James Edwards, DC
Serving Whom? Why I Will Never Sign the ACA Pledge
As a past seven-year member of the American Chiropractic Association (ACA) Board of Governors and a past two-year chairman of the board, I was stunned when I heard about the ACA's new "branding" and "Choose Wisely" programs. After watching the Facebook presentation1 twice, I respectfully and strongly disagree. It is beyond my comprehension that a membership association that has lost thousands of members is essentially now trying to "brand" itself as some kind of quasi national licensing board. And that is exactly what it is attempting to do.
Do What Your Members Want
The ACA's pledge states: "As an ACA chiropractor, I pledge to make Accountability to my patients and the public a priority by adhering to treatment standards and best practices adopted by the association and by focusing on patient outcomes." [Emphasis Added] Seriously?
I cannot imagine that statement being warmly received by rank-and-file ACA members because it smacks of "Big Brother." Someday, the ACA might realize that it should salute smartly and carry out the wishes of its dues-paying members instead of attempting to establish treatment standards "adopted by the association."
After serving eight years as a member of the Kansas State Board of Healing Arts – which licenses medical physicians and doctors of chiropractic – I will "choose wisely" by never signing the ACA pledge because I will follow the rules, regulations and statutes of the state in which I am licensed to practice. I will never place the policies, positions and/or standards of any trade association above them ... and I strongly recommend you take the same position.
Since very few ACA leaders have ever served on a state licensing board, they have no right, background, expertise or authority to try establish practice standards. For the ACA to attempt to insert itself as an authority in place of or in competition with the rules, regulations and statutes of a state licensing board is again, beyond my comprehension.
My suggestion for ACA leaders who want to be state licensing board members is to pursue that path ... just as I did. But don't try to anoint the ACA as a new national governing / licensing body for your dues-paying members, because that is not your job and totally exceeds your authority as membership trade association. In that regard, did the ACA obtain the formal approval the Federation of Chiropractic Licensing Boards (FCLB) before attempting to usurp the authority of their state boards? Of course not.
The Rest of the Story
To quote the late, great Paul Harvey, "Here is the rest of the story." To be candid and with great chagrin, I have watched ACA leadership work against its members for a number of years when in fact it should have been protecting the interests of its members. Below are just a few documented examples of how the ACA has burdened its members by making it harder for them to practice effectively and by removing their ability to have a voice in selecting top ACA leaders.
The ACA recently began promoting "Choosing Wisely" by participating in the American Board of Internal Medicine Foundation's campaign. And what was the ACA's "lead pony" in beginning this effort? It was supporting the foundation's recommendation that radiographic imaging should not be used to assess adults with acute low back pain until after six weeks, barring the presence of certain "red flags." So, if you sign the "ACA Pledge," you could face an ACA ethics complaint or even lose your membership for not following the association's dictates.
More importantly, it is my strong opinion that these recommendations are out of line with the established standards of chiropractic practice; ignore the large body of clinical and outcomes data that demonstrates the utility, indeed clinical wisdom of such procedures; and clearly can and will, if followed unquestioningly, place patients at risk by delaying or denying diagnostic imaging procedures that have been proven to best serve their needs.
While this "Choosing Wisely" standard may or may not be best for medical physicians, as a longtime chiropractic expert witness, I can tell you the first element discussed by a patient's attorney is that the chiropractor did not even take an X-ray. And for the record and as a 40-year practitioner, I have routinely X-rayed almost every adult patient during that time and have found fractures, cancer and abdominal aortic aneurysms that would have gone undetected and in a number of cases could have cost the patient his/her life had X-rays not been taken.
Even in the face of the opioid disaster killing 91 Americans every day,2 many ACA leaders are still fervently committed to obtaining prescriptive rights. To that end, the ACA House of Delegates unbelievably passed two resolutions for doing just that and which are still in effect today. The first was a resolution that includes two elements that call for "prescriptive authority"; the second established the ACA "College of Chiropractic Pharmacology and Toxicology."3
I believe I can say without successful contradiction that those two pro-drug resolutions do not represent the views and positions of the majority of ACA members, especially when the AHCPR Guidelines4 found manipulation to be the only treatment that can relieve symptoms, increase function and hasten recovery for adults with acute low back pain. Not to mention that in the face of the opioid crisis, few if any state legislators will now say, "Yes, I will support your prescriptive rights bill because we need more doctors prescribing pain medications."
As detailed in a previous column,5 the ACA Clinical Documentation Committee adopted the following provision: "Chiropractic is different than standard medical practice in that the DC provides both the diagnosis and the treatment. This can cause confusion when it comes to chiropractic documentation. It is important to note that less documentation is required for a routine visit for continuing care on an established care plan than on a patient encounter when an E/M service is performed."
Was the committee's approved provision included in the Clinical Documentation Manual? Sorry, but no! That's because an ACA officer overruled the committee and got that very important provision stricken. Therefore, it does not appear in the manual and a magnificent opportunity has been lost.
If you are asking yourself why anyone would take that most unusual and unwarranted action – which makes "treatment" visit documentation far more cumbersome than it should be for practicing doctors of chiropractic – I suggest you ask the ACA for an answer.
Last year, the ACA changed its Bylaws so that ACA members cannot elect the president through the vote of elected ACA delegates. Instead, the members of the Board of Governors will now be chosen by a select Nominating Committee, which will then elect the ACA president after the House of Delegates has adjourned. If you ever wanted to lose your voice as a dues-paying ACA member in regard to who leads the association, this is how.
What Is the Solution?
You can keep paying your ACA dues in the hope of changing the association's path, which is what I have chosen to do solely because of its legislative abilities. But I am not hopeful. I believe it is much more likely the current ACA leadership will continue to place needless barriers in front of you, making it more and more difficult to build and maintain a successful practice.
The bottom line is this: Unless and until ACA members let state delegates know that their job is to represent members' interests, the ACA will continue its efforts to become a national licensing board, and is so doing will add additional and unnecessary layers of control on members' practices.
- Watch the ACA presentation on Facebook: https://www.facebook.com/acatoday.org/videos/10154254487992609/.
- Edwards J. "The Opioid Epidemic: It's Time We Stand and Fight." Dynamic Chiropractic, Oct. 1, 2017.
- "A House Divided?" Dynamic Chiropractic, April 15, 2015.
- Bigos S, et al. Acute Low Back Problems in Adults: Clinical Practice Guideline No. 14. AHCPR Publication No. 95-0642. Rockville, MD, December 1994.
- Edwards J. "SOAP Notes: It's Time for a Cleaning." Dynamic Chiropractic, May 15, 2013.