I want to take this opportunity to thank you on behalf of the Physical Medicine Research Foundation (PMRF) for Arthur Croft's article in Dynamic Chiropractic under Spinal Rounds on December 4, 1995.
The PMRF office has received over 35 inquiries regarding the subject matter as well as requests to join the Foundation's mailing list. Readers on the internet may wish to join our multidisciplinary scholarly discussion list restricted to clinicians, educators and researchers.
I would however like to point out that PMRF did endorse the QTF (Quebec Task Force) Guidelines, as it represents the best evidence-based study to-date. The Foundation is committed to raising funds to support further multidisciplinary research which can add to our knowledge base.
If it were not for disagreement, consensus conferences would not be needed, and we would have the disputable pleasure of agreeing with each other on all matters.
Andrew Chalmers, MD
Western Canada Multidisciplinary Committee
Marc I. White, Executive Director
Physical Medicine Research Foundation,
Suite 510, 207 West Hastings St.,
Vancouver, BC, V6B 1H7
Phone (604) 684-4148 Facsimile (604) 684-6247
The Only Dissenting Vote
I would like to point out a mistake in Dr. Croft's Spinal Rounds article (December 4, 1995 "DC") regarding the Eighth International Symposium at the Physical Medicine Research Foundation (PMRF). The consensus conference, held by PMRF at this meeting did endorse the clinical guidelines for the practice of whiplash associated disorders as published by the Quebec Task Force on Whiplash Associated Disorders. The only dissenting vote was Dr. Croft. Your readers should ask themselves why he alone, amongst an international group of whiplash experts, refused to endorse the guidelines. I should add that the Physical Medicine Research Foundation is now pursuing a continuing medical education strategy in the province of British Columbia to widely disseminate the Quebec guidelines. Similar efforts are taking place in Saskatchewan and Sweden.
J. David Cassidy, DC, PhD
Centre for Neuromuscular Health
Department of Orthopaedics,
Royal University Hospital
Health Purchasers Need to Be Strongly Influenced
I have just completed going through volume 13, No. 26 of Dynamic Chiropractic (December 18th issue). I'd like to offer my congratulations to Dr. Arnold Cianciulli for his article, "The Latest Hoax." This is a cogent summary of the outcome from purely politically-based thinking with respect to efforts to influence society and its decision making. I applaud his call for a summit and encourage the leaders of this profession to seriously reconsider their political action emphasis.
I hope any future long-range planning for chiropractic political action with resources will give serious consideration to the different strata of social policymaking: politicians, bureaucrats, technical experts/consultants and local health care purchasers. What is clear from our experience and reflected in the outcomes described by Dr. Cianciulli is that politicians, the principal focus of chiropractic effort for the last several decades, can be influenced on a day-to-day basis by those who court their favor. The bureaucrats and expert consultants advising both bureaucracy and politicians are a different and equally important strata of influence. These are the people who make the regulations to implement and enforce the regulations empowered by the actions of law makers.
While legislators may come and go based upon political whim, the bureaucrats and their expert consultants tend to be life-long government employees, as are the academicians and researchers who advise them. The third stratum (local health care purchasers) have increasing power on the actual gatekeeping process. These individuals need to be strongly influenced, based upon practical day-to-day issues with clear evidence supporting change in their attitudes toward utilization of chiropractic services, before we can expect the increase in access to chiropractic services by the patients who may need them.
John Triano, DC, MA
Texas Back Institute
Time for a Summit Meeting
It is about time we got a wake up call for all leadership groups to come together at a summit meeting.
Dr. Arnold Cianciulli states in "The Latest Hoax" in the December 18, 1995 Dynamic Chiropractic, the most important reasons for chiropractic survival and why it is imperative for such a meeting to take place. We did the same when we had the congress of presidents and found directions the profession would follow. We did it with the Federation of Chiropractic Licensing Boards. Now we have to include the CCE, ACA, ICA, COSCA, FCER, NCMIC and the National Association of Chiropractic Attorneys to find where we will direct our efforts in the next 10 years into the 21st century.
The chiropractic profession is more than any one individual or association, we must listen to the warnings of our past warriors in chiropractic and have this summit.
Valerio Pasqua, DC, DABCO
Bronx, New York
"... fed up with promises and half truths ..."
A resounding "thank you" to Dr. Cianciulli for his article, "The Latest Hoax." I too am fed up with promises and half truths and unearned back slapping by our so-called national organizations. For 18 years I have often dug deep into my pocket to support the ACA political action committee, often at a great personal sacrifice. And I wake today to find nothing has changed in Medicare for our patients. Still we and they are second-class citizens: no more money unless I know it goes to a congressman or senator who I can believe is interested in fighting for our patients and our profession. Of course until we as a profession mature and work as one, nobody can respect us, and why should they? No more promises! I'll only pay for and fight for results. Thank you Dr. Cianciulli.
James Tormey Sr., DC
Chesnut Hill, Pennsylvania
The Managed Care Challenge
A recent issue of Dynamic Chiropractic (December 18) included on its cover data taken from a survey conducted by The Robert Wood Johnson Foundation. The information presented implies that in contrast to fee-for-service health care programs, managed care programs are less "patient friendly" and therefore a less desirable health plan. Our reading of the information prompted a response in favor of balance.
- Four of the eight complaints were related to the providers' behavior (difficulty obtaining appointments, long waits in the office, poor patient education, and poor or no medication instructions), not variables within the control of a managed care organization. These complaints have long been reported by patients independent of type of health plan. These findings cannot be taken as proof that managed care is not patient friendly, but perhaps may suggest that providers discriminate against those patients who are funded by managed care.
- The data does not indicate who the survey respondents were. What forms of managed care were represented? Patients of staff model HMOs may be less satisfied than a sample that included patients of various forms of managed care plans.
- The combined responses of the managed care and fee-for-service patients represented a minority of patients surveyed. On average less than 2 of 10 patients complained about their managed care plan. It is assumed then, that 8 of 10 must be either satisfied or neutral, a statistic similar to what patients report about their satisfaction with their provider.
- The better measure of managed care versus fee-for-service is cost and outcome. Inarguably managed care is more cost effective for the patient and the entity that provides the health plan to the patient. Considerable data is available to point out that patients in managed care achieve the same or better outcomes, and in a more timely fashion, than patients funded by indemnity benefits.
Managed care is a challenge for providers and patients alike, and is a force that will not be remembered as a fad of the '90s. It is incumbent on all health care professionals to accommodate to change, recognize the value and efficacy of managed care, and serve the patient through acceptance of the accountability placed upon them by managed care. Criticizing managed care, however, well intentioned or naive, while favoring a reimbursement system that is irreversibly in decline, serves no meaningful purpose.
Gregory Lang, PhD
Director of Network Development
Alignis, the HandsOn Healthcare Company
Thoughtful and Provocative
Dr. Linda Elyad always writes a thoughtful and at times provocative column. I appreciate her insights and moral/ethical approach. All the more so because it's somewhat rare in most professional discussions.
Peter Patsakos, DC
Grand Rapids, Michigan
The Use of the Word "Proprioceptor"
We greatly appreciate the kind comments made by Dr. Innes in his review of our book, Basic and Clinical Anatomy of the Spine, Spinal Cord, and ANS. His views are highly regarded by many chiropractic students and practicing chiropractors and we consider his opinions to be important. Because of this we feel compelled to respond to his comments related to the topic of sensory receptors.
More specifically, Dr. Innes questioned our use of proprioceptor in his article. There are several ways of classifying sensory receptors of the peripheral nervous system. After reviewing the current literature, Dr. Darby felt the best approach to this topic was to first discuss the different methods used to categorize receptors and then to discuss the different types of receptors using the terminology that is currently most commonly used by the discipline of neuroanatomy. This is what appears in the text. The term proprioceptor was used in its proper way to describe those mechanoreceptors in muscle, joints, and tendons which convey information used to determine the position of the limbs in space. Other widely accepted sources that use the term in precisely the same manner as we did include Gray's Anatomy(16), Barr and Kiernan's text, The Human Nervous System(1), and many others.(2,3,7,14,15) In addition, both clinical and basic scientists currently involved in research on proprioception use terminology in their daily discussions and in their publications precisely consistent with that of our text.(4,5,6,8,9.10,11,12,13,17, more available upon request). We remain puzzled that Dr. Innes would spend such a large part of his column objecting to a term used in the manner currently accepted by the neuroscientific community. Our most recent literature search on this topic was November 12, 1995, and we can find no literature suggesting a change in the use of currently accepted terminology (the terminology used in our text). The literature search did reveal that scientists currently doing research in the field of sensory receptors and proprioception are quite comfortable with the word proprioceptor.
Again, we greatly appreciate the kind comments Dr. Innes made in the beginning and at the end of his review of our book. We also thank him for his rating of "9" (of course we think it is a "10"). However, we feel that his objection to our use of proprioceptor was too strong in light of its current use in the neuroscientific community.
References available upon request.
Gregory Cramer, DC, PhD
Susan Darby, PhD
National College of Chiropractic
200 E. Roosevelt Road
Lombard, IL 60148
Increase the Time Devoted to Clinical Skills
Dr. Peter Martin's article "Upgrading Our Educational Standards" in the 12-4-95 issue raises some issues I wish to respond to. When I entered Palmer in 1990, the primary science prerequisites included two classes in chemistry, and one in physics and biology, all with labs. They were all very helpful in adding to my comprehension of the basic science classes which made up the first two years of the program. If the college presidents and the CCE feel pressed to add to the pre-credentials of their students, I hope they will add to the required list some basic classes in epidemiology, public health, and anatomy/physiology. An introductory A&P class would have made my anatomy classes much more useful and considerably less stressful.
The average chiropractic student takes 28-30 credit hours of class per trimester. Most of the students I knew stumbled from one exam cram session to another, with minimal time to absorb and reflect on the data presented. If the prerequisites reflected a wider range of the material to be covered later on in the program, the impact would be better understanding and retention. Doctor comes from the Latin docere, meaning "to teach." The first one the doctor must teach is himself!
I ask Dr. Martin to do me a favor if he is truly interested in improving the quality of graduates. Set guidelines (with actual enforcement) for each professor to write new exam questions each trimester, rather than relying on the same old pool of old exams, which many students at present routinely study from. Just check out the crowd at the copiers the day before any exam! When your students are forced to fully learn the material, rather than simply reviewing the pool of questions, you will see a drastic reduction in extracurricular activities like taking that extra six credit class to get a B.S. at graduation! That will really advance you towards the goal of a mandated B.S. degree before entry.
Residency and internship are what really separates our program from the allopathic model of teaching. The time devoted to basic science at the doctoral level is eating valuable time you need. The best side effect of more prerequisites will be to increase the amount of time available to practice and develop clinical skills. The development of algorithmic logic, the ability to turn basic science into understanding, and the increased time available to develop these skills before we are turned loose, should be the new goal of chiropractic academia. I hope this is what your article suggests.
Frank Painter, DC
Oak Park, Illinois
The Essence of the Matter
Once again I am compelled to step forward and speak out for my profession: not chiromed, not medipractic, not New Age therapeutics, etc., but chiropractic.
This time, a Joseph Keating Jr., PhD, professor at LACC (professor of what he does not say) has a problem with definitions as much as did Dr. Gatterman in her article regarding "Manipulation vs. Adjustment" in "DC" in October.
In the professor's letter to the editor titled, "Faculty Conclusions," he picks at the term "natural" as used in a quote in "DC" in November, in which the writer used the term "natural" in describing chiropractic care as opposed to pharmaceutical administration as discussed in a USA Today article. He asks for a definition of the term, "natural."
Okay, professor, how about this definition from the American Heritage Dictionary:
"One suited by nature for a certain purpose or function.'
There's that word "function" again!
Since the intent of administering a chiropractic adjustment is to restore normal function, the term natural seems ... natural.
If the professor would care to step out of his paradigm and inquire as to the nature of chiropractic philosophy and practice, which is -- when you care to read it -- supported by a growing library of scientific research and clinical support, his tunnel vision might clear up! That Professor Keating Jr. does not "get it" is no surprise when you consider under whose tutelage he now teaches and where he teaches.
Finally, having educators who do not understand the relationship of what they teach to the whole of the subject -- in this case chiropractic -- is not their fault, if they have attempted, without predisposed prejudices, to understand the essence of that subject.
Go ahead professor, ask me what I mean by "essence."
Michael Willis, DC
Simi Valley, California