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Majority of Alabama Chiropractors Favor Limited Prescription Rights

Source Chiropractic Economics

The Alabama State Chiropractic Association (ASCA) conducted a survey of member practitioners in 2010 regarding the scope of practice in Alabama. Overall, results indicated that a majority of surveyed chiropractors are in favor of the inclusion of injectable vitamins and nutrients and prescriptive rights in the scope of practice…

Within the group of 255 respondents, 63 percent percent agreed or strongly agreed that chiropractic is a drugless alternative to allopathic medical care, and the same proportion of respondents felt that chiropractic is the detection and correction of subluxations. Seventy-six percent agreed that subluxation is an important cause of disease and correction can restore health.

However, 41 percent responded that the chiropractic profession should abandon the term subluxation and focus on a broader scope of practice in general. A majority were also in favor of chiropractors utilizing injectable vitamins and nutrients (58 percent), as well as prescriptions of certain drugs (60 percent).

Survey respondents also believed that expanding the scope of practice in Alabama would both increase membership to the ASCA, as well as the number of patients seeking chiropractic care. Seventy-eight percent of the ASCA membership responded to this survey, which indicates that the outcome is a good representation of the climate of the chiropractic profession statewide.

Read the ASCA Survey Results

Read the Current Alabama Chiropractic Scope of Practice

20 comments to Majority of Alabama Chiropractors Favor Limited Prescription Rights

  • I am glad to hear that more DCs are abandoning the term, “subluxation”. That term already has a definition: “less than a dislocation”, and use of this term with a different definition only serves to confuse the use of BOTH terms.

    I describe the Chiropractic adjustment to patients and other health care professionals as a tool of mobilization — a means of restoring normal range of movement to a joint that is lacking it. For this purpose, the adjustment is a phenomenal tool. And, this description is supported by research, by common sense, and is measurable. Additional benefits of the adjustment may very well exist, but just aren’t justifiable by evidence or reproducible.

    Thank you for posting this information — very helpful!

    Sincerely,
    Daniel Bockmann, DC

  • Hi Daniel

    Personally, I like the term “subluxation”, and I have no issue with the ever-evolving understanding of that term.

    Research is making it more clear how spinal adjusting helps with LBP, chronic neck, and headache. I believe over time we will see more research that helps tease out WHY some people with “asthma” seem to improve.

    And…I believe it will become apparent that Dale Nansel was right…people who were adjusted and later noted improvement in their “asthma” NEVER actually had asthma…they had a “somatic dysfunction” that simulated a Visceral Disease. Abnormal nerve supply leading to loss of normal lung function. That’s what has been classically defined as the sequela of the “subluxation”. Right Church, just the wrong pew. Our profession delivers the goods, we just haven’t finalized what we call it yet. So what?

    Read this brilliant article…it’s a real eye-opener:

    Somatic Dysfunction and the Phenomenon of Visceral Disease Simulation: A Probable Explanation for the Apparent Effectiveness of Somatic Therapy in Patients Presumed to be Suffering from True Visceral Disease
    J Manipulative Physiol Ther 1995 (Jul); 18 (6): 379–397
    http://www.chiro.org/research/ABSTRACTS/Visceral_Disease_Simulation.shtml

  • karl

    I’m not sure how I feel about “limited prescription” rights yet. The profession is evolving and the management of health care is evolving. I will say this, having the ability to prescribe also grants one the ability to say “no” to a prescription.

  • Joseph Doughty, DC

    So if we abandon the use of the term subluxation and start prescribing drugs what would make us unique and different in the marketplace? Oh I see, to “get more patients”. Doctors who are having issue “getting more new patents” are willing to prescribe drugs and abandon the term subluxation. One could extrapolate this to be a financial and not “altruistic” motivation.
    Just a thought.

  • Frank — I had never heard that hypothesis before — fascinating! Perhaps I should have further qualified my statement by saying that I feel it’s very likely that research will “catch up” with what clinicians (and patients) are seeing anecdotally. This is often the case with research, since there has to be at least SOME evidence supporting a hypothesis before any research will be done to test it.

    Until then, however, I simply make sure to avoid making claims I can’t justify with evidence.

    Thanks for sharing that JMPT article — what an amazing idea!

  • Maine Chiropractor

    I guess I would be on board with “injectable vitamins and nutrients”, but I don’t feel that great about the idea of prescribing drugs. I do think that we should be able to tell patients “stop taking that drug it is harming you” without getting in trouble for it.

  • I had hoped to avoid the central theme of this posting…about DCs attempting to get Rx rights. Personally, I think it’s insane.

    There are 2 powerful professions that already prescribe drugs. Remember that (almost) thousand hours you spent, learning adjusting? What do you think they spent their thousand hours on? Why not leave them to their specialty?

    How can a DC moan about untrained PTs manipulating people, and at the same time intend to poach on someone else’s profession? I thought the *Big Idea* was to level the playing field, not to join the other team.

    Are these folks prepared for the **** storm the AMA is going to rain on them? Don’t they know that the AMA budget for stamps probably exceeds ACA’s total yearly income? Who’s gonna be left to bury us all?

  • I am a chiropractor in OR. We have the broadest scope in continental US and don’t capitalize on it because the rest of the profession looks down on the use of drugs and surgery. Let’s work together for some autonomy. Why do we have so many chiropractic associations? Wouldn’t it be more efficient if we have one chiropractic association? I’m okay with the use of subluxation-we just need to come to an agreement on what that means. A universal definition. There are over 100 definitions and that confuses not only our profession but every other profession as well. When we unite, we will be unstoppable.

  • I agree, Frank. And I’ll further submit that the Chiropractic argument for and against Rx rights has both philosophical and practical components.

    We can probably all agree that medication can serve a very valuable function. Antiobiotics save people from dying of infection. Blood thinners save people from pulmonary embolism and paralysis. And although some meds may be overprescribed, we certainly wouldn’t want to do away with them entirely. If I have a heart attack, I want to be treated by an MD — not a DC. And if, for example, a DC takes insulin for her diabetes, why wouldn’t that same DC feel comfortable prescribing meds to others who might need them?

    Which brings us to the argument of practicality. In order to become proficient in the prescription of pharmaceuticals, a DC would need MUCH more education. And while I understand this post discusses “limited” Rx rights, I think the battle to gain these rights would be huge compared to the limited benefits we would gain, and the added schooling we would need to have. Not to mention the fact that as providers of “alternatives” to allopathic treatment we would be adding a built-in conflict to that mission.

    Personally, I much prefer being a specialist, a “go-to guy” for conditions musculoskeletal and neurological. I would rather be the very best at a few things than be mediocre at many. I believe that is how our profession will become fully accepted by the public and the healthcare community (which we need to be, by the way).

    We need to “brand” ourselves — define our field then excel in it.

  • Maine Chiropractor

    Has the term “injectable vitamins and nutrients” been defined? I’m not opposed to using a needle if it is a means of delivering nutrition that cannot be administered orally for whatever reason. I do NOT wish to give drugs to people however.

  • Alan Dinehart, DC

    With the onslaught of the baby boomer generation, the health care system in this country is being overwhelmed. Primary care is being taken over by nurse practitioners, physician’s assistants and foreign trained medical doctors. Chiropractors treat patients differently yet have much the same training as medical doctors. To have prescription rights would open the profession to a larger percentage of patients (Above the 6% we now see) and we could teach patients that they need to be responsible for their health (Wellness teaching). We must expand our scope in order to survive. After National Health fully comes about, we will lose the 6% 2 we now treat to lesser trained individuals.

  • Alan Dinehart, DC

    Are any of you aware that virtually all Chiropractic Colleges, with the exception of the few that identify themselves as “Straight Chiropractic” teach pharmacology?

    If you want to stop a patient from taking a pharmaceutical, you have to have the authority to prescribe the drug.

    With National Health around the corner, this profession is doomed if we do not adapt to a broader scope.

  • There is an expanded discussion on circleofdocs.com a website and forum for chiropractors only, I urge all of you to request membership and join the fight for expanded scope.

  • Dr. D

    There is now a group on Facebook called “Chiropractors for Prescriptive Rights.” Apparently the goal of the group is to serve as a legislative action center and also to keep group members up-to-date on changes as they develop. So far it seems to be catching on with people???

  • Alan Dinehart, DC

    WHERE DO WE GO FROM HERE?

    In the beginning of the Allegory of the Cave Plato represents man’s condition as being “chained in a cave,” with only a fire behind him. He perceives the world by watching the shadows on the wall. He sits in darkness with the false light of the fire and does not realize that this existence is wrong or lacking. It merely is his existence — he knows no other nor offers any complaint.
    Plato next imagines in the Allegory of the Cave what would occur if the chained man were suddenly released from his bondage and let out into the world. Plato describes how some people would immediately be frightened and want to return to the cave and the familiar dark existence. Others would look at the sun and finally see the world as it truly is.
    They would know their previous existence was farce, a shadow of truth, and they would come to understand that their lives had been one of deception. A few would embrace the sun, and the true life and have a far better understanding of “truth.” They would also want to return to the cave to free the others in bondage, and would be puzzled by people still in the cave who would not believe the now “enlightened” truth bearer. Many would refuse to acknowledge any truth beyond their current existence in the cave.

    The cave dwellers are the Chiropractors in today’s health care system. Many Chiropractors practicing in the country today attended schools that focused on Chiropractic Philosophy rather than scientific knowledge. Relying on the Chiropractic philosophy, It became more comfortable to remain in the cave than to venture to and see the light of reality. Today’s health care relies on evidence based forms of treatment, rather than philosophy. If you can’t prove it works, you can’t expect a third party payer to accept responsibility for paying a claim. National health is a reality and we all can expect some drastic changes.

    With the advent of a National Health Care Plan, emphasis is being placed on the primary care sector rather than on the medical specialists. The idea is not unique as other countries that have a national health system have always relied on the primary care to address the majority of the health care needs of the population. However, in the United States, the number of primary care practitioners is severely lacking. Currently, the American College of Family Practitioners estimates that there is a shortage of 6000 family practitioners to fill the current needs. With the increasing age and numbers of the ‘Baby Boomers”, this shortage increases to 20,000 by the year 2020.

    As most new medical school graduates feel that primary care is not how they want to spend their careers, the gap is being filled by foreign trained physicians, Nurse Practitioners and Physician’s Assistants. In and of itself, this is not a bad situation if you are not in the cave. The reality is that Chiropractic has failed to practice primary care and therefore will be left by the wayside when it comes to inclusion in any future reimbursement plans. Are you starting to see the light at the opening of the cave?

    With the passage of a national healthcare law, we must realize that there are finite dollars in the system and the payers must divvy the pie up in the most effective manner. If you have been in the Chiropractic profession for any length of time, you realize that the more powerful lobbies have the most say. I have heard the analogy that healthcare is like the basic automobile. And, Chiropractic is an expensive option. Sure, it works but the car runs perfectly well without it! This is the excuse that will be used when coverage is to be determined. Unfortunately, we, as a profession, have turned ourselves into a One Trick Pony. We spend most of our resources defending ourselves rather than expanding our service base.

    Recently, the State of New Mexico adopted a new program called Advanced Chiropractic Physician. This designation comes after a set educational course and allows those Chiropractors who have completed the requisite hours of training to utilize a formulary of medications and the injection of vitamins. Although this sounds good to some, it really does not come close to being adequate to fill the role of a primary care practitioner. To be an independent primary care practitioner, there can be no restraints on which medications can be used or prescribed.

    Currently, in the United States, there are fourteen states and the District of Columbia that have licensing laws pertaining to Naturopathic Medicine. However, out of the fourteen, Utah and the District of Columbia have not issued any licenses.

    Arizona and Oregon are the only two states that have Naturopathic laws that would qualify the practitioner as a true primary care physician. As the scope of practice is slightly less restrictive, Arizona’s law should be used as a model for future legislation. For reference, this website will take you to the Arizona Naturopathic Medical Board http://www.npbomex.az.gov/. Naturopathy is also licensed in Canada and the province of British Columbia has recently adopted laws allowing prescriptive rights to Naturopathic Doctors, licensed in the province.
    This was done to fill their increasing need for primary care doctors.

    Now, in order for our profession to survive in the national healthcare arena, we must offer more medical services and expand our scope of practice. A decision will have to be made weather the advancement comes through a program in Naturopathic Medicine taught in our schools, leading to a DC/ND degree or expanding the scope from within by establishing an Advanced Chiropractic Practice certificate, taught at Chiropractic Colleges on the post graduate level. To date, there are two Chiropractic Colleges that have started Naturopathic Schools under their university umbrella. These are University of Bridgeport and National University of Health Sciences.

    Most Chiropractors don’t understand that scope of practice is determined from within the profession, not from without. If the demand is there, the state associations lobby the legislature and laws are passed. Chiropractic Boards do not determine the scope of practice. Their job is to determine what the current laws say and enforce them. When they determine that a practice is within the law or outside the law, they can be wrong. And, if so, can be challenged in court. We all know that two people can read a rule and interpret it differently.

    For those of you who exist in an all cash practice or those who are close to retirement, this article is of little use. However, if you are among the vast majority, especially the new graduates who carry massive debt in student loans, this should be a wake-up call to action.

    What can be done? Well, the profession needs to decide which way it wants to go. Currently, there are three options:

    One, interact with the Naturopathic profession and have the schools begin opening Naturopathic schools on their campuses. This would allow students to graduate with a duel degree. The schools could also develop programs for practicing Chiropractors to get their ND degree and practice accordingly.

    Second, develop an advanced chiropractic practitioner program and attempt to get state and national Chiropractic organizations to promote the idea.

    Third, do nothing and ultimately dissolve from the health care industry and be a footnote in history. Without moving forward, you move backward.

    The future of your profession is up to the current practitioners and the current students. I urge you to take a few minutes and write a letter to your school or to your state or national organization and express your concern. Give them the direction you feel your profession should be going. The urgency of this matter cannot be over emphasized as the camps are already staking out their position in the national healthcare arena. You can make a difference by doing something or by doing nothing.

  • Hi Alan

    I hope you don’t mind me using my reply to today’s e-mail as a response to your posting on the Blog.

    I am not a straight fanatic, but I do believe (and have so written) that trying to move into medicine’s prescriptive domain will most likely create a massive backlash from the AMA and all those others who are predisposed to dislike our existence and success. I see that as counter-productive.

    Other than that, I do not predict the demise of chiropractic from prescribing. I do feel that it will be a major confounder in determining whether it was the adjustment OR the meds that helped the patient. If it was argued that it was the meds that helped (even though we KNOW that is unlikely), that will just give organized medicine one more stink bomb to throw at us in their ongoing disinformation campaign(s).

    I took the 3-year post grad program in rehabilitation through LACC (here in Chicago) so I’m not an ultra-straight, but I am a Palmer grad, and I believe (and see daily) that the adjustment, all by itself, is sufficient for most patients. I have never used any forms of therapy in the office, other than icing the infrequent acute patient during the first few visits, and have found that chiropractic stands beautifully on it’s own 2 feet.

    I also use McKenzie protocol, and consider it vastly superior (not to mention more cost-effective) than the various flexion-distraction gadgets and tables on the market. It makes me ill to hear from patients that some doctor down the street tried to sell them on 36 visits of distraction. It rarely takes me more than 9-12 visits (1 month on McKenzie plus chiropractic) to quiet the worst radicular findings, whether caused by low back or neck disc derangement.

    More importantly, my practice mostly relies on what Liebenson (and others) refer to as “active care”, and I rapidly reduce the frequency of care so that I can determine how well the patient is stabilizing. By and large, that works very well for most patients.

    I disagree with your contention that “the only way you can remove a drug from the regime is to be able to prescribe drugs” Perhaps this is semantics, but I regularly discuss my patient’s reliance on pain meds and muscle relaxants, and ask if they would consider withdrawing their use, so we can see how chiropractic is serving them. Further, you can not cancel another doctor’s prescription, all you can do is with hold your own, so the issue really is moot.

    I am not alarmed at declining enrollment in some chiropractic schools. That’s simply market forces at work. In some States, it seems like there is DC on every street corner. If I had based my decision to become a DC on how much money I would make, I’d probably have become an orthopedic surgeon (or a drug company rep), so I could eat my fill at the trough. As it is, I am THRILLED to be a DC, and from my personal experience with my patients, I have seen NO need for prescriptions.

    If you feel you’ll do a better job with them, then best of luck. My personal opinion is that you are much more likely to injure the profession by poaching on medicine’s turf. As I said earlier, the AMA’s annual stamp budget is probably more than ACA’s whole war chest, and unlike the Wilk case, there will be no sympathetic public cheering you on when the AMA disembowels the “expanded scope” partisans (and just perhaps, the rest of us). It’s a hopeless (and perhaps pointless) battle.

    One question: Why can’t you simply develop a referral relationship with your local MDs and send patients as needed to support them? Most of the “we want prescriptive rights” people are really saying “Gee, if I could prescribe, I could get more patients (market share)”. Personally, I feel you’d get more business by cultivating relationships with local MDs, and (definitely) by not over-treating patients, than by poaching on medicine’s prescriptive rights. JMHO.

  • Alan Dinehart, DC

    For all of you who are pro expansion, I wrote this a few months ago for publication. Enjoy!

    For the past few years, the American public has been debating the immigration situation. As usual, there are two sides and opponents of both sides feel they are correct. One common battle cry is the immigrants’ failure to assimilate. They don’t adapt to the culture and they don’t like the way Americans do things.

    Now, I want you to examine the Chiropractic profession as it relates to the above scenario. We are the immigrants who refuse to assimilate to the medical model. We prefer to cling to a culture that often cannot be justified scientifically. We don’t scrutinize our methods or our philosophy to science yet we want to be called Doctors.

    Chiropractic landed in the US in the latter part of the nineteenth century. With it came some strong yet unproven theories of health and disease. The believers were from all over but they all had the fire of conviction that what they were doing was right and that allopathic medicine was doing it all wrong. We all know that nothing is all wrong or all right.

    At the time of its inception, Chiropractic was an alternative to allopathic medicine. Allopathic medicine was still very primitive and unorganized. The treatments were not necessarily scientific and relied on word of mouth and apprenticeship training. However, they had sufficient political clout to legislatively protect their “turf”. Thus, anyone that was a perceived threat was prosecuted.

    In the ensuing 116 years, the Chiropractic profession has grown from a single school to 18 accredited schools in the United States as well as schools in several other countries. This is in contrast to the 129 medical colleges and 26 Colleges of Osteopathic Medicine in the US.

    Initially, Chiropractic defined itself as a “Drugless Profession” which the leaders of the time thought would relieve them of the charge of “Practicing Medicine without a License”. In some jurisdictions, this was true. In California all practitioners were licensed by the Medical Board and the Medical Board even had a category of license labeled “Drugless Practitioner”. This license was issued to Chiropractors, Naturopaths, Osteopaths and several other fringe practitioners.

    Chiropractic continued on this path and further restricted itself by redefining itself as a separate form of therapy that does not utilize Drugs or Surgery. Thus, we became a profession that was defined by what we did not do rather than what we do. We continued and further restricted ourselves to musculoskeletal problems and lost the other fields which we practiced.

    In 1922, the Chiropractic profession managed to get an initiative act on the ballot in California. At the same time, the Osteopathic profession also secured a place on the ballot. Both of these propositions passed and became the law of the land. The primary difference between the two laws was the definition of Chiropractic was spelled out and restrictive while the definition of Osteopathic medicine was vague and was to be determined by the profession itself. This simple distinction allowed the Osteopathic profession to expand as the body of knowledge expanded.

    Chiropractors were relegated to maintain the status quo unless they were to have the original Chiropractic Act amended by a vote of the people. This act has been amended several times throughout the years and increases in education hours, increased in prerequisite education have been added. However, no one has attempted to expand the scope of practice or remove the “Without the use of Drugs or Surgery” clause from the body of the original act. The requirements for licensure has been upgraded and the number of hours required has been upgraded yet our scope of practice has actually been diminished since the original act was approved. One has to ask why there was a demand for more education if the task was to remain the same or be less than originally intended.

    It is apparent that it is the Chiropractic profession itself that refuses to assimilate and increase its service to their patients. We cling to a premise that continues to be incompatible with western medicine and thus continue to be ostracized from mainstream medicine and its benefits.

    We are now on the cusp of a medical revolution in this country. For the first time in our history, there is the enactment of a national healthcare system. This along with the ever aging Baby Boomer population and the demand for increased medical services. For us, this is the Perfect Storm!

    In order to assist the country in meeting its medical needs, we need to expand our scope to include the general practice of medicine. Having reviewed the curriculum of all the CCE schools, except for a couple of schools, the training received in Chiropractic Colleges is on a par with the majority of Medical and Osteopathic schools. The main difference between Chiropractic training and Medical training is the inclusion of the hospital based internship year. This is the point in the training where it all comes together. It also introduces the new graduates to the roles of specialists and the protocols of referrals.

    Obviously, the move to enter the practice general medicine will not make everyone happy. So, those that want to expand their scope would need to advance their education. Our schools along with the CCE should formulate programs that lead to an advanced practice degree such as Doctor of Chiropractic Medicine (DCM) or Doctor of Advanced Chiropractic (DAC). This eliminates confusion by the general public.

    Legislatively, we could petition the states to allow Chiropractors wishing to practice in an advanced setting, permission to sit for the United States Medical Licensing Exam (USMLE) and enter a rotating internship. This is a viable answer but I fear a few steps ahead of where we are right now.

    Now it’s time to reflect inward and say, what can I do to improve my career, my practice and how can I improve my patients overall health. Assimilation is the answer and education is the path.

  • Maine Chiropractor

    Frank, I could not agree more. Your assessment of this issue is spot on.

    Dr. Dinehart and Chiropractic Physician, I wholeheartedly agree with you on the idea of an internship as part of a chiropractic education. There is no excuse for our profession not to have one.

    I do respectfully disagree with the idea that we should prescribe drugs. It is exactly the inability to write a prescription that has driven so many advances in manual medicine. Without the impetus to “find another way”, why wouldn’t we just become practitioners who write a script for vicodin to any patient with pain? The whole eastern European school of manual medicine came from a scarcity of drugs and imaging resources in the old soviet block countries, and necessity was the mother of invention. Would Janda and Lewit have been the innovators that they were and are without this necessity driving them? I don’t believe they would have.

    I think this push for prescription rights is really a push for market share. Some have seen that the public demands their drugs and wish to cater to that demand. Does that make it right? Does that fall in line with “first do no harm”? Why would one voluntarily join a drugless profession and then seek to alter it? Chiropractic is what it it is. Most of us eschew the idea of drugs and surgery except as a last resort. If people do not realize this when deciding to enter the profession, then there is either a failure to communicate between DC’s and their patients, or individuals are indeed becoming chiropractors who would rather have gone to medical school.

    Why are other manual therapists not pushing for prescription rights? Are other non-prescribing professions trying to get prescription rights? Some are. For example, psychologists are pushing for prescription rights where PT’s and OT’s aren’t. Why not? Psychologists are seeing dwindling market share and PT’s and OT’s aren’t is the simple answer.

    I don’t see the benefit of so many medications and surgeries. Where is the evidence for statin drugs, anti-depressants, spinal fusions etc…? Why would we want to become a part of that? The research on many, many medications and surgeries are sorely lacking and are far from being evidence based. Somehow the idea that allopathic medicine’s treatments are inherently evidence based has become accepted by many in our profession. This is simply not the case.

    Some within the profession would see our identity eroded to the point where we no longer have one. The some people would point to D.O.s as an example of successful assimilation, but I would argue. D.O.’s in our community regularly send us patients, after a course of manipulative therapy with them (2-3 visits) has not seen results. Typically these are not complicated cases, the D.O. just does not have the time to devote because their office is full of seasonal flu and strep throat. Is that why we became chiropractors?

  • A profession should not define itself on what it can’t do. (i.e. Drugless Profession)
    Now, in order for our profession to survive in the national healthcare arena, we must offer more medical services and expand our scope of practice. Chiropractors were almost pushed out of doing DOT physicals because we are “drugless.” I have pharmacology background and it would be easy for the chiropractic schools to add a couple classes to meet public safety. A decision will have to be made weather the advancement comes through a program in Naturopathic Medicine taught in our schools, leading to a DC/ND degree or expanding the scope from within by establishing an Advanced Chiropractic Practice certificate, taught at Chiropractic Colleges on the post graduate level.

    • Dr Bellacov,

      I don’t believe that saying I am a “drugless healer” defines me by what I *can’t do*, but we both know this is a semantic and philosophical argument. I *choose* not to use drugs because the risks are high, and their track record is NOT remarkable.

      Considering that there is a large number of DCs opposed to incorporating prescriptive rights into the practice (and legislation of) chiropractic, I believe your suggestion to adopt a second degree that empowers one to use them is a good one.

      If an MD applied to a chiropractic school, they would not have to take most of the first 6 semesters of classes, so they could jump into palpation, technique, spinal anatomy and biomechanics immediately. It should work the same for DCs who want to adopt a second doctorate that already has drug privileges.

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