According to a recent survey in the Journal of the American Medical Association, the number of graduating medical students planning on working in primary care has dropped to 2 percent. This number is down from the already low 9 percent reported in a similar survey in 1991.2 Why is this decrease in primary care physicians important for chiropractors? Because as the public's options dwindle with regard to primary care, DCs should expect more "nonchiropractic cases" to enter their offices over the next few years. As they do, chiropractors should be perfectly positioned to assist in, if not take over, the role of gatekeepers for a changing American health care system.
I fully expect this article to rekindle the chiropractor as primary care physician debate. I remember this controversy from when I was in college. One group of students - the philosophically principled - felt that primary care, as discussed in the modern medical context, is not chiropractic at all, but the practice of medicine. They felt any movement in that direction would be an abandonment of the principles on which our illustrious profession was founded. Chiropractic is, and has always bee,n the detection and correction of spinal subluxations, they say. Leave the medical doctoring to its own profession, including all forms of medical diagnosis. As such, seeing the chiropractor as primary care physician is a moot point.
The other group of students - the "let's enter the mainstream health care market and serve the most people" faction - saw the chiropractor as primary care physician option simply as a no-brainer. Why wouldn't we want to have the broadest scope possible, to help as many people as we can, and to embed ourselves in a potentially lucrative financial position? To this group, it made sense to study all the academic courses in college, regardless of whether they were chiropractically or medically oriented, and to also use all the tools learned in those courses to provide adequate patient care.
So, who's right? Interestingly, both groups are, to a degree. The principled faction is absolutely correct: We must maintain our unique identity. We are not medical doctors; we operate from an entirely different premise. We treat people naturally, without drugs, without surgery, to facilitate the innate healing powers of the body. No matter whether you are a pain doctor or a wellness doctor, or a combination thereof, the major premise by which you practice your craft is that the body heals itself; and as a chiropractor, you help it along through this process by administering an adjustment. (I personally do not care what language each individual doctor uses to describe this process.)
Because chiropractic is unique, both in premise and in practice, our greatest contribution to the public health is to maintain this distinctiveness. As I've heard it said by others, and with which I fully agree, if the patient is looking for a medical doctor or physical therapist, they probably shouldn't be walking into a chiropractor's office. However, this does not mean that we should shirk our responsibility as doctors. We owe it to our clients to be well-versed in and cognizant of standard diagnostic procedures. People see chiropractors as doctors, so they enter chiropractic offices with concerns about their general health. They don't give a hoot about the profession's philosophical differences.
Yes, some chiropractors will argue it's about educating the public on our true role is as spinal health experts - that we correct spinal subluxations and leave the medical conditions to medical doctors. To those who believe this, I pose this question: Do you really think the public understands how to differentiate between spinal and organic conditions? If they did, what the heck would they need us for?
This brings to mind a recent experience I had in my office. Early one morning in July, we received a call from Mary, who was concerned because her son, Jim, was suffering from "terrible neck pain and headaches." My office manager assured her that we would take good care of him. When the 25-year-old Jim came in, he appeared languid. He said he had a terrible headache and "sore" neck, and asked if I could just give him "a quick adjustment."
Upon questioning, I learned that Jim had been knocked unconscious by a thug at a Hollywood nightclub the week before. He disclosed that he was "out for 10 minutes," and that he had swallowed copious amounts of his own blood, on which he nearly choked. He had regained consciousness, opted out of an ER visit, and been taken home by his friends, whereupon he passed out until the next morning. He reported feeling lethargic, vomiting every day, having excruciating headaches, and losing 15 pounds (unconfirmed) due to a loss of appetite.
I immediately sent Jim via cab to the radiology center in my area for a CT scan. I knew he would be getting top-notch scans there and that they would send him over to the ER if necessary. It appeared to me that he had some intracranial bleeding going on, which would make sense considering his recent trauma and presenting complaints. Turns out he had a subarachnoid hematoma. Jim was immediately sent to USC Medical Center for further evaluation and emergency surgery. He is now recovering beautifully from his injuries and should be able to resume a normal life within a few months.
Here is the gist of the story: Despite what some chiropractors think, we do not always get to choose our patients. People often call with what they think is one problem - a sore neck and terrible headache, for example - and yet may have something entirely different. It is our responsibility as doctors to differentiate between musculoskeletal pain and more severe maladies. Our patients rely on us to help them with their health problems; if nothing else, to direct them to the appropriate place to find appropriate help.
I understand that some chiropractors have a different focus. They are wellness doctors and emphasize optimal health through the removal of spinal subluxations. I get it, and I'm all for it. My point here, though, is that it takes very careful patient education to teach patients what one's scope is. If you don't do diagnosis, then you'd better tell your incoming patients so. And if you are still accepting pain cases, you might be contradicting your own principles.
If you do accept pain patients and your focus (even if only a portion) is pain relief, then you absolutely must have basic diagnostic skills. Basic diagnostic skills encompass the ability to distinguish between chiropractic and nonchiropractic cases, understanding red flags and knowing when to refer.
This referral point should resonate with principled chiropractors, as it relates to what we've all learned as limitations of matter. As explained in Chiro Philosophy 101, if a person falls off a 10-story building, there isn't much chiropractic can do for them. We can all agree, though, that patients do not always know the difference with some conditions, as leg pain with large, deep purple spots seems to some people like something a chiropractor should be able to treat. I have plenty of patients who trust me enough to bring their painful purple legs into my office.
So, the original question is, should chiropractors position themselves as gatekeepers to tomorrow's reformed health care system? My belief is a resounding yes. The reality is that medical doctors, for various reasons, are abandoning the post for greener and more lucrative pastures in specialization. The options available to fill the primary care niche are registered nurses and nurse practitioners, doctors of physical therapy (it's coming!), foreign-trained medical doctors or chiropractors. Nurses are adequate, but in short supply; however, in no way are they better trained than chiropractors. Physical therapists are not yet doctors, and their education to this point is limited. I suspect that foreign-born MDs will increase over the next several years, as current reports list their numbers at 25 percent of the medical work force.3
With these four options in mind, it seems to me that the most likely scenario will include some combination of the four professions acting as primary health care gatekeepers. As chiropractic doctors, we should not let this opportunity slip us by. Our training and licensure put us in a perfect position to fill at least a partial role as primary care doctors.
I am certain that this notion will make some of the more traditionally minded, principled chiropractors very upset, for the reasons I have mentioned previously. I believe the reason for this is that I am suggesting change, and very few people adopt change without kicking and screaming along the way. However, I do not believe that those wishing to continue to practice in a traditional, wellness-based model should stop doing so. That type of focus is necessary and appreciated as an integral part of a holistic health care system, as long as incoming clients understand that distinction. But for those who wish to establish themselves more firmly in the mainstream health care arena, taking on the role of primary care gatekeeper will be essential to filling a very real void that is forming and will continue to grow as medical doctors increasingly leave behind their primary care practices.
- Hauer KE, Durning SJ, Kernan WN, et al. Factors associated with medical students' career choices regarding internal medicine.JAMA2008;300(10):1154-64.
- Schwartz MD, Linzer M, Babbott D, et al. Medical student interest in internal medicine. Initial report of the Society of General Internal Medicine Interest Group Survey on Factors Influencing Career Choice in Internal Medicine. Ann Intern Med, Jan. 1, 1991;114(1):6-15.
- Migration Policy Institute Web site. Migration Information Source, U.S. in Focus, Foreign-Born Health-Care Workers in the United States. (www.migrationinformation.org/USFocus/display.cfm?ID=583).
Dr. Nicolas Campos graduated from U.C. Berkeley in 1994 with a degree in molecular and cell biology, and then attended Cleveland Chiropractic College Los Angeles, graduating in 2000. The author of Six Keys to Optimal Health, Dr. Campos practices in West Hollywood, Calif.