Editor's note: Following on the heels of Dr. Craig Nelson's article, "Chiropractic Scope of Practice," we offer a different view on the question of DCs as primary care providers.
The future of the chiropractic profession and the fate of the patients we serve are in grave danger unless the profession unites educationally and politically and supports expansive research. Widespread ignorance about the appropriate role of the chiropractic profession among the public, government policy makers, insurance companies, and the media must be addressed immediately. Nothing is more vital to our future than communicating to all parties that the modern chiropractic physician is well educated and competent to offer primary care within a holistic paradigm.
Primary Care
There is considerable disagreement about the precise meaning of primary care. In January 1976, a committee for the National Academy of Sciences reviewed 38 definitions of primary care and concluded that it cannot be defined by the location of care, by the provider's disciplinary training, nor by the provision of a particular set of services.1 This does not support the position of those within the chiropractic profession who are of the opinion that the nondrug/nonsurgical license for chiropractic is a limitation that excludes us from a primary care role.
The scope, character, and integration of services, therefore, are the basis of the definition.2 Primary care does not mean full service care; practitioners can be trained in a variety of disciplines, from family nurse practitioners and physician assistants to allopaths, osteopaths, and chiropractors. In most cases, the complete array of primary care services, "cannot be offered by a single individual and shall be provided by a team which includes physicians, nurses, physician assistants, technicians, and others. No single provider is capable of performing all primary care responsibilities."3 The chiropractic physician is legally and clinically included in the primary care definition.
Dr. Meredith Gonyea, of the Center for Studies in Health Policy, Inc., recently completed a study for the Foundation for Chiropractic Education and Research in which she addressed the role of the doctor of chiropractic in the health care system and compared the qualifications of chiropractic physicians with MDs and DOs for a primary care gatekeeper function. She concluded: "The DC can provide all three levels of primary care interventions and therefore is a primary care provider, as are MDs and DOs. The doctor of chiropractic is a gatekeeper to the health care system and an independent practitioner who provides primary care services. The DC's office is a direct access portal of entry to the full scope of service."4
Alternative Primary Care: The Chiropractic Advantage
Chiropractic is the largest alternative healing profession in the U.S. According to the Department of Health Education and Welfare, 10-15 percent of Americans have used chiropractic in their lifetimes.5 As a licensed profession in all 50 states, recognized by Medicare, Medicaid, workers' compensation boards in all states, and virtually all third party payers, chiropractic remains the most respected alternative to today's biomedical complex.
Chiropractic care may very well restore health to people who have diverse clinical problems for which we do not yet have an explanation. Medical specialists admit that chiropractic may be beneficial to a limited number of musculoskeletal problems, particularly mechanical low-back pain, but deny chiropractic's claim to treat a wider spectrum of functional illnesses. However, chiropractic is a popular approach to treating just this sort of problem. While the theories and specific treatments of medicine and chiropractic are different, they both share the clinical art, which Dr. Pellegrino argues is based upon the relationship between the patient and the doctor, and which is the architectonic principle of medicine: "an organizing principle derived from an empirical and phenomenological examination of medicine as a human activity of a special and unique kind."6 This definition focuses upon medicine as a healing process rather than upon its content (scientific concepts) or upon its goal (health). Chiropractic shares this process with allopathy, despite other differences.
Back to the Future
From its inception, chiropractic has emphasized two basic tenets. The first tenet is general: that illness results from imbalance, disharmony, or failure of the homeostatic drive toward health. Manifestations of illness are nonspecific dysfunctions that progress to disease when the homeostatic mechanisms fail. Chiropractic does not adhere to the tenet that a specific cause results in a specific disease. Rather, chiropractic has maintained that there are other factors, such as age, environment, immunity, lifestyle, poverty, and genetics, which must be factored into the equation before disease results. We all know of situations where some in the population become clinical after exposure to a pathogen, while others fail to develop the clinical syndrome and are subepidemiological. Chiropractic emphasizes these other "health promoting factors." Present day research is confirming our holistic hypotheses. The profession must broaden its research interests to include these subjects.
The second basic tenet is that musculoskeletal structures, particularly the spine and pelvis, are capable of disturbing the nervous system; thereby decreasing the body's inherent recuperative abilities and resulting in illness. These chiropractic tenets signify the profession's physiological holistic foundation.
The Future
As the private and public sectors move toward reducing health care expenses, the shift from high tech/specialty driven care to primary care (with its patient centered/personal care) takes center stage. The biomedical model is being replaced by Engle's biopsychosocial model7 which places the patient, not disease, at the center of health care. The new perspective is prevention, personal care, high touch, and a devaluation of the high tech bias which biomedicine ushered in.
The realization that the biomedical model is not only expensive but relatively noneffective in the chronic diseases has reached the most powerful health policy decision makers. There is a scramble on within the allopathic educational system to "sell primary care" to the new medical students. However, the lure of primary care does not seem to be enticing these students. It will take another 30 years before the U.S. has sufficient numbers of primary care physicians. This does not satisfy today's reform needs. The U.S. needs primary care providers now!
Where is there today a better pool of qualified primary care providers than within the chiropractic profession? Why have we not addressed this need and begun the necessary dialogue with the decision makers? It seems that chiropractic wants hospital privileges when the shift is to ambulatory care. Some talk about the need for drugs and surgery in order to qualify, yet more Americans are choosing alternative/holistic care than ever before, even though it is not primarily paid for by insurance.
Some within the chiropractic profession feel that we should follow the role similar to dentistry. That is, become proficient within a designated area and encourage interdependent activity. While this is a fine approach, the reality is that dentistry has no competition. If a tooth-related pathology develops, the patient utilizes a dentist. There are no viable alternatives. Furthermore, dentistry offers full services. They prescribe all classifications of drugs, and they are skilled in the oral surgeries pertinent to their field. The dentist's practice is restricted anatomically, not methodologically. The DDS does not attend to conditions involved within the tonsils, adenoids, sinuses, etc.
The DC has a different mission than the dentist: to offer alternatives for multisystem patient complaints, and at the same time, not act as a full service doctor in all body systems. Consequently, the DC is educated and trained to perform a comprehensive history, execute the relevant physical examination, and order or perform bioanalytical testing and diagnostic imaging, etc., in order to differentially diagnose the patient's problem. The DC is well skilled to be the sentinel for functional health problems plaguing Americans today. Our chiropractic institutions have emphasized the centrality of the patient within our care system. They have placed the patient's needs first and foremost in all our educational experiences, but they stressed that our most effective role is to offer the public a natural and holistic alternative, one that realizes the need for cooperation with allopaths and others, but that competes with them whenever appropriate.
Since 1895, political medicine has opposed chiropractic and has done everything possible to destroy us. Why? Perhaps the chiropractic principles which appreciate the patient as a whole entity and our ability to attend to the patient's feelings are key elements in a truly scientific clinical approach. Our approach respects patient autonomy and participation in managing their illness. Patients feel more satisfied with chiropractic care. This has potential for the use of less expensive technology. The multitude of symptoms that are self limited are better resolved with the personal care of a chiropractor, than by the use of prescriptions, etc., which lead to iatrogenic reactions, including death and addiction in some cases.
Conclusion
The profession of chiropractic has always been a nondrug, nonsurgical solution for a wide spectrum of clinical problems. At this point, national health care policy will demand global budgets for health care related expenses. The proposed Clinton plan allows patients to choose their health plan, which at present is the almost exclusive domain of employers. Our profession has within it the ability to communicate that we are conservative health care providers who place the patient at the center of our clinical attention. We practice primary care according to a biopsychosocial model and are not a duplication of the allopathic model with its overwhelming worship of technology and specialization.
Our strength lies in our practices and our patients. Our real skills are those of patient education, interpersonal communication, and our respect for the magnificence of the human body to function harmoniously on this planet. For more information about securing chiropractic's place in primary care, please contact the Foundation for Chiropractic Education and Research at (800) 637-6244.
Footnotes
Many relevant diagnostic signs are not performed deliberately by the examiner or by the patient at the examiner’s direction. They are observed as the patient reacts to their condition. Fortin’s finger sign, Minor’s sign, and Vanzetti’s sign are three examples of this principle.
On Feb. 1, 2024, two more legislators – John R. Carter (R-Texas) and Robert “Bob” Good (R-Va.) – co-sponsored the Chiropractic Medicare Coverage Modernization Act of 2023, bringing the co-sponsor total to 155, two more than the total achieved over the entire two-year congressional cycle in which identical legislation last appeared (2021-22).
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.
