Editor's Note: Let's continue our Q&A with Stephen Perlstein, DC, APC, chair of the New Mexico Chiropractic Association PAC and president of the American Academy of Chiropractic Physicians. Part 1 of this interview appeared in the May 1 issue.
Many DCs cringe at the thought of chiropractors having prescriptive privileges of any sort. What's your response to these concerns and how have you overcome them? I completely understand the concerns of those chiropractors who wish to hold to the premise that drugs have no place in the chiropractic profession. Long ago, I held to that party line. It made sense in that chiropractic had a defined boundary and a unique identity.
Yet one cannot help but notice that the chiropractic profession is not growing and hasn't been for quite awhile. Although some of us have thriving practices, many do not. The public accepts chiropractic care, but not in the numbers that sustain growth. The public support is a trickle compared to the relatively unquestionable support the other health care professions have.
It is my opinion that we remain a viable, yet quirky profession the public does not completely understand because we don't understand it, certainly not enough to present a unified front. The answer may come not from chiropractic being one thing, but rather when all of us can embrace the diversity of chiropractic and present unity on that front.
Prescriptive privilege is simply another modality in a range of modalities we can use. When I came into the profession in 1981, you were not considered to be a "real" chiropractor if you used anything more than the chiropractic adjustment. It also meant someone who practiced that way did not honor and respect the value of the chiropractic adjustment or the chiropractic profession itself. None of the above conclusions is true.
I believe the longer we hold onto an arbitrary definition of what constitutes chiropractic, the more difficult it is to discover just what chiropractic is and may become. There are so many variations of what a "straight" chiropractor is that there truly is no longer any reason to have that designation. Our scopes of practice do not require us to use chiropractic adjustments, although we define ourselves by their use. I do believe most of us do use adjustments as part of our treatment regimen, yet it is not the only thing we use.
If we look at the modalities we do use apart from chiropractic adjustments, we see a diversity. These range from hot and cold treatments to functional medicine, and they all have value to the patient. So, what is the difference between a prescription medicine given to a patient vs. an ultrasound treatment given to a patient? Intrinsically, there is no difference. They are just treatments that have their inherent values. It is only when we attach a certain significance to them by comparing them that they become extrinsic.
The argument I repeatedly hear is, "Drugs are bad." That's assigning an extrinsic value. I think it is important to grasp that drugs are not bad in and of themselves. It is the improper utilization of drugs that does not work and can be harmful. I cannot tell you how many times a patient has thanked me for the prescription of cyclobenzaprine, a muscle relaxant, that helped them with their sleep and pain modulation after injury just when they needed it most. When used judiciously over a short period of time, it supports the efficacy of the chiropractic adjustment.
Why should they have to go to another physician for a prescription, most likely to the overtaxed ER, because they need it right away, when they could obtain that prescription from their chiropractic physician? The fear of many chiropractors seems to be that by prescribing drugs, we are presenting ourselves as a health care profession no different than the other health care professions who prescribe drugs. They fear we will stop adjusting people, replace the adjustment with drug treatment, lose our identity, and become unrecognizable. This quite simply couldn't be further than the truth.
Not one patient of mine has ever wondered why I, a chiropractic physician, is prescribing any medication. They are just grateful for all the help they can get. They have come to me for a conservative approach and know my prescription is not a first line of treatment.
I believe we can keep intact the best of chiropractic, and add the very smart and judicious use of pharmaceutical assistance in a way other health care professions do not. That is what the public wants and what we can provide. Chiropractic care is conservative care, and there is no reason to believe that chiropractic physicians, having proceeded through the rigorous and extensive training it takes to have prescriptive privilege, would begin to practice different than their fundamental training has prepared them for.
To the public, what so far has distinguished us from the others is our lack of unity. Chiropractic is a confusion and a misunderstanding to many, and patients stay away because of that. We have completely failed at educating the public about chiropractic because we are so fractured. We simply do not have a cohesive message. The public, except for those we have convinced in our individual ways, couldn't care less about our issues. We have so many different and conflicting messages, and having that kind of uncertainty breeds confusion and discourages growth. In fact, it kills it.
In essence, our fear that we may lose our identity helps perpetuate the loss. You get what you resist. In my opinion, that is where we stand today. Our insistence on remaining a niche profession while proclaiming that we are not keeps us from growing. When the public has exposure to chiropractic physicians practicing not only chiropractic, but more mainstream services smartly, they embrace us fully as physicians. They will come to us more freely knowing that their needs are going to be met. It will be these physicians, having more privileges, that will train our patients how to accept drugs as a secondary focus of treatment.
I'm sure you've heard the criticisms of advanced practice – that it "medicalizes" the profession, that we will become "just like the DOs" or that it is really just a way to make more money, etc. How do you respond? Again, I started my career as a confirmed straight chiropractor, and I thought it foolish to diverge from that in philosophy or practice. I had a particular mindset regarding this issue, and nobody could budge me. When my approach finally softened 15 years in, when I began to see that pharmaceuticals used wisely were no different from any other modality I was using and how they could benefit my patients, I was and am more than willing to see scope expansion as a natural progression for the chiropractic profession in the best way possible.
If one holds tight to the point of view that chiropractic is one way and one way only, such that drugs are bad and chiropractic must not include the use of drugs, no matter what, then the only way to react to what we have done in New Mexico and what other states are currently exploring is to continue to attempt to isolate chiropractic by contrasting it with other health care professions, as well as stop the advance of scope expansion.
The downside to this is we are disenfranchising ourselves from the public when we say we wish to avoid "medicalization" or that we will become "just like the DOs." The point is missed about what the public wants. The public wants the judicious use of medicines when appropriate. Patients want to get better and they want to be safe. Who better to provide a comprehensive treatment regimen than chiropractic physicians?
It has been said chiropractic physicians are too stupid to be able to take on the training for the use of pharmaceuticals in their practices. I was there when it was said, and it was said by a leader in our profession. It was truly an embarrassing moment. It was said as a way of stopping the advance of scope expansion; to preserve an antiquated view of chiropractic, one rooted in another century whose values and education were different from present day.
What it did do for the legislators present was to dumb down our entire profession. Whatever credibility we had with them was nearly lost. I do believe that one can adhere to vitalistic constructs for health care and add allopathy into our practices for the benefit of our patients.
All of the accusations against scope expansion are blatantly untrue, in my opinion. More money is not made from providing prescriptions unless you, absurdly, become a licensed pharmacy. Might more patients want to come to a physician who can provide more services? Yes, in the same way that people may want to see the physician who has nonpharmaceutical treatment modalities additional to traditional chiropractic treatment. Why should a patient have to go to two practitioners, one of whom may take six weeks to get an appointment with, when they can get service at one?
Standing on principles seems quite appropriate for whomever believes the preservation and growth of chiropractic is based on adherence to those principles. If those principles were as sound as one thinks, then why aren't patients flocking to us? We should be having a chiropractic shortage, yet that is furthest from the truth. (Please attempt to explain it without being dogmatic.)
I have come to fully believe that the fundamental principles of chiropractic have become the personal identity for many who believe chiropractic must not stray from its foundation. Expansion of chiropractic scope of practice has become a personal issue and not the professional one it should be. In doing so, expansion has become a personal attack, and those who fight back are doing so personally.
To me, this is a professional issue and should remain as such. This is about the future of this profession, and our patients' needs should be more of the deciding difference than our personal needs. Our division is an embarrassment in the world of health care and will continue to be the source of our stagnation.
Tell us about the American Academy of Chiropractic Physicians, for which you serve as president – what is its purpose? What should our readers know about it?
The American Academy of Chiropractic Physicians (AACP – www.aacp.net) is an organization formed in 2014 to promote advanced scopes of practice for the chiropractic profession. Our stated purpose is: To provide the home for scope-of-practice initiatives through education and legislation; to advocate for plenary licensure, based upon education and certification; to develop, in collaboration with higher education institutions, education and clinical training for plenary scope of practice.
AACP is the international clearinghouse for legislative and cultural advancement of chiropractic scope of practice. AACP assists any state or jurisdiction desiring advancement by providing resources for that process. AACP's objective is to advocate for the highest levels of licensure, but we recognize there are states that do not want to go that far, and therefore, support states' rights to regulate themselves according to the desires of their constituents.
AACP is an affiliate of the Association of Health Sciences Colleges and Universities (AHSCU – www.ahscu.com), a nonprofit formed in 2012 whose purpose is to improve integrative health sciences education for optimal compatibility of that education and scope of practice. There are currently four member institutions: National University of Health Sciences, University of Western States, Texas Chiropractic College and Southern California University of Health Sciences. To put it simply, AACP is the legislative arm of the educational consortium, AHSCU. It is a collaborative relationship.
Some may recognize the acronym AACP and the full name of the organization. In 1999, AACP was formed to promote primary care physician status for chiropractors, and was a credentialing agency that provided the examination for the advanced-practice requirements in New Mexico. We created the Academy of Chiropractic Physicians in 2014 and sought permission from AACP to trademark a name very close to theirs. Given that AACP had not been operational for some time and didn't have aspirations to be, we were given the trade name AACP and the domain name with their blessings. It must be noted that AACP is not a credentialing agency and our sole focus is on scope expansion.
AACP has experience with scope expansion and understands the process necessary to achieve it. AACP has a lobbyist who will act as a state's lobbyist coach, an invaluable service given that the lobbyist is also the New Mexico Chiropractic Association lobbyist and has been instrumental in gaining passage of our scope expansion in recent years. Being a member of AACP means you are in partnership with your fellow, like-minded colleagues who would like to see chiropractic expand. Membership in AACP provides the funds for national and international legislative efforts that can augment state and jurisdiction-wide efforts.
Membership in AACP provides the funds to bring the message into the public arena through national media coverage. AACP provides a home for those who wish to see the chiropractic profession expand beyond the dogmatic conversation that holds us back. AACP is the organization that legislators will recognize as having validity in the political arena.
AACP will only provide assistance to a particular state or jurisdiction when invited to do so, and the invitation will come from members only. We do not have a standard scope of practice that we wish to implement in all states; nor do we wish to dictate how a particular state should expand. AACP is here to provide the resources necessary to negotiate scope expansion state by state and jurisdiction by jurisdiction. It is an idea whose time has come.
Membership is not free, in that free membership, especially in regard to the political arena, does not constitute a true organization. Having a viable organization will allow the issue of scope expansion to be respected and listened to among legislators and the general public. All the information covered in this interview and more is there, including audio and video interviews about advanced practice, as well as the history of advanced practice in New Mexico.
Ideally, how does advanced practice mesh with standard chiropractic in terms of ensuring the chiropractic profession survives and thrives? By providing advanced practice as part of standard chiropractic practice, we chiropractic physicians will be providing our patients with the best of both worlds. To disallow these services is to continue to promote our profession as a small, niche player in the health care world.
Some may feel that is enough; that we should continue to isolate ourselves. Some may feel that to depart from the foundational principles forces our identity to be comprised, sacrificing our uniqueness and rendering us "just like everyone else." I believe that position is exceptionally shortsighted, not to mention quite insulting to our intelligence and our enormous expertise as doctors. It stunts our growth.
We are clearly seeing that all of the years spent not allowing this profession to expand beyond questionable fundamental principles is what is killing it. All of the cheerleading, all of the rallies and all of the fundamentalist war councils are essentially for naught, because this profession has expanded, is expanding and will continue to expand regardless of how many attempts at shouting it down goes on.
The public is the deciding factor here. It wants more access to primary services and our profession can help fill that void. The more we go in that direction, the more legitimate and stronger we become.
I know fundamentalists think our strength and survival depends on those fundamental principles, but they do not. Our survival depends more on how we meet the needs of our patients as primary care physicians. The days of popping and praying; of the call for the elimination of the subluxation as if the subluxation were a parasite; of adjusting our patients five or more times per week for years because the belief that more is better ignored evidenced-based medicine – all of this must end. We have disenfranchised and defeated ourselves, and now we have to redefine ourselves.
It is more than conceivable that standard chiropractic practice can mesh with advanced practice. It has been happening now in New Mexico on a daily basis over the past eight years. The predicted plagues besetting the Earth and fire falling from the sky have not materialized, as predicted they would.
I would like to see the chiropractic profession not only survive, but prosper robustly. I would remind everyone that in order to get to where we want to go, we must recognize the conversation that has gotten us to this point is inadequate to get us any further. The new conversation is strongly exemplified by the principles of the American Academy of Chiropractic Physicians. Put the past in the past, be open to what chiropractic can become, and it will survive more successfully than we can imagine.
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.
