On February 24, 1993, The Wall Street Journal ran an article on the shortage of primary care physicians in the United States. It seems that our medical schools are turning out plenty of specialists well-versed in the latest high-tech diagnostic tests and treatments, but nowhere near enough family physicians, pediatricians, and general internists. The article then went on to identify medical specialists as the chief reason why United States health care is the world's most expensive.
Indeed, it is the dominant role of specialists coupled with high-tech medicine that is largely responsible for our rapidly rising health costs. Last year the New England Medical Center's Health Institute conducted a study which found that medical specialists order more tests, perform more procedures, and hospitalize more patients than primary care doctors treating the same symptoms.
Furthermore, many medical specialists own or have financial interests in diagnostic labs, imaging facilities, and other auxiliary services. Orthopedists, for example, frequently own or are involved in joint ventures of rehabilitation facilities in which studies have demonstrated considerable overutilization occurs.
In our current health care system, medical specialists justify treating all sorts of vague symptoms as a result of high-tech testing. According to Lynn Payer in her recently published book, Disease Mongers, "The five to 10 billion medical tests ordered in the United States each year cost as much as $27 billion, about six percent of the nation's health care budget and as much as the combined spending on drugs and medical supplies." Although there is little doubt that some tests are beneficial, there is a lot of evidence that a great deal of testing is actually harmful or unnecessary. Ms. Payer quotes Robert H. Brook, MD, SD, of the RAND Corporation and UCLA Medical School as saying that "at least a third if not more than half of what we do is of no benefit or of such marginal benefit that I think we could reach agreement in society that insurance should not pay for it."
"We know that primary care saves money" says Dr. Leiyu Shi of the University of South Carolina School of Public Health. In fact, in a recent article in the Journal of Health Care for the Poor, Dr. Shi said that primary care was not only cost effective, but that it "also saves lives." Dr. Shi's findings demonstrate the need to "reorient the medical profession from the currently expensive, clinically-based, treatment-focused practice to a more cost-effective, prevention-oriented primary care system."
But changing the way medical schools educate doctors is not going to be easy. The vast majority of the nation's 126 medical schools are designed to produce specialists. Medical faculties are overwhelmingly made up of specialists and curricula are narrowly focused on high-tech, low-touch hospital care even as more and more treatments are performed in outpatient settings.
And according to The Wall Street Journal, "Even primary care training has a decidedly high-tech emphasis." Although some medical schools are making an attempt to revamp their curricula, none of these reforms promise a quick solution to the primary care shortage. The Wall Street Journal quotes a University of Wisconsin study which says that even if half of all the U.S. medical school graduates choose general medicine beginning in 1995, the work force won't be evenly split between generalists and specialists until 2040. The lack of sufficient primary care providers will make the transition from our current system of health care to managed care much more difficult. Primary care is the cornerstone of all managed care systems. Furthermore, in countries like Canada and Germany, the ratio of primary care physicians to specialists is far higher than here.
There now exists a huge vacuum in primary care in the United States. Because nature abhors vacuums, the opportunity exists for chiropractic to move in and help to alleviate the shortage of primary health care providers. Make no mistake about it, other providers will also move into this crucial role. In fact, it is already happening. Nurse practitioners, nurse midwives, and physician assistants are already taking over the role of the general practice physicians and with generally good results.
A recent study conducted for the American Nurses Association (ANA) revealed that advanced practice nurses perform as well or better than medical doctors in delivery of primary care. ANA President Virginia Trotter Betts says, "Between 60 percent and 80 percent of the basic health care performed by doctors can be done by nurses with the same quality outcomes at a much lower cost." The study, a "meta-analysis" of some 53 studies of advanced practice nurses, noted that nurses scored higher than medics on most quality of care measures, including diagnostic accuracy.
Nurses expect to continue expanding their primary care role. The ANA's Ms. Betts was recently quoted in USA Today as saying the USA's largest group of health care providers, some 2.1 million nurses, stand ready to be mobilized. But in spite of what Betts says, only 100,000 of the 2.1 million are qualified advanced practice nurses, not enough to alleviate the shortage of primary care medics. So the door is open for chiropractic, but we must move quickly and with determination. Failure to achieve primary care gatekeeper status will mean that chiropractic is likely to be considered a neuromusculoskeletal specialty and be rationed. It will be subject to the whims of nonchiropractic gatekeepers: general practice medics, advanced practice nurses, and physician assistants. The only way to avoid such an outcome is for chiropractic to make its case as a primary care provider now while the reform debate is heating up all over the country.
The Foundation for Chiropractic Education and Research has been closely following developments within the health care arena. FCER has developed its new strategic plan to come to grips with the challenge of securing primary care gatekeeper status for chiropractors. This will be achieved in a variety of ways including focused research on chiropractic's cost effectiveness, treatment of internal conditions, and other nonback related disorders. Central to FCER's mission is to amass data on chiropractic treatments of all kinds and make it available to chiropractic organizations, state associations, licensing boards, and individual practitioners. Also of great importance is the development of informative booklets on chiropractic efficacy as supported by scientific and economic studies.
In a well-reasoned and powerful essay recently published by Arnold Cianciulli, DC, MS, FICC, FACC, member of the FCER Board of Trustees, argues convincingly that the doctor of chiropractic is well trained to be a primary care provider. In the booklet, Chiropractic: A Primary Care Gatekeeper, Dr. Cianciulli presents to the reader the facts about chiropractic education, including a thorough description of chiropractic diagnostic procedures. He explains chiropractic's unique role as a cost-effective alternative to medicine which operates within a preventive, nondrug, nonsurgical, holistic paradigm. And he explains the unique way chiropractic physicians evaluate patient data from a holistic viewpoint. The definition of primary care by the National Academy of Sciences and the unique patient-chiropractor relationship are both described in depth.
To any informed reader, the case for chiropractic as a primary-care profession is convincingly made. It is obvious that doctors of chiropractic possess equivalent skills to the medic and superior training to advanced practice nurses. These facts coupled with the cost effectiveness of chiropractic case management and the high degree of patient satisfaction with chiropractic treatments, provide a compelling argument for chiropractors acting as primary care providers.
Time is of the essence, however, if legislators, policymakers, and the buyers of health care are to be influenced in time to make a difference. Dr. Cianciulli's essay should be read by all these officials, both state and federal. This would be a positive first step in setting the stage for acceptance of chiropractic as a primary care gatekeeper.
A case in point is the state of New Jersey, which is currently undergoing extensive changes in its health planning process. Central concerns in New Jersey are the issues of defining which professions are capable of providing preventive and primary care and ensuring that the public has access to all qualified primary care providers.
The original draft of the state health plan included MDs, DOs, nurse practitioners, and dentists as primary care providers, but excluded chiropractors. This omission was brought to the attention of the New Jersey Board of Chiropractic Examiners. The board used the FCER booklet Chiropractic: A Primary Care Gatekeeper to bolster its position when petitioning the State Health Planning Board for inclusion of chiropractic as a primary care provider. On February 4, 1993, the New Jersey Health Planning Board amended its plan to include the chiropractic profession within the preventive and primary care section. To quote Dr. Cianciulli, "This was a victory, not only for chiropractic in New Jersey, but for the entire chiropractic profession."
Stephen R. Seater, CAE
FCER Executive Director
Arlington, Virginia
Foundation for Chiropractic Education and Research 1701 Clarendon Blvd. Arlington, VA 22209 Tele: (703) 276-7445
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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.
