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Dynamic Chiropractic – September 1, 2004, Vol. 22, Issue 18

To Tier or Not to Tier Chiropractic?

By James Winterstein, DC, President, National University of Health Sciences, Reed Phillips, DC, PhD and Reiner G. Kremer

It is high time to honor the didactic and clinical educational dualism within the chiropractic profession. By respecting this dualism, one simplifies the intraprofessional debate and grants permission for chiropractic to move out of the inextricable position in which it currently finds itself.

What has spawned this article is the realization that one of our/your children has just entered high school, and has clearly stated his or her intent to become a natural medicine physician. He or she has observed cutting-edge chiropractic interventions using natural medicines and leading diagnostic procedures for the care of the sick and infirmed; has observed the practice of natural family medicine; and is impressed with the patient satisfaction and the clinical results. Chiropractic's low-risk interventions are seen to have high clinical utility and favorable outcomes.

So, why not plan on going to chiropractic college? The concern is that the chiropractic professional opportunities of the '70s, '80s and '90s may not be as readily available in this new millennium.

Significant and real questions arise when pondering our/your children's future choices. Is health care delivery a good choice? If so, what choice within health care delivery is the best choice to enjoy the unrestricted practice of natural medicine health care? Grave concerns abound with regard to the health and future of the chiropractic profession.

There is a reason why American chiropractic college enrollment is down. Are other doctors of chiropractic feeling similar concerns? Has our once-great profession imploded? Why are certain international programs granting chiropractic certificates of completion and licensure after two or three years of education? Is this the wave of the future on the international scene? Are U.S., Canadian, Australian and European DCs overtrained? Are we going to see a "dumbing downward" of the profession?

There are ominous movements afoot that will impact the future of our once highly desirable profession. Chiropractic tuition is now comparable to traditional public-supported medical school tuition ($75,000-$110,000). Private medical school tuition alone can run up a debt in excess of $150,000. This means that as schools get closer to requiring four years of pre-chiropractic education, students are continuing to carefully investigate all health care delivery options for the greatest value and potential.

In addition, there is the phenomenal growth of nurse practitioners and physician assistants who are filling the primary care void. There are the plans of the American Physical Therapy Association to push direct patient access of physical therapists in all 50 states, promoting doctoral PT programs that will teach diagnosis with some level of prescriptive authority. Let's not forget that there is direct and growing competition from the naturopathic profession. They have modified their identity from "naturopaths" practicing "naturopathy" to "naturopathic physicians who practice naturopathic medicine in a primary care setting," as demonstrated by legislative changes in Arizona since 1996.

In the 1970s, the chiropractic profession was uniquely positioned to offer integrated natural family medicine health care services. The profession has literally stagnated over the past two to three decades due to the academic avarice of some, professional infighting, and the glaring lack of a methodical, national broad-scope legislative identity.

The delivery of the chiropractic health care product has been all over the board. There currently exist programs that have minimized the emphasis placed on the teaching of differential diagnosis and natural medicine, graduating doctors of chiropractic with a minimalist, narrow-scope view. Then there are others who are on the opposite end: broad-scope primary care physicians who have learned differential diagnosis and the basics of the application of natural approaches to health care.

The stark reality is that our profession is tiered in many ways, and has been tiered since the days of D.D. and B.J. Palmer. Let's honor these men by doing the honorable. We all know there are doctors who are comfortable practicing "subluxation-based chiropractic," following the tenets of B.J. Palmer and others. There are those who wish to practice broad-scope chiropractic medicine, following the tenets of D.D. Palmer, Joseph Janse and others. And there are a large number of practitioners functioning somewhere between these two ends of the spectrum.

Chiropractic: At a Crossroad

The profession is at a crossroad. How do you deal with such diversity? How does the profession re-establish confidence with the variety of stakeholders, when it is filled with internal debate and wrangling? We recognize that diversity exists within the profession, and because of this diversity, we should honor it, respect it, be thankful for it and allow tiering to take place.

Should all college programs be mandated to become broad-scope in their training? Absolutely not! Should all college programs become subluxation-based or narrow-scope in their training? Absolutely not!

The given is that professional infighting continues, both on the local and national levels. There are those who are profiting from the infighting, at the expense of the patient and the practitioner.

Clearly there are two separate and distinct groups within the profession, with a significant third group blending in somewhere in the middle. This dichotomy results in "heartburn" for all groups within chiropractic, whether legislative, professional or educational. This self-inflicted professional confusion has caused doctors of chiropractic to be defined by the lowest common denominator of service and diagnosis. The diagnosis: subluxation; the service: adjustment. Does it really take five academic years to learn this?

Global chiropractic cognitive clinical abilities are seriously in question. There is no consensus within the profession that all doctors of chiropractic are trained equally, such that all graduating DCs are able to competently perform a differential diagnosis.

And there is the additional issue of consumer protection and public safety. How does one know that the doctor of chiropractic one has chosen is broad-scope or subluxation-based before the first appointment? How can an individual seeking out a doctor of chiropractic identify who is competent? The consumer protection and public safety issue is both significant and germane to the profession's current state of affairs.

Recommendations for Change

The Pew Health Professions Commission Report, Reforming Healthcare Workforce Regulation Policy: Considerations for the 21st Century, made 10 significant recommendations that have utility and application to our profession. Four are included in our discussion:

  • States should use standardized and understandable language for health professions regulation and its functions to clearly describe them for consumers, provider organizations, businesses and the professions.
  • States should base practice acts on demonstrated initial and continuing competence. This process must allow and expect different professions to share overlapping scopes of practice. States should explore pathways to allow all professionals to provide services to the full extent of their current knowledge, training, experience and skills.
  • States should redesign health professional boards and their functions to reflect the interdisciplinary and public accountability demands of the changing health care delivery system.
  • States should require each board to develop, implement and evaluate continuing competency requirements to assure the continuing competence of regulated health care professions.

Of particular interest is the recommendation that states should base practice acts on demonstrated initial and continuing competence, which, in the future, may include periodic examination for licensure.

This recommendation allows and expects different professions to share overlapping scopes of practice for consumer choice and interprofessional and intraprofessional competition. The reality is that the adjustment is not, and will not, be exclusive to our profession, no matter how much money is spent in the courts.

States should explore pathways to allow all professionals, including trained chiropractic physicians, to provide services to the full extent of their current knowledge, training, experience and skills. Broad-scope, primary-care-trained chiropractic physicians should be clearly identified and allowed to practice broad-scope, primary-care medicine. Narrow-scope, subluxation-based chiropractors should be clearly identified and allowed to practice narrow-scope, subluxation-based chiropractic. Let us honor and respect our diversity!

Is the Time for the Tiering of the Chiropractic Profession Now?

In the state of Washington, health plans have started tiered networks for primary care physicians. This tiering is based on clinical outcomes, most notably efficacy. In this brave new world, all doctors are going to be profiled for not only their costs, but also their clinical outcomes. Their skill, art and science will be monitored through patient outcomes. Tiering based on clinical outcomes appears to be here to stay, at least for the near future.

Would it not be appropriate for tiering to take place to identify philosophical and educational differences? We have a clear and distinct dichotomy within our profession, and this dichotomy should be honored. We should honor the subluxation-based practitioner as a chiropractor.

It has been my experience that the subluxation-based practitioner has difficulty with the rendering of a standard, traditional diagnosis and feels very comfortable in limiting his or her practice to the detection and correction of the vertebral subluxation. This position is being promoted by international, national and local groups.

Conversely, we should honor those who choose to be trained in broad-scope, primary care and who wish to practice as advanced practice: chiropractic physicians willing to assume greater clinical responsibility and decision-making.

To protect both the consumer and the public, there must be a clear and significant distinction made between the broad-scope, clinically trained and educated chiropractic physician (who has intensive training and expertise in broad-scope differential diagnosis), and the limited-scope, subluxation-based chiropractor (who has intensive training and expertise regarding the "subluxation").

The public has the right to know what level of chiropractic diagnostic evaluation and therapeutic intervention it is going to get prior to the first visit, and it is incumbent upon the profession to facilitate this distinction, so that the consumer can make an informed and educated choice.

Tiering of the chiropractic profession has been recommended by policy-makers including state and national regulatory entities (e.g., Bruce Douglas, JD, former director, Department of Regulatory Agencies - Colorado; and member of the PEW Task Force on Health Care Workforce Regulation).

It is our belief that the tiering of the profession will vitalize both groups at each end of the spectrum, as well as the large group in the middle.

The profession should honor and allow the subluxation-based practitioners to be chiropractors. In this realm, they can be recognized as providing adjustments, detecting and correcting the vertebral subluxation. As chiropractors, they can market themselves to the public as such, and the public will know who and what products and services they have to offer.

Chiropractic physicians, by contrast, are broad-scope or advanced-practice chiropractic medicine practitioners and are distinguished from the chiropractor by providing broad-scope services, including differential diagnoses, manual medicine, nutritional products, and natural and physical medicine services. A broad-scope practitioner would be prepared to integrate into traditional medical settings, such as hospital services, community health care, and working shoulder-to-shoulder with other physicians when offering collaborative and integrated health care services.

This tiering must be brought to all state licensure and national legislative entities. Let's stop offending one another! Why not recognize and identify the intraprofessional diversity? Allow the marketplace the choice of narrow-scope, subluxation-based chiropractors or the advanced-practice chiropractic medical practitioner who uses a broad scope of therapeutic and diagnostic interventions.

The AMI Blue Cross/Blue Shield Illinois model has demonstrated effectively that the advanced practitioner of chiropractic medicine provides services that decrease prescription drug costs, hospital stays and outpatient procedures. [Editor's note: For more information, see "DCs as Primary Care Providers: New Managed Care Study Finds Improved Patient Outcomes and Significant Cost Savings With DC Gatekeepers" on the front page of this issue.] Although the subluxation-based practice could possibly result in similar savings, we have no current information for review and analysis.

Additionally, advanced-practice chiropractic physicians have demonstrated ongoing high consumer satisfaction.

Giving permission for tiering to take place allows the chiropractor and the advanced-practice chiropractic physician to practice within the scope of his or her clinical training and education.

The time has come for tiering to occur; in fact, it is past time. Professional tiering gives permission for each group to be recognized for its science, training and competencies. Think about it: the subluxation-based chiropractor and the broad-scope advanced practitioner of chiropractic medicine.

The American Academy of Chiropractic Physicians endorses chiropractic professional tiering. We trust that this article will stimulate intellectual discussions regarding this concept and that the process of tiering will formally take place soon. You see, it is our desire that our/your children will be able to choose and become competent, advanced practitioners of chiropractic medicine who can practice the entire scope of their education and training. It is our hope that professional infighting will be minimized, and that consumers will be able to easily identify and choose to whom they are going - either the chiropractor or the advanced-practice chiropractic physician - up front. May the time come when chiropractors and advanced-practice chiropractic physicians will be respected interprofessionally and intraprofes-sionally for their skills, their competencies and their training.

Reiner Kremer, DC, DABCI, FAACP
Chairman, American Academy of Chiropractic Physicians
Franktown, Colorado

James Winterstein, DC, DABCR, FAACP (Hon)
President, National University of Health Sciences
Lombard, Illinois

Reed Phillips, DC, PhD
President, Southern California University of Health Sciences
Whittier, California

[Editor's note: As a chiropractor, what is your reaction to the recommendations presented in this article? And if the profession were to be tiered, which tier would you want to be a part of? Send an e-mail to and voice your opinion!]

Dr. James Winterstein, president of National University of Health Sciences since 1986, graduated from then-National Chiropractic College in 1968. Among his varied professional accomplishments, he is a former president and board chair of the Council on Chiropractic Education, and a former president of the American Chiropractic College of Radiology.
Click here for previous articles by Reed Phillips, DC, PhD.

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