The article, "From the Bully Pulpit" (DC, March 26, 2001 issue or online at www.chiroweb.com/archives/19/07/15.html) rings so true.I first met the author, Garrison Pomeroy, at the initial Council on Chiropractic Practice meetings with the "leaders of chiropractic" on the development of the CCP Practice Guidelines. I was one of the original members of the CCP board, and then I was suddenly dropped from the board without notification.
It started immediately after a meeting in which I mentioned the scope of the guidelines. I questioned the excessive generality of the guidelines. I stated that they were not strong enough for the field chiropractor to use in dealing with third-party payers. Payers would hide behind a weak document and state that it gave them no directions on reasonable and necessary care. This allowed the third-party carrier to develop its own guideline for reasonable care.
After that statement, I was no longer notified of meetings, and I was not given any rough drafts to review. I was not notified that I was dismissed from the CCP until I received my CCP Guidelines. What a way to be notified that all your research reviews were really appreciated!
It's amazing how Terry Rondberg uses people. At the time of the Guidelines, no one realized they were being written for Dr. Rondberg's malpractice insurance company, creating a guideline that would make it easy to defend a chiropractor's clinical decisions. There's nothing wrong with that, if everyone knows up front the reason for the guidelines. But to dismiss board members because of their honest opinions is not professional.
I have wanted to tell this story for quite some time - even consulting an attorney - but decided against it because of Dr. Rondberg's "bully pulpit."
Mark Van Hemert,DC,DACS
"This is a matter of personal and professional responsibility..."
To the editor:
While reading the article by John Voss III,Esq., "DC Not Required to Make 'Medical Analysis'" (Dynamic Chiropractic, March 26, 2001 issue, on line at www.chiroweb.com/archives/19/07/15.html), I could not help but detect an air of approval, even smugness, on Mr. Voss' part. The case was decided in the chiropractor's favor, but at what cost? The decision in this case does chiropractic a grave disservice. The case involved failure to diagnose and inform, as well as failure on the chiropractor's part to fulfill his responsibility to his patient by taking action appropriate to the situation.
The patient presented with numbness in the arms and hands. At this time, the working diagnosis of neuropathy secondary to old trauma may have been reasonable. But when the patient presented with severe left chest pain radiating down both arms, it was the doctor's responsibility to make sure the patient received a proper workup. This was a big red flag. Advanced diagnostic skills are not required to know this patient should go to the ER. Much information about her presentation was not given in the article. Was her breathing labored? Was she nauseous? Did she perspire more than expected? What was the quality of her pain? Was she in a state of anxiety? How was her color? Did the chiropractor even consider asking himself these questions?
This was not a frivolous lawsuit. It raises significant issues about the future of the profession. The fact that this chiropractor succeeded in persuading the court that he should not be held accountable for a fundamental responsibility of every physician is a sad thing for the chiropractic profession as a whole, and sets a dangerous precedent. It is bad case law: bad for the patient, and bad for the profession. It robs patients of their rights to redress in cases of clear malpractice. It has the effect of absolving chiropractors from accountability for their actions and blunders. By absolving chiropractors from the standard of care universally mandated in mainstream health care, it relegates them to second-rate status. If chiropractors are to be taken seriously, they cannot afford the diminished status implicit in this decision.
The court's decision has major negative implications for the public's and the lawmakers' perceptions of chiropractors. The case tells us that chiropractors:
- are not doctors, and go to great lengths to avoid the responsibility being a doctor entails;
- lack the intellectual capacity and training to make clinical decisions;
- lack the understanding necessary to make even the most elementary diagnoses;
- have a deficient understanding of anatomy, physiology and pathology;
- possess incompetence that is excusable, even if patient deaths result from their negligence. Why? Because they are too stupid to be held accountable;
- when unsupervised, should not be entrusted with primary patient care because their lack of understanding of the human body and the "ills to which the flesh is heir" makes them dangerous; and they
- do not belong in mainstream health care.
Is this "excellence?" Is this the public image chiropractors wish to project? The Reikemans; Williamses; Barges; and Rondbergs of this world, to name but a few, seem content with and even proud of this image and do everything in their power to further this embarrassing public posture. This group will doubtless see this case as a victory, but it is not.
The case reflects the fundamental irreconcilable dichotomy within the profession. Dr. Jim Winterstein thinks chiropractic should be split into two professions, and I am inclined to agree with him. In fact, we already are two professions and have been ever since I can remember. Those of us in the progressive camp are doctors and take full responsibility for all this designation entails. This includes differential diagnosis. We owe this to our patients - and to our profession, if we are to establish any meaningful presence in mainstream health care.
Progressive chiropractic physicians do not begrudge anyone the right to practice as they see fit. The zealots and true believers, however, have always felt threatened, and have always done everything in their powers to prevent the progressive wing from expanding practice parameters. This is under the guise of protecting the purity of so-called "subluxation based" chiropractic. I have never witnessed any movement on the part of this group of pompous, pontificating ideologues toward a "live-and-let-live" posture. Let those who prefer to rigidly adhere to the dogma of the late 19th century remain as they are. It is better to sever ties and move ahead, than to continue to be dragged down from behind out of a misguided hope for unity with this stubborn and dogmatic group.
It is shameful that a chiropractor in Michigan has successfully evaded the personal and professional responsibility implicit in the title "doctor." The words of a classmate many years ago have never stopped echoing in my mind. We were coming out of a basic physiology class, and he was quite angry. He said, "What do I have to learn this BS for? I want to be a chiropractor, not a doctor." He was obviously going into a different profession than I. And please spare me the epithets "medipractor" or "MD wanna-be." This is a matter of personal and professional responsibility, not ideology - of ethics, not dogma.
The Cavalry Has No Clothes
Recently, Dynamic Chiropractic published an article from Dr. Daryl Wills, regarding a problem in Nebraska related to nomenclature. The medicolegal terminology acceptable to the courts of that state requires chiropractors to be called chiropractic physicians to allow their legal status to be upheld regarding physician liens, third-party reimbursement or testimony in court cases. The needed nomenclature/terminology change was to benefit and protect chiropractic patients, chiropractic providers, and the entire profession in Nebraska.
Undermining the state association's ability to resolve the problem was the "cavalry" of the "principled" practitioners who, although a minority, brought in their spokesmen to effectively stop that association from resolving the problem as they could have done. It also made our profession look fragmented, immature and disorganized, and basically reduced the credibility of the chiropractic association that had likely taken decades to create.
In Rhode Island, we face a similar problem. The chiropractic patients and providers have been abused by a health care system that has for decades discriminated against us, not for rational and logical reasons, or one founded in public safety or health issues, but due to prejudice and ignorance.
The Chiropractic Society of Rhode Island (CSRI), the only chiropractic association ever to exist in our state, and viable since 1918, sought to remedy the situation, but the CSRI was faced with similar problems as confronted Nebraska. To get the ultimate solution to our profession's needs, based on our own state laws, the fundamental problem was in the nomenclature and terminology with which chiropractors were referenced in different statutes and laws on record. In some places, we were chiropractic physicians; in other places we were listed as chiropractors. We needed consistency in the statutes so that we could carry forth our case of eliminating the different discrimination issues that the profession has been confronting. We needed the terminology to meet modern-day standards of commonly accepted and utilized verbiage that related to the current health care environment, and to address the terminology used by the courts. Fortunately, for chiropractic patients and providers alike, the Rhode Island legislature passed the nomenclature bill.
Now we are clearly in all statutes and laws in the state consistently referred to as chiropractic physicians practicing our own unique form of health care; chiropractic medicine. This did not affect our scope of practice. This was not a bill put forth by our association to add prescription drug rights, or any such nonsense as might be professed by the so-called "principled practitioners." The door has now been opened to use other resources to fight the discrimination battle: the attorney general's office, the department of business regulation, the insurance commissioner, etc.
Shortly after the bill passed, the self-appointed "principled" among our profession in RI began a new chiropractic organization. Dr. Riekeman came right out to help "kick off" their new fund-raising activities with a special program. Is this what the "leaders" of our profession do? Is this what leadership is all about - how to undo the little unity that our profession has had? There were many among our state's practitioners and a large number of Palmer graduates who were very disappointed and upset about the choice of affiliation and the support of the new president of Palmer College.
Whether Drs. Riekeman, Williams, Clum, Hoffman and others like it or not, we are doctors of chiropractic; chiropractic physicians; chiropractors; or ancillary health care providers. It all depends on our state law. We all practice chiropractic, chiropractic medicine, or ancillary health care services, or whatever, at the discretion of the terminology existent in state laws and statutes. We have to deal with the practice parameters set forth in the 50 states, and even more abroad. The plan of the profession to legislate as broadly as possible, so that our practitioners can practice as narrowly as they choose, is still the best direction for it. There is no movement to limit the license of practitioners in our state who are "straight," with no legislation to take away their physician status; no cries of "irresponsible health care providers" being sent to the department of health. Wellness concepts and regular ongoing chiropractic care are not condemned and vilified by the vast majority of our profession. There is a strong desire to see the research go to support and document all of these aspects of chiropractic care. Why do the "principled" practitioners seek to limit the majority's right to practice within the scope of our state license? Why do they not appreciate the benefits the profession can obtain by working together in a unified manner?
The claim of the "principled" few is that they are saving "pure" chiropractic, but they are not. In Rhode Island, as in Nebraska, these few are undermining the advances made due to the hard work and efforts of our associations, and their dedicated membership who volunteer their time, money, and expertise selflessly to the betterment of the profession and the patients they serve. The jargon put out by this group sends a confused message to our state legislatures, our department of health, our governor's office and the powers that be, and can only serve to set our profession back.
As past president of the CSRI, I think I speak for the vast majority of chiropractors when I state that until we come to the day that all practitioners of this great healing art can come together with understanding and mutual respect, we won't see the public embrace the profession and the potential that chiropractic has to offer the world. Those who seek to be remembered by history as true contributors to the advancement of our profession are urged to rethink their positions. Do not alienate your colleagues. We are all human beings. We have different past experiences and different levels of consciousness and understanding, and our perceptions are not all alike. We all have different physical and mental capabilities, limitations, and gifts. We may not all see a specific problem as being amenable to the exact same forms of treatment. That is a dynamic that needs to be worked out between the patient and the physician, based on state laws, statutes and parameters set forth by the licensing boards in each state. Working together with the intent of advancing the great calling to which we as a profession have all heeded, we can accomplish things beyond our imagination.
If, however, we choose to continue this perpetual state of disagreement, disenfranchisement, and disturbance, we not only will fail to see the blooming flowers of the future spring forth, but we may witness the wilting away of potential that our world could so greatly use. I truly hope the "cavalry" leadership understands this message.
Newport, Rhode Island
Shocked and Dismayed by Chiropoll Responses
I first want to let you know I love DC. I read it on line or on paper as much as possible, and have a website linked to yours because you offer some of the best information, and provide valuable contributions to chiropractic. But I have to question the motive behind these polls that you do. Have you read the responses to the polls? Between the grammar, the spelling, and overall negative content, they make us look quite uneducated. I don't mean to sound like I'm in favor of censorship, but I hardly see the necessity for giving the profession an opportunity to air dirty laundry to the public. We gain favorable ground one difficult step at a time, so why keep beating dents in our own armor?
About a year ago, I wrote and strongly suggested the forums not be open to the public. Whether or not everyone who participated was actually a DC is questionable, but there were a few too many that sounded more than a little crazy. I'm glad to see it now has a registration requirement. Everything else on the web site is so objective and informative. I've only responded to the polls twice, and after having read the other responses, I'm embarrassed to have a lot of these people waving their flags as collegues in what I truly believe is a noble profession. I don't even want to look at the responses any more; for the most part, they put a damper on the day.
Chiropractors and Acupuncturists: Not Done Yet
As a dually trained and dually licensed chiropractor and acupuncturist, my perspective in your debates ("DCs Who Perform Acupuncture - Turf War, or Question of Training?" May 21 issue, or on line at www.chiroweb.com/archives/19/11/01.html) may be useful.
My initial acupuncture education was the 100-hour National College of Chiropractic course before attending a traditional Chinese medicine school in nearby Chicago. This allowed me to satisfy my home state's requirements for acupuncture practice.
The chiropractic education by far surpassed the acupuncture education in standard anatomy; physiology; microbiology; physiologic therapeutics; pathology; biochemistry; laboratory and x-ray diagnosis; clinical diagnosis; and recordkeeping. I learned a lot more about electrodiagnostics and treatments of accupoints there, but I had no hands-on clinical supervision in meridian therapy there. That is the crux of a short-course's deficiency in clinical practice. A supervisor in my student clinic had passed the same 100-hour course but never practiced acupuncture.
The acupuncture school's clinicians helped me formulate treatment strategy and answered my questions about my chiropractic clinic acupuncture patients. My needling techniques and point locations were refined there. Observing seasoned acupuncturists and working hundreds of cases under their direct supervision made me a competent and confident acupuncturist.
The feedback from my 100-hour acupuncture class, and at cocktail parties for graduates of our medical acupuncture courses, was overwhelming lack of confidence in point location and needling techniques, due to too little clinical supervision by experienced doctors/acupuncturists, and minimal standards in clinical education hours in acupuncture alone. Similar chiropractic technique minimums are established by the acupuncturists' accreditation body. I strongly believe they are the bare minimum for a beginning practitioner based on my experience as a clinic supervisor, tutor and accreditation site visitor.
The acupuncturists' national certifying body develops examination criterion for an entry-level practitioner based on the skills required for the job, similar to the process the chiropractic national examination body pursued for an entry level chiropractor. If the national standards are respected, there is no basis for a turf war. If not, then chiropractors need to re-invent their own wheel with which to train and certify the skills of their acupuncturists, clinically as well as didactically.
This experience was like my chiropractic internship, where some clinicians were "recycled" recent graduates and others were seasoned veterans. Clusters of eager students would flock to this older doctor who was great at cervical adjusting and to that one who finessed the sacroiliacs. Over three years, our spinal and extremity palpation skills and our diversified; motion palpation; toggle; SOT; and flexion-distraction techniques were critiqued and improved with their help. Feedback and guidance by a variety of experienced acupuncturists, while treating clinic patients, has the same benefit, versus practicing briefly on healthy doctors in weekend seminars. Excessive academic inbreeding is anathema to sound higher education principles.
Palpation for acupoints and for bony landmarks and joint play both require a fine sense of touch, but refined by different methods, the one not being a basis for the other. Needle acupuncture; manipulation of the needle; surgery; spinal adjusting; and soft tissue manipulation are also different skills not based on each other. Thus, acupuncture cannot be taught in a brief diplomate course, like those based on prior chiropractic or medical practice education.
In practice, cost-effectiveness rules with insurance companies and individual patients. That the more experienced acupuncturist would correct a problem faster is reasonable. Credentialing by insurance providers leans toward protocols, set by national groups to reduce their liability as a credentialing body. Chiropractors fare well supporting spinal manipulation as satisfying such protocols, as do medical doctors for surgery and drug prescription, but neither can apply the same educational and examination criterion to their 100-300-hour acupuncture courses and state that they satisfy similar protocols.
Acupuncturists need better science courses. MDs and DCs, with their superior science background, have a certain didactic and clinical preparedness that opens them to a significant reduction in core curriculum requirements to add acupuncture to their practice. But the 100-300-hour courses fall far short of both didactic training at a higher education level and badly lack in supervised, experienced clinical hours, invaluable in preparing any skilled entry-level practitioner.
Runnemede, New Jersey