With the publication of yet another article that attempts to discredit chiropractic (Smith WS, Johnston SC, Skalabrin EJ, Weaver M, Azari P, Albers GW, Gress DR.Spinal manipulative therapy is an independent risk factor for vertebral artery dissection. Neurology 2003;60:1424-28), the media has again demonstrated its disregard for journalistic integrity with respect to the known facts regarding VAD.
Additionally, insurance industry challenges, scope-of-practice issues and interprofessional feuding have all appeared to escalate in recent months. The level of attack to which some organizations and individuals have degenerated is enough to cause even the most apathetic provider to take notice. For any group or individual to suggest a concerted effort be undertaken to remove a DC from the U.S. capitol, after decades of struggle to obtain that position - simply because of the perception that this DC's power has been diminished - is unconscionable. Other activities around the country that clearly can be classified as self-inflicted wounds also must be viewed in light of their effects. The chiropractic terrorism so prevalent in today's emotionally charged environment is perhaps cause for each of us to take a few steps back and view the landscape in a reasoned fashion. I feel the following is timely; I am pleased to provide a forum for the incisive commentary, and hope this will generate "reason" that will provide a basis for future action by doctors of chiropractic as we move to address these issues. It might be time to adopt the motto: "The only people you should ever want to get even with are those who have helped you." It's a good place to start in our thinking.
A practitioner from Canada wrote a recent article that appeared in the Journal of the Canadian Chiropractic Association concerning issues as relevant to the chiropractors in the U.S. and the rest of the world as they relate to Canadian DCs. This article is reprinted below with permission.
Victims Again? Who Is the Problem?
by J. Ronald Carter, DC
Alfred Russell Wallace, a contemporary of Charles Darwin, was in his laboratory observing an emperor butterfly trying to get free from its cocoon. The struggle was intense, with life-or-death consequences. He wondered, "What would happen if I assisted in the process?" So, with a knife, he made a slit down the length of the cocoon. This is what happened, in his words: "The butterfly emerged, spread its wings, drooped perceptibly and died. The pain and intensity of the struggle had been denied it, and it had failed to grow. It could not emerge into the world with the strength it needed to survive."1
Dr. Scott Peck's famous opening line in The Road Less Traveled was, "Life is difficult," to which he added, "Life is complex," in The Road Less Traveled & Beyond. He reminds us to learn to deal with life's conflicts, problems and paradoxes to find the true simplicity that lies on the other side of complexity.2
Like the emperor butterfly, the chiropractic profession is going through an intense struggle with life-and-death consequences. Akin to the emperor butterfly, I believe we will successfully emerge, accepting our struggles over the last year as essential to our evolution. We will learn to accept that our lives will continue to be difficult and complex. It is then that we will begin to understand what life is about.
Albeit, we convince ourselves that the "victim" role serves our best interests. It allows us to do little or nothing about our conditions, and at other times, we actually believe that we will be rescued. For example, we say: "If the public really knew our story, they would correct the wrongs that have been done," or "If the press was on our side, things would be far different," or "Until all chiropractors think and practice as I do, our problems will never be over."
Each of us has been driven into "victimhood" by the chaos of the last year. The actions of the antagonistic physicians, health-care cuts and restrictions on our role to practice are only three of numerous events that have impacted us. When looking at issues through a "new pair of glasses," through evolutionary change, rather than as victims, a realization occurs that these events were all necessary for our development and growth when we choose to react to them differently. Mark Twain said, "We have two types of people: victims and warriors." A quick review of three events of this last year is intended to take us beyond our victim role.
The Political System
Health-care issues are being reconstructed, and life as a health-care provider will be remolded almost on a daily basis. The case provided is an example of where a positive action resulted:
In a highly significant and uncharacteristic move, the Provincial Government of Manitoba reversed an earlier decision that denied payment for chiropractic services to anyone under the age of nineteen. The reversal of the controversial policy signals an important victory for chiropractic in that the completely unsupportable and prejudicial restriction of reimbursement for younger patients has been rescinded.3
Although some provinces have had "across-the-board" cuts in provincial funding, there is an emerging number of chiropractors being appointed to provincial advisory boards that can help educate the uninformed. The process is changing. Health-care decisions in the future will be based more on the advice of advisory boards and data provided, rather than in our political relationships. The victim response is "poor me," while the opportunist sees evolutionary change and prepares for it through responsible representation and facts.
Insurance: Providers of Chiropractic Benefits
(Aetna Insurance, in its "Coverage Policy Bulletins Number 0107 - Chiropractic Services")
Policy - Aetna covers chiropractic services, subject to any applicable benefit limitations and exclusions, when all of the following criteria are met:
- chiropractic care is either a covered benefit under the plan; there is an optional rider that covers chiropractic care, or coverage of chiropractic care is mandated by state law;
- the patient has a neuromuscular disorder;
- the medical necessity for treatment is clearly documented; and
- improvement is documented within the initial two weeks of chiropractic care.
If no improvement is documented within the initial two weeks, additional chiropractic treatment is not medically necessary and is not covered unless the chiropractic treatment is modified.
If no improvement is documented within 30 days despite modification of chiropractic treatment, continued chiropractic treatment is not considered medically necessary and is not covered.
Once the maximum therapeutic benefit has been achieved, continuing care is not considered medically necessary and thus is not covered.
Chiropractic manipulation in asymptomatic patients or in patients without an identifiable clinical condition is considered not medically necessary and is not covered.
Chiropractic care in patients whose condition is neither regressing nor improving, is considered not medically necessary and is not covered...5
(The full document is eight pages in length and includes techniques not covered and a listing of conditions commonly treated by a chiropractor. The above policy is based on 89 references. Check www.aetna.com/cpb/data/PrtCPBA0107.html.)
"The defining of the scope of chiropractic services is being taken from us," is the cry of the victim. Who better can say "what we do" and "who we are" than ourselves? Our guidelines in the past were self-serving articles and failed to gain the acceptance, respect or support of the stakeholders. Guidelines such as the Aetna Policy, CARF and other documents are becoming the standards of chiropractic care. The CCA recognizes the weakness of our numerous guidelines and has seized the opportunity to rewrite our standards again. When this is completed in a responsible manner, our scope of practice will be a document upon which others can rely and build upon. The external guidelines have been a catalyst, with some of their efforts benefiting our new guideline and standards.
Carey testified that reports by neurologists "exaggerating" the danger of strokes caused by chiropractic treatment have scared away so many patients that some practitioners have been forced to leave the profession. Other chiropractors report they are losing 15 percent to 30 percent of their incomes, Carey also testified. The impact has cost Canada's 6,000 chiropractors an estimated $100 million in the last 18 months, he said.5
Without question, becoming a victim happens very quickly when large amounts of money are lost, but there have also been many very positive benefits during this stroke issue to consider. (This is not the time to list them.) As the inquest continues, more positive and supportive issues will be brought forth. At the conclusion of the inquest I would like to see these issues brought forth by those closely involved, which could be a detailed historical recording of this evolution. I am looking forward with great anticipation to reading about this "fast-tracking" time in our profession.
Our Professional Turf
This is an area that can put many of us into victimhood. We all share a common belief that chiropractic's place/role is the adjusting/manipulating of the spine. The following is a summary from a literature review dealing with cervical manipulation. "One must weigh the effectiveness of this treatment against the relative risks for each specific patient surrounding cervical spine manipulation prior to using it as a treatment technique. Rivett stated that based upon the current outcome of risk versus benefit, evidence supports the continued judicial use of cervical-spine manipulation when applied by a prudent, properly trained physical therapist."6 The ownership of our birthright cannot be settled in the courts; rather, we gain position through our proficiency and research. Striving to do what we do best is the answer that will keep us from becoming victims.
What we are experiencing is our evolution, and there is good to be seen in it.
The wisdom of Buddha may provide some of the answers of which Dr. Carter speaks:Do not believe what you have heard.
Do not believe in tradition because it is handed down many generations.
Do not believe in anything that has been spoken of many times.
Do not believe because the written statements come from the same old saga.
Do not believe in conjecture.
Do not believe in authority or teachers or elders.
But after careful observation and analysis, when it agrees with reason and it will benefit one and all, then accept it and live by it.7
Buddha says when it agrees with reason - that is, when you know it to be true based on your own observation and experience - and it is beneficial to one and all, then and only then you can live by it! As chiropractors, we have observed and experienced the benefit of our service to others. Accept this, cherish it and allow it to grow. Life will always remain difficult and complex.
- Arthur Caliandro. Simple Steps-Ten Things You Can Do To Create an Exceptional Life, McGraw-Hill, 2000, p.185.
- Scott Peck. The Road Less Travelled and Beyond. Simon and Schuster, 1997, Flap.
- Ronald Hendrickson, The Chiropractic Choice, September, 2002, p.10.
- Aetna, Coverage Policy Bulletin Number 0107: Subject Chiropractic Services.
- Peter Small, The Toronto Star 22.10.2002 p.B4.
- David Clubb, Cervical manipulation and vertebral artery injury: A literature review, Journal of Manual and Manipulative Therapies Vol. 10 No 1 (2002) p.15-16
- Wayne Dyer. Wisdom of the Ages, Quill, 1998.
Louis Sportelli, DC
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