Recently, I have been following an American Chiropractic Association "open forum" discussion regarding the need for more primary care providers in America. The shortage of primary care physicians in America is not a recent dilemma, but a concern that has been expressed in the literature for more than 20 years.
The shortage of primary care physicians increases cost of care and reduces access to necessary medical care.1 Some in the chiropractic community suggest chiropractic physicians should be trained and credentialed to provide primary care. Could chiropractic primary care physicians be a possible solution to the shortage of primary care providers?
Primary Care Salaries
Chiropractic providers working within health care systems, such as community health centers, realize nurses may pursue advanced training and certification to become primary care providers. As the physician assistant champion at the University of Bridgeport, I understand a minority of the physician assistants pursue primary care positions, similar to medical school graduates, because of economics.
Specialists usually earn nearly twice the amount of a primary care physician. Hence, the shortage of primary care providers and primary care physicians creates a potential for chiropractic physicians to serve as either primary care providers or primary care physicians – and earn a reasonable salary with benefits.
According to a recently published survey of physicians conducted by Medscape, internal medicine doctors' salaries average $243,000 annually. That's a little over half of what the highest earners, orthopedic physicians, make with an average annual salary of $482,000. Family medicine and pediatrics earn even less than internal medicine, at $231,000 and $225,000 per year, respectively.2
Providers vs. Physicians
If chiropractic physicians became certified to provide primary care, it is important to differentiate the status of a primary care provider from that of a primary care physician. The primary care provider is usually an advanced-practice registered nurse (APRN) or a physician assistant (PA). Both of these primary care providers are mid-level providers. The salary range for a mid-level provider is less than a primary care physician; and the salary range for mid-level providers varies significantly depending on the location and responsibilities.
Normally, a mid-level provider will receive a starting salary from $65,000 to $100,000, whereas a primary care physician may start at $125,000 to $250,000. Unfortunately, chiropractic physicians are oftentimes hired as a mid-level with a lower salary than a medical physician.
Prescriptive Authority
Federally Qualified Health Centers and Community Health Centers hire both primary care providers and primary care physicians. Both provider levels are expected to have prescriptive authority. Therefore, in most states in America and provinces in Canada, chiropractic physicians would not be permitted to function as primary care providers or primary care physicians.
Note: Advanced-practice chiropractic physicians in New Mexico might be able to function as primary care physicians because they have prescriptive authority.
Prescriptive Authority: The limited authority to prescribe certain medications according to established protocol. In the U.S., prescriptive authority has been granted to advanced practice nurses, optometrists, osteopaths, physicians, podiatrists, and veterinarians among other health care professionals.3
Neuromuscular Specialists?
Federally Qualified Health Centers (FQHCs) may credential a chiropractic specialist within a primary care facility. Usually, the chiropractic specialists evaluate and manage patients with chronic pain and neuromusculoskeletal conditions.
Recently, I became aware of a chiropractic physician who was granted privileges to practice nonpharmacological pediatrics within an FQHC. The neuromusculoskeletal medicine program at the University of Bridgeport was developed to meet the need for chiropractic physicians to qualify to provide treatment within FQHCs.
Federally Qualified Health Centers are community-based health care providers that receive funds from the HRSA Health Center Program to provide primary care services in underserved areas. They must meet a stringent set of requirements, including providing care on a sliding fee scale based on ability to pay and operating under a governing board that includes patients.
Federally Qualified Health Centers may be Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Health Centers for Residents of Public Housing.
The defining legislation for Federally Qualified Health Centers (under the Consolidated Health Center Program) is Section 1905(l)(2)(B) of the Social Security Act.4
Federally Qualified Health Centers, Community Health Centers, Rural Health Centers, hospitals, and medical centers are serving patients with chronic neuromusculoskeletal pain syndromes, plus other chronic diseases including obesity, addictions, heart disease, and diabetes without many chiropractic physicians. The integration of chiropractic physicians is part of the solution to the evaluation and management of patients with chronic diseases.
Ethical and Legal Responsibilities
If chiropractic physicians intend to become primary care providers or primary care physicians, postdoctoral programs must provide high-quality, evidence-based and patient-centered primary care training that leads to advanced-practice status. The DC behind a chiropractic physician's name should not indicate "Don't Continue" training.
Of course, chiropractic primary care physicians will bear a higher level of ethical and legal responsibilities with prescriptive authority. Primum non nocere!
Health care workers have a legal and ethical responsibility to protect the patients they care for. When these responsibilities are ignored, patients suffer. Additionally, health care workers can be held responsible for these behaviors. Ethical behavior or responsibility is doing the right thing for the patient.5
Food for Thought
If you would like to pursue integration into a health care system as a chiropractic specialist, primary care provider or physician, now is the time to take action.
References
Many relevant diagnostic signs are not performed deliberately by the examiner or by the patient at the examiner’s direction. They are observed as the patient reacts to their condition. Fortin’s finger sign, Minor’s sign, and Vanzetti’s sign are three examples of this principle.
Spearheaded by burgeoning scientific and clinical research literature, psychedelics have reached a level of media coverage and popular interest that has not been seen for over half a century. By “psychedelics,” we are referring to the unique class of substances that includes psilocybin (the active compound found in so-called “magic mushrooms”), LSD, dimethyltryptamine (DMT), ayahuasca, 5-MeO-DMT, and mescaline – each of which occurs in the natural world (except for LSD, which is a semi-synthetic compound).
While working at the Lovelace Medical Center in Albuquerque, N.M., one of the primary care physicians stated that imaging every patient prior to receiving chiropractic was not medically necessary. It was at that point I reconsidered the need for the imaging of every patient to avoid malpractice.
