numerically among the health-care professions. This causes an output of poor practitioners, which kills our profession. We have a great profession, so let's have only the best out there building our cause. I may seem pompous and cocky, but there are some people in my class I could not imagine having the esteemed title of "Doctor." Step it up schools; it's our future your dealing with, please do not run it into the ground.

Tyler Fowler
Davenport, Iowa

Dear Editor:

Although I share many of the concerns expressed by John W. O'Neal, MS, DC, in his letter to the editor, I believe he has overlooked a central factor in the matter of upgrading education. U.S. chiropractic schools are not going to improve significantly unless and until they find alternative sources of revenue. With tuition dependencies of 70 percent to 90 percent, these poverty-stricken institutions will do what they must to survive. Raising admissions standards is fine, as far as it goes, but the real challenge is to increase selectivity in the admissions process. There doesn't seem to be much point in administering an entrance examination, if a college is going to accept anyone who meets the minimum standards (whatever they may be) and can afford the hefty tuition. Excessive tuition dependence impacts not only the choice of students, but that of faculty, staff and quality of educational services.

B.J. Palmer worked out a financial dynamic for chiropractic education a century ago, and there has been little deviation among American colleges (outside the U.S., things have improved). I look optimistically to the model that may be created by Florida State University. A few schools receive a bit of help from state governments. There may be other, nontuition sources of support for the training of chiropractors, such as private philanthropy and profit-generating subsidiaries at the nonprofit colleges (e.g., nursing homes, academic publishing). Requests for greater support from alumni and the field-at-large date to as early as the 1920s, and the ACA contributed significant dues dollars to the schools during the 1960s to aid in the quest for federally recognized accreditation. These days, the American schools are pretty much on their own. Individual colleges may or may not like the rut they're in, but they haven't yet found a way to climb out.

Joseph C. Keating Jr., PhD
Phoenix, Arizona

Dear Editor:

I have a goal of joining the ACA as soon as I am solvent and show a profit. I thought this would be accomplished by now, but every time a funding source becomes available, such as IMEs, videofloroscopy, EMGs and physical modalities, there are those (DCs) at my state level who move quickly to disqualify me as a provider of that service. I don't believe most really care about the philosophy attached to the nonadjusting procedures. I just think it is so difficult for all practices to succeed that many want to see others limited and failing; misery loves company. In my state, we have a DC working for Medicaid who is paid to sign off on reviews that deny payment to DCs if they don't have yearly radiographs on Medicaid patients - even in the case of pregnancy.

The ACA moves forward on stuff such as the VA to have another fight with the DC chairing the committee. I fight all day long to stay above water!

And then there's that "patient thing!" I was born a health care provider. I chose chiropractic not because of a desire to fulfill its dogma, but because it most closely fit my convictions and talents. In fact, I believe the chiropractic dogma sometimes prevents me from providing the most humane care to my patients. To sacrifice and give money to the ACA, when many DCs actively and ignorantly suspend compassion in the name of ideology, would be inconsistent with my value system.

As stated, when I have profit, the ACA will be paid. I hope that's this year. Please encourage those who came first to fight for profitability for my generation. Further note, I write my congresspersons, and lobby state and local officials actively. Not paying the ACA doesn't mean I don't fight for DC patient care.

Tracy Hendershot, DC
Mineral Wells, West Virginia

Editor's note: The following letter was sent to Steve Freeman, DC, in response to his article, "Peer Review & Professional Responsibility" (DC, Feb. 24, 2003).

Dr. Freeman:

I wanted to drop you a quick note to thank you for your article. Your philosophy is exactly what we need to hear, and too few of us are preaching it. I have preached it for many years, and can see both sides of the issue. I have been in practice 21 years, graduated from a "straight" college (PCC), and have also been an IME doctor since 1987. I have performed over 400 IMEs, usually for auto-accident or workers' compensation cases. I have literally "seen it all" - good doctors and bad doctors, neurotic patients, malingerers, and severely injured patients with legitimate problems. I also have given many seminars to insurance adjustors, to inform them about chiropractic issues and how to properly adjudicate chiropractic claims. I also practice in Michigan, arguably the most restricted of all 50 states, and have seen what happens when licensure is too narrowly constructed. For all these reasons, your discussion of peer-review reality was most appreciated.

I'd like to mention several other problems we also need to address:

1. Most egregious cases of overutilization occur with a handful of doctors. These shady characters abuse the system because they have institutionalized the tactics within their practice philosophy and procedures. Essentially, they are greedy, so when the cash-cow auto cases come through their doors, they inherently try to milk the cows dry. Our state licensing boards are not doing a good job reining in these abusive few in our ranks. We need to start suspending and revoking licenses for doctors with unethical patterns of behavior, not just those convicted of criminal or sexual misbehavior. I think we should broaden our disciplinary tactics to include ethical breaches in billing and utilization. In all my years of practice, I have never seen a chiropractor reprimanded for ethics violations, so long as he or she has technically not broken any laws. This a sad state of affairs that assures the continuation of the worst doctors among us.
2. We must acknowledge that we have allowed the philosophy (and especially the "high-volume" cultism) of some of the practice-builder gurus to permeate our practice philosophy. Sadly, many of these guys teach our CE classes and are featured as keynote speakers at our state conventions. Our colleges (Life University is the most obvious example) also have not done a good job in speaking out against such chicanery. We all know how disastrous this "philosophy-over-science" mentality was in Life's current problems. Instead of rallying the troops to march on the CCE, we need to encourage our troops to applaud the whistleblowers and sustain those who call for higher ethics and standards. We should be grateful whenever our house gets cleaned, rather than grumble at the "trouble-makers" who find the dirt in our corners.

   With respect to your article, I would debate your first two points about "utilizing all chiropractors (for peer review) on a random basis." In theory, this would be good, if we could be assured that the overutilizers and abusers needing review themselves were somehow excluded from this pool. Otherwise, it would quickly become a "good-old-boy" network by which one hand washes the other. And frankly, a good IME requires major time and talent. I typically put in four hours, or much more, for each IME I perform. A high-volume practitioner with questionable ethics would never devote the effort to do it right. Some of these cases have hundreds of pages to review, tracking many years of care and dozens of involved specialists. I question whether our general chiropractic body could adequately perform IMEs without training.

   Your second point also addresses a legitimate point about "dictating a predetermined number of peer reviews an individual doctor may perform over the course of one year's time." You suggest this to avoid a class of "professional reviewers." My point here to you would be that just as you want a professional judge with years of experience on the legal bench, the experience and expertise of a well-informed chiropractor is exactly what the insurance companies want to adjudicate these cases. They don't want the arbitrary impression of every Tom, Dick and Harry who has a chiropractic degree locking them into future costs and care approval, as much as it gives them an "out" if the opinion recommends case closure. Therefore, many third parties now require a certification or approval process for their IME doctors. This would not be viable to all DCs by virtue of their chiropractic license alone.

   I think this second point is also addressed by requiring that IME and peer-review doctors be in full-time practice, and that a set percentage of their income be earned in full-time practice, rather than in peer review. For example, most of my IME contractors have in-house qualifications that at least 85 percent of my income be generated through my seeing of my own patients. This assures them that I have no financial interest in altering my findings to please them, and enhances my claim of impartiality. They are not stupid, and they realize a doctor who only puts bread in his or her mouth by doing peer reviews can easily be challenged about this in court. Therefore, my point is not that I disagree with your motive, but rather that this is usually a nonissue with ethical third-party review companies.

   Other than these few provisos, I wholeheartedly support your excellent article. I hope more voices emerge to help us learn to accept and even embrace peer review. We need to elevate our professionalism and accept the responsibilities that come with it. Thank you again for your comments.

Garth Aamodt, DC
Grand Rapids, Michigan