Within the last 10 years, a new factor has emerged that makes it increasingly urgent that chiropractic define itself more clearly.That factor is competition. Of course chiropractors have always competed with orthopedic surgeons, neurosurgeons and neurologists, but until recently medicine has largely ignored the province of conservative care for back pain. All that has changed in the last decade. Medicine has finally discovered the back. A partial list of medical back clinics in this area (Minneapolis/St. Paul) includes:
- Metropolitan Spine Group
- Physicians Neck and Back Clinic
- Institute for Low Back Pain
- Low Back Clinic of Minneapolis
- Methodist Hospital Back and Neck Clinic
- Minnesota Lumbar Spine Clinic
- Chronic Pain and Rehabilitation Center
- Fairview Southdale Back Pain Clinic
These clinics, with one exception, all started within the last 10 years. More significantly, they all emphasize conservative, nonsurgical treatment for back pain and several of them offer nothing but conservative care, even eschewing medication whenever possible. This conservative care includes exercise, rehabilitation and even manipulation. My own firsthand experience with several of these clinics convinces me that the physicians running them are serious, dedicated, talented and committed to providing the best possible care for back pain. In other words, they are formidable competition. I am convinced that medicine's interest in conservative back care in general and manipulation in particular will continue to expand.
There continues to be an antipathy by many in the health care industry toward chiropractic. In the past this antipathy was countered by the fact that there weren't any real alternatives to chiropractic in the area of conservative back care. That is no longer true and given this continued antipathy, I'm sure an HMO, an insurance company or a government agency would be much more inclined to send patients to one of these medical back clinics than to a chiropractor. If we allow this challenge to go unanswered by not enthusiastically embracing the title of back specialist, discussions like this will be moot. Chiropractic cannot survive economically if our position as the preeminent back care specialists continues to erode.
No matter what scope of practice chiropractic adopts, it will be competing in the next century, as will all health care professions, for patients and health care dollars. Scope of practice skirmishes will continue to take place at the peripheries of each discipline. Orthopedic and neurosurgeons will contest the right to do back surgery, optometrists and ophthalmologists will fight over glaucoma, and chiropractors will be doing battle on many different fronts. If I many extend this military metaphor a bit, chiropractic, like all professions, must set up a defensive perimeter from which it can defend its territory. If we expand that perimeter wide enough to include primary care, the perimeter becomes porous and indefensible. We must choose to compete in our areas of strength, not in our areas of weakness.
One reason for chiropractic enthusiasm for the PC role is a basic insecurity about who we are and what we do. We want the respectability and legitimacy the medical profession enjoys. We have been overly concerned about where we stand in the health care hierarchy. We seem to have concluded that this hierarchy is led by PC physicians. To be anything other than that is to be a second class doctor of some sort, and if we allow ourselves to be pigeonholed as "back doctors" we will occupy the lowest rung on the health care ladder. This insecurity is manifest in a number of ways. For reasons I do not understand, some chiropractors seem to be embarrassed by the fact that they make their living treating back pain. In discussions of scope of practice the phrase "just back pain" often comes up, as in, "we don't want to be reduced to treating just back pain," or, "we don't want to become too orthopedically oriented." This is astonishing. It's like telling an endocrinologist not to be so "hormonally focused," or telling a urologist to get rid of his "bladder obsession." There is the sense that treating back pain is a grubby sort of business best left to some lesser type of doctor or therapist. There is the hope that someday as the profession evolves, we may be able to leave the treatment of back pain to lesser health care providers. What's really important are things like asthma, ulcers, colitis; you know, real doctor stuff. In fact, plain old back pain is one of the most important health problems in industrialized countries. It cost tens of billions of dollars annually in treatment and lost productivity, it produces profound misery and suffering among those afflicted. Back pain counts. It matters.
As noted above, medicine certainly no longer regards back pain as the backwaters of health care. It is eye opening to spend some time at clinics such as those mentioned above and see the time and effort and resources that are devoted to studying and treating back pain. You will see neurosurgeons, the most exalted members of the medical pantheon, whose entire professional life is devoted to the spine from L4 to S1. Whereas chiropractors might disagree with some of their clinical conclusions and therapeutic recommendations, their erudition is impeccable. I am convinced that medicine's interest in back care in general and manipulation in particular will continue to expand.
Further, there seems to be the sentiment that treating back pain, at least for chiropractors, is a simple matter. Haven't we basically settle that question? In fact, the question of how best to treat back pain remains largely unanswered. Those studies, while producing some nice PR for the profession, did nothing more than suggest that what chiropractors do for back pain is useful. Treating back pain is a difficult thing, something that can be done well or done badly, even by chiropractors. A patient with back pain deserves the attention of a back pain specialist -- a chiropractor.
The profession also has a significant emotional investment in the PC role. There is the feeling that to settle for something less than a PC role is, well, to settle for something less. Bus it is only that, an emotional investment. Somewhere along the line we saw a Norman Rockwell painting of a country doctor, a GP no doubt, and decided that's what we want to be. Unfortunately, the model just doesn't fit. We will not achieve that respectability and legitimacy that we understandably desire by copying a medical role model that does not apply to us. Chiropractic is not less than, it is not subordinate to, it is not inferior to, but is most certainly different from, PC doctoring.
The use of the acronym "PC," which might be confused with the phrase "politically correct," is intentional. There is an element of political correctness in the concept of the chiropractor as primary care provider, if not as a fact, at least as a goal. This area has achieved within the profession the status of unquestioned truth. Even as astute an observer of the chiropractic landscape as Keating has succumbed to this. Keating advises the profession in a recent paper that if certain corrective actions are taken, then "chiropractic may be saved from a slow devolution into a musculoskeletal specialty."8
Devolution?! The implied comparison seem to be: primary care is to [N]MS specialist as a primate is to ... is to what? a reptile? a nematode? a flatworm? The profession is suffering from a severe case of PC envy.
The practice of chiropractic may not be as dramatic as neurosurgery, and Norman Rockwell never painted a picture of a chiropractor, but it is still a good thing.
Our Friend, the Dentist
If we want to choose a profession to model ourselves after, I would not choose a family practitioner, I would choose a dentist. Consider the advantages of the dental model.
- Dentists have established themselves as the absolute, undisputed authorities in tooth care. No one suggests they should not be portal of entry providers. No other profession even wants to mess around with teeth or gums.
- In the public's perception, dentists are among the most highly esteemed of the health care professions.
- Dentists enjoy greater economic rewards and security than do chiropractors.
- The services that dentists provide, limited though they are, are of immense benefit to the health and well-being of the public. If you doubt this, go to a family practitioner next time you have an abscessed tooth.
With this model in mind, and given the preceding discussion, I suggest the chiropractic scope of practice be based on the following principles:
1. What do chiropractors do better than others? 2. What do chiropractors do that is not done by others? 3. What do other practitioners do better than chiropractors? 4. What does our education and training qualify us to do? 5. Where is there an opening in the health care marketplace? 6. For what services are the public and insurance companies willing to pay chiropractors?
From these I conclude that:
- The educational and political institutions of chiropractic should embrace enthusiastically, openly and without qualification the principle that chiropractors are neuromusculoskeletal specialists and abandon the use of the term "primary care" in describing chiropractic. Neuromusculoskeletal includes disorders relating to the spine, extremities and peripheral nervous system.
- In this role, chiropractors should serve as portal of entry physicians and primary diagnosticians.
- Chiropractors should act as the primary treating physician for these problems using a broad range of conservative therapeutic modalities including, but not limited to, manipulation, physical therapy, diet and exercise. To the extent these conditions are not amenable to conservative care, chiropractors will integrate their care with appropriate health care professionals.
- Chiropractors should treat, with the assistance of other health care professionals, those non-neuromusculoskeletal conditions that are found to be responsive to manipulative care.
What could chiropractic gain and what would it lose by adopting this scope of practice? On the plus side, we gain credibility. Even opponents of this scope of practice acknowledge that much of the anti-chiropractic animus would disappear if we adopted this position. From this enhanced credibility would flow all those things that most chiropractors want: better third party reimbursement, government support for chiropractic education and research, inclusion of chiropractic in any national health care reform, and greater demand for chiropractic services. Let me expand on the last item. Imagine if we were able to create in the public's mind an association between chiropractic and back pain as strong as the association between dentists and tooth problems; if chiropractors saw, in other words, virtually all patients with back pain. Throw in headaches, extremity problems, and a few other odds and ends for good measure, and the demand for chiropractic services could not be met if there were five times the number of DCs there are now. None of these things are guaranteed. All have to be fought for and won. But we will be in a far better position to win if we adopt a rational and credible scope of practice.
What do we lose? The right to see asthma or ulcer patients? Again, we hardly see any of these people anyway, and that won't change until we can show some effectiveness in those cases. We will lose the warm and fuzzy feeling we seem to get from calling ourselves primary care physicians. But we will only be losing the feeling, we won't be giving up anything that we really have. It will require that we deflate some of the pretensions of chiropractic, that we can be all things to all people, that we are both generalists and specialists at the same time. I cannot see that we give up: a) anything that we already have or b) anything of value.
If you regard chiropractic as a cause or a crusade, I suppose you lose a great deal. If you believe that the ultimate objective of chiropractic is to supplant the medical establishment and reduce them to a peripheral and marginal role in health care, you certainly lose a lot and I would not expect anyone so inclined to endorse this position.
Chiropractic cannot have it all. We cannot claim concurrently to be generalists in the family practitioner mode, and neuromusculoskeletal specialists and that we achieve all this in four years of professional training. It is an affront to common sense to suggest that this is possible. There is no evidence that chiropractors either function as, are trained as, are perceived by the public as, or are recognized by other health professionals as primary care providers. What are chiropractors? In questions of this sort, it's useful to apply the duck test. The duck test states that if it looks like a duck, if it walks like a duck, and if it quacks like a duck, one is obliged to call it a duck. Applied to this question, if it looks like a neuromusculoskeletal specialist (chiropractic education), if it walks like a neuromusculoskeletal specialist (chiropractic practice), and if it quacks like a neuromusculoskeletal specialist (the public's perception of chiropractic), then it is a neuromusculoskeletal specialist. The words of Woody Allen are instructive here: "Reality is still the only place you can get a good steak."
Chiropractors never miss an opportunity to miss an opportunity. The country is on the threshold of making fundamental changes in its health care system. There is an increasing appreciation of the importance of spinal and related disorders as public health problems. There is an increasing recognition of the inherent advantages of conservative health care: cost and safety. There is acknowledgment of the effectiveness of chiropractic care for certain conditions. All these factors conspire to create an extraordinary opportunity for chiropractic. However, if we fail to define ourselves more coherently, if we try to be everything to everybody, if we don't exploit our strengths and concede our weaknesses, not only will that opportunity be lost, but chiropractic risks becoming more peripheral and marginal than it is now.
Craig Nelson, DC
Northwestern College of Chiropractic
2501 West 84th Street
Bloomington, MN 55431-1599
8. Keating J. Shades of straight: diversity among purists. J Manipulative Physio Ther 1992;15:203-8.