Reactions I have seen to the proposition that chiropractors are primary care providers run anywhere from a rolling of the eyes, to guarded acceptance within a neuromusculoskeletal framework, to emphatic approbation. What light (instead of heat) can we add to this still-explosive topic, debates of which go back at least as far back to the profession's centennial in 1995?1 This issue has to be taken seriously, if for no other reason than that skeptics looking from the outside - who don't know better - could be branding chiropractors as anything from spine doctors to spin doctors.
The problem begins with how you frame it, harking back to the classic quotation, "The answer lies within the question." This is because multiple definitions of "primary care" abound, so the outcome pretty much depends on which version you embrace. Consider the following widely divergent takes on primary care:
Looking at these definitions, you realize chiropractors can state their case in some of these definitions, but make little headway in others.
To assess chiropractic primary care from a multiplicity of viewpoints (capacity, potential and perception by the public), 10 years ago the FCER awarded a grant funded by the National Chiropractic Mutual Insurance Company to a health consulting firm in many aspects similar to the RAND Corporation, but based in Cambridge, Mass. Its principal findings were both sobering and hopeful. The authors of a subcontracted project out of Cleveland Chiropractic College in Kansas City pointed out that, if the competence of chiropractors is ever to "enjoy a wider traditional covenant" including primary care, students as well as practitioners must obviously be able to document their competence in such pursuits - including their performance on validated examinations. Such was the undertaking in this study, which compared exam scores of students from three chiropractic colleges with those from a small cohort of medical students entering their residency programs.
Overall, medical students scored higher than chiropractic students in 19 out of 20 categories, except in musculoskeletal conditions, in which their (the medical students') performance was markedly inferior, confirming findings obtained recently by Freedman and Bernstein, in which orthopedic residents failed a validated competency examination in musculoskeletal evaluation.7,8 In certain other areas (injuries and trauma, management of acute and chronic conditions, neurological conditions, and even infectious diseases to some extent) the performance of chiropractic students in at least some schools was not that inferior to the medical cohort. But in others areas (cardiovascular conditions, genitourinary conditions, and screening and prevention), the chiropractic scores were markedly poorer.9 Scores relative to screening and prevention are particularly distressing in that much of the chiropractic profession has attempted to position itself as experts in wellness and prevention. A problem with this comparison is the fact that chiropractic students in their final year have been matched against medical students entering their first year of residency, which means the latter group has benefited uniquely from more advanced training than their chiropractic counterparts and would thus be expected to perform at a higher level. It also underscores the unmistakable fact, cited elsewhere,10 that chiropractic programs must offer far more extensive and varied clinical exposure to their students if they are to be effective in the practice of primary care.
But the prominent and distinguishing characteristic of the chiropractor, as opposed to any other manual therapist, is both the training and the capability to be able to perform complete medical diagnoses in the examination of the patient, independently from any other health care professional. This assertion was supported by a second portion of the study conducted by Abt Associates, Inc. It reviewed both the capabilities of and barriers to the delivery of primary care by chiropractors, following a methodology of using both a multidisicplinary and an all-chiropractic panel that had previously been employed by RAND.11-13 The Abt study concluded that with respect to a list of 53 primary care functions found to occur daily in medical offices, chiropractors are capable of issuing diagnoses in 92 percent of these activities and making therapeutic contributions in more than 50 percent of them.14 Clearly, there is room for interpretation as to the definitions of "primary care" and "therapeutic contributions," although it seems apparent that from the perspectives of both training and performance, chiropractors (compared to physical therapists) have the better potential to perform the complete evaluation and diagnosis of patients.
Thus, the need for chiropractors to distinguish their profession by utilizing their capacity to provide diagnoses has never been more acute. This has provided the starting point to review their abilities to perform in a primary care role, both supported and refuted by a modest body of literature which has been reviewed in this discussion. One distinction that must be kept in mind is how chiropractors are taught, as opposed to what they are allowed to practice in their diverse locations. In such areas as interpreting laboratory chemistry determinations from blood, urine and stool specimens, for example, ample opportunities exist to excel and even surpass their medical counterparts; however, various practice and antiphlebotomy laws act as unfortunate disincentives to performing this vital diagnostic service. These barriers to practice have been extensively reviewed by Gaumer, representing a third component of FCER's aforementioned project conducted by Abt Associates.15
Yet chiropractic primary care may yet endure. Consider these findings:
These are not grounds, however, to pop any champagne corks or issue any manifestos. For while a survey of practitioners listed in the National Directory of Chiropractic shows no less than 90.4 percent answering "yes" to the question, "Do you consider yourself a primary care practitioner?"21 patients do not see it that way. They see chiropractors largely for neuromusculoskelal conditions.22,23 So, the burden of proof remains upon the chiropractic community to demonstrate that the cognitive as well as the manual contributions of qualified chiropractors are an essential component for arriving at meaningful, efficient and cost-effective solutions to the proliferation of neuromusculoskeletal problems in today's society. It depends upon the support of future research, largely through FCER, to validate the possibility that chiropractors may make substantial offerings to the primary care management of specific somatovisceral conditions, in addition to being able to achieve the ultimate goals of patient wellness and prevention that are already in the process of being embraced by allopathic medicine.24 It also depends upon proper education and training of the chiropractic physician, as explicitly mandated by the Council on Chiropractic Education.25 All of these measures are essential to avoid ever having to bear the onus of being a spin doctor, a role better left to a politician rather than a health care provider.
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.
