Analysis of the Diagnosis
By Reed Phillips, DC, PhDEverything is vague to a degree. You do not realize how vague until you try to make it precise.
-- Bertrand Russell
At the beginning of the second century of chiropractic, the Association of Chiropractic Colleges, composed of 16 chiropractic colleges in North America, released two position statements
Since the release of those two statements, discord continues in the ranks. For example, the Council on Chiropractic Education (CCE) passed a motion to increase admission standards. While the voting was not unanimous, a two thirds majority carried the motion. In the ensuing months, well before the change was to take effect, one member of the band objected to the change and filed a complaint with the U.S. Office of Education in protest against the CCE. This same school now threatens legal action and has filed a second complaint to the U.S. Office of Education claiming that such action to improve standards discriminates against minorities.
It is not my desire to argue the value of increasing admission
A good example is the issue of diagnosis. The ACC statement reads as follows:
2.0 Defining Chiropractic Scope
Since human function is neurologically integrated, doctors of chiropractic evaluate and facilitate biomechanical and neurobiological function and integrity through the use of appropriate conservative, diagnostic and chiropractic care procedures.
3.0 Defining Chiropractic Practice
A. Diagnostic -- Doctors of chiropractic, as primary contact health care providers, employ the education, knowledge, diagnostic skill, and clinical judgment necessary to determine appropriate chiropractic care and management. Doctors of chiropractic have access to diagnostic and/or referral resources as required.
Analysis or Diagnosis?
Colloquially speaking, diagnosis and analysis are interchangeable terms. We frequently immerse ourselves in the process of analysis. It is time to buy a new car. A conclusion based on an analysis of current transportation needs balanced with revenue, savings and expenditures. The next step in the analytic process is to decide the type of car. Many variables are plugged into an equation that weighs value, dependability, style, personal needs, etc. We ponder the advertised sales. We barter with the sales staff and their ever-elusive managers. Finally, our analysis leads to the conclusion to buy and we proudly drive the shiny new vehicle home and show it off to the neighbors.
After a fitful night's sleep, where thoughts of monthly payments have displaced the sheep, we arise for a joy ride. To our surprise, there is a rattle, a squeak, a wobble in the wheel or something that wasn't noticed before. Our minds immediately spring into action as we strive to determine the source of the anomaly. We delve deeply into the process of diagnosis. First, it is a system check. No red lights flashing on the dashboard and no oil leaks underneath. We peer under the hood to see if something has come loose, or if some fluid level is less than optimal. We listen intently as the engine purrs, then sputters, and finally we decide to have a mechanic take a look.
The first step to a diagnosis, after confirming a suitable method of payment for service, is to take a history. This is followed by routine screening tests conducted with a variety of instrumentation connected at various critical points or pushed into a gas emitting orifice (the tailpipe). The rattle can be rehabilitated with the tightening of a screw. The squeak is lubricated into nonexistence and the wobble in the wheel is corrected by adjusting the alignment of the wheels. Later we follow with preventive maintenance care, oil changes, tune ups and transmission checks. If we are diligent in the care and keeping of our vehicle (no hot rodding, no four wheeling), longevity of service with minimal repairs is hoped for. Even with our best care, systems fail and more radical procedures are required.
Application to a Patient
A patient's most precious possession, even more precious than the new car, is their health. When healthy, they proudly demonstrate their strength, the agility and endurance by prancing down the street in the latest running wear or unveiling massive motifs of muscular bulges through spaghetti strap tank tops at the gym. But the presence of pain and illness drains them of energy and ego, and the recognition that help is needed drives them from the gym into the doctor's office. Some degree of analysis of one's current functionability leads to the conclusion that help is needed.
When they enter the doctor's office, the process of diagnosis begins. After a method of payment has been determined a history is taken. Actually, the mere presence of a person with a complaint indicates mobility and warmth, two significant indicators that life is present. A diagnostic analysis has already begun.
A history is designed to give the clinician some indication why the patient came to the office. It is an important part of the diagnostic evaluation or the process of spinal analysis. The depth of the history can vary from a simple explanation of the event or events leading to the decision to seek care, or it can encompass an in depth analysis of previous conditions, family health and other health related items. The extent of historical information obtained likely varies according to clinical objectives.
Heart rate and sounds, respiratory rate, height, weight, blood pressure and temperature constitute the bare essentials of a diagnostic process designed to differentiate normal from abnormal findings. I assume the presence of abnormal vital signs could be considered indicators of a spinal subluxation and thereby constitute the bare essentials of a spinal analysis.
Subluxation Based Chiropractic or Condition Based Chiropractic
The college presidents agreed that beyond the determination that a patient is alive and can pay their bill, a diagnosis should be established. The disagreement enters when diagnosis is defined. If one falls to the "condition" side of the spectrum, a detailed history, vital signs and multiple examination procedures are usually included in the definition. A subluxation may actually be a condition included in the diagnostic appraisal, and its removal could be part of a treatment program.
A subluxation based approach to care will place a greater emphasis on a variety of methods designed to determine the presence or absence of a subluxation. Condition defining procedures may or may not be helpful in the determination of the subluxation. While conditions may be present, they do not fall into the realm of a treatment program designed specifically for the removal of subluxations.
The basis for disagreement lies in the depth of the application of the meaning. In a colloquial sense, diagnosis and analysis can be interchanged. So when the ACC speaks of diagnosis, analysis could be substituted in the minds of some. However, when taken to a more precise level, the two terms differ significantly in their application.
When a patient goes to a doctor, much like when we take our car to the mechanic, we place trust in those individuals and presume their skills are sufficient to effectively render an improvement to an unsatisfactory condition. The subluxation based chiropractor informs the patient at the beginning of the doctor patient encounter that subluxation detection and removal is their sole purpose. Conditions and their associated signs and symptoms are only relevant to the extent they support the subluxation detection. Any unusual or abnormal findings in the subluxation detection process (spinal analysis) would warrant the need to seek care from another health care provider. This scenario is not unlike the mechanic and the car. The subluxation based approach is more like a specialty shop, such as a tire and brake store, as opposed to a full service garage. The level of expertise and the thoroughness of the process can and should be at its highest level. Tires and brakes are no trivial matter in the transportation business. This metaphor breaks down, however, when one tries to link poor tire alignment to improper engine function.
The condition based approach assumes responsibility for the signs and symptoms with which the patient presents. This responsibility implies that the doctor will identify the appropriate need for care or will make an appropriate referral if necessary. Here again, application of meaning takes on significance. To what level is the doctor of chiropractic expected to conduct the diagnostic process? A history and vital signs can indicate the presence of abnormal findings. System review allows one to isolate the system(s) involved. Laboratory and radiographic findings add to the accumulation of knowledge. A myriad of specialty exams are now available.
No one individual can be an expert in all aspects of diagnosis. However, a level of commonality can be achieved that assures proper patient care. Even though a full service shop may not have the ability to change a transmission, they have the ability to recognize that the car has a transmission problem and can make the appropriate referral.
So where does this leave us? Both the subluxation based and the condition based chiropractic approach will argue that they are patient centered. What they are doing is improving the patient's health. Both will argue that their methods of diagnosis or analysis are rigorous and demanding; that thorough training is essential to be competent. Both believe they are rendering a needed service and can cite numerous examples of success in the application of their services. Scientific support leans more to the condition based approach primarily because of the long standing relationship with traditional medical care. Furthermore, the subluxation based approach suffers from multiple definitions and a short history of developing reliable detection methodologies.
The practice of chiropractic covers a wide spectrum. At the two ends of this spectrum are the two approaches to diagnosis previously described. If we are a mature profession dedicated to the health and well being of our patients (the public), then it is imperative that we define ourselves for what we really are. We need to recognize that there are two kinds of chiropractors who have different objectives in their approach to patient care.
Reed B. Phillips, DC, PhD
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