Dynamic Chiropractic – July 30, 2007, Vol. 25, Issue 16

Threat or Opportunity?

By Donald M. Petersen Jr., BS, HCD(hc), FICC(h), Publisher

According to a 2004 National Ambulatory Medical Care Survey, musculoskeletal conditions were the number-one reason for visits to U.S. medical doctors, with approximately 92.1 million cases reported annually.1 Doing the quick math, if those people went directly to their chiropractor (a musculoskeletal specialist) instead of to their MD (a generalist), that would mean approximately 1,500 new patients for every U.S.

doctor of chiropractic every year.

But instead of coming to us, they went to their medical doctor - probably not the best choice. A recent study of Harvard Medical School students reveals just how poor a choice that really is.2 A group of 608 Harvard medical students were given a "30-question survey and a nationally validated basic competency exam in musculoskeletal medicine." The results, quoted verbatim as follows, proved interesting:

  • On average, participants estimated that musculoskeletal problems comprise between 40% and 45% of all primary care visits. [The actual percentage is somewhere between 15% and 30%.]
  • The students considered musculoskeletal education to be of major importance.
  • When asked to rank eight different preclinical curriculum topics in the order of importance, third- and fourth-year students ranked musculoskeletal medicine as the third-most important topic to their future medical career, behind only cardiovascular and pulmonary medicine.
  • A comparison between participants' confidence levels in examining the musculoskeletal and pulmonary systems demonstrates that although students generally felt a high level of confidence in examining the pulmonary system, the same students felt a low to average level of confidence in examining the musculoskeletal system.
  • [T]he overall passing rate on the validated exam was 2% (2/98), 7% (9/129), and 26% (22/84) for second-, third-, and fourth-year students, respectively.
  • [T]he students felt that there was insufficient curriculum time devoted to musculoskeletal medicine.

The authors believe that "the inadequacy of musculoskeletal education [is] consistent with both their [the students'] lack of clinical confidence in examining the musculoskeletal system as well as their lack of cognitive mastery in basic musculoskeletal medicine." Harvard offers a "required two weeks of preclinical instruction focused on musculoskeletal medicine" which is "consistent with the national average of curricular time devoted to this field." The authors also noted that it may be "reasonable to infer that a large portion of U.S. and Canadian medical schools face a similar challenge in effectively addressing musculoskeletal medicine in their curricula."

If Harvard is producing medical doctors who have little education and confidence about musculoskeletal ailments, certainly the rest of the medical world can't be much better. So, why is it that the chiropractic profession only sees about 10 percent of the musculoskeletal patients the medical profession sees? One would think that most MDs would be very willing to refer those cases they didn't feel confident handling. If they are referring, to whom are they referring? The level of referrals to DCs seems very small.

As with most things in life, it all comes down to relationships. I just finished filling out a customer survey for a company I used for the first time. They asked me the primary reason I used them instead of one of their competitors. The answer: "Referral from a friend or relative."

Whether it's a good restaurant, an honest auto mechanic, an aggressive attorney or a great hair stylist, we tend to rely on people we know for referrals. The same holds true for the health care world. A solid relationship, built upon trust, is essential if you are expecting to receive referrals from another health care provider. They have to know you will take care of their patients and provide them with the appropriate reports and documentation in a timely manner.

Perhaps in our effort to be a "separate and distinct" health care profession, we have separated ourselves from the relationships that could foster greater referrals and better care for patients. It should still be possible to disagree with the medical paradigm and still work together for the benefit of the patient. (We also might educate individual medical doctors along the way.)

This isn't the first study to point out the lack of musculoskeletal training in the medical profession. Harvard Medical School is now "in the process of designing a four-year musculoskeletal curriculum." Even when that curriculum takes effect, doctors of chiropractic will still possess far more expertise in the management of nonsurgical musculoskeletal ailments than the vast majority of MDs.

There is, and will remain, an incredible opportunity for musculoskeletal referrals from medical providers. We need to seriously consider the best ways to develop relationships with those providers who could be open to such a relationship. They are seeing more than 92 million musculoskeletal cases every year, and generally aren't sure what to do with them. We have the expertise those patients need to regain their health using conservative care. They really want to regain their health and avoid surgery.

It sure seems like an opportunity to me.


  1. Hing E, Cherry DK, Woodwell DA, et al. National Ambulatory Medical Care Survey: 2004 summary. Adv Data, 2006;374:1-33.
  2. Day CS, Yeh AC, Franko O, Ramirez M, Krupat E. Musculoskeletal medicine: an assessment of the attitudes and knowledge of medical students at Harvard Medical School. Acad Med, 2007;82:452-457.


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