Chiropractic–primary Care, Neuromusculoskeletal Care, or
Musculoskeletal Care? Results of a Survey of Chiropractic
College Presidents, Chiropractic Organization Leaders,
and Connecticut-licensed Doctors of ChiropracticThis section is compiled by Frank M. Painter, D.C.
Send all comments or additions to: Frankp@chiro.org
FROM: J Manipulative Physiol Ther 2003 (Oct); 26 (8): 510–523 ~ FULL TEXT
Duenas R, Carucci GM, Funk MF, Gurney MWBACKGROUND: The Connecticut Chiropractic Association authorized an ad hoc committee to study Connecticut chiropractic scope of practice in January 1999. This committee was chaired by Richard Duenas, DC, and included 4 other Connecticut-licensed doctors of chiropractic who responded to an appeal to participate.
OBJECTIVE: Committee members investigated the terms primary care, primary care provider (PCP) (clinician, physician), neuromusculoskeletal care, neuromusculoskeletal care provider (clinician, physician), musculoskeletal care, and musculoskeletal care provider (clinician, physician) to determine which, if any, apply to the practice of chiropractic.
DATA SOURCES: A literature review was performed with in-depth analysis of the definitions of these terms and an interpretation of Connecticut Statutes for chiropractic, comparing the legal description of chiropractic practice to the term definitions. The literature review produced several detailed definitions of primary care and/or primary care provider (clinician, physician); however, no accurate description of neuromusculoskeletal (NMS) care or musculoskeletal care was found.
RESULTS: Two opinion surveys were conducted: 1 survey included presidents of accredited chiropractic colleges, as well as leaders of chiropractic organizations throughout the world. The other survey was sent to doctors of chiropractic (DC) licensed in the State of Connecticut. Survey topics addressed definitions of primary care and PCP, the formulation of these terms, neuromusculoskeletal care and neuromusculoskeletal care provider, individual rights in selecting a PCP, and the types of practitioners considered PCPs. The consensus among chiropractic college presidents, organization leaders, and Connecticut-licensed doctors of chiropractic was that the doctor of chiropractic is qualified to provide primary care. Most considered any definition of primary care invalid if the chiropractic profession was not involved in its formulation. The overwhelming majority felt the patient should retain the ultimate choice in determining who should be their PCP. Mission statements of accredited chiropractic colleges were reviewed, paying particular attention to educational goals and professional qualifications of graduates. The committee found these institutions strive to train students in all aspects of primary care.
CONCLUSIONS: Upon review of the literature and term definitions, interpretation of the statutes pertaining to chiropractic practice, results of both surveys, and review of the chiropractic college mission statements, the committee concluded that the Connecticut-licensed DC, by education, licensure, definition, and intraprofessional consensus, qualifies as a PCP.
From the Full-Text Article:
Discussion
Based on this study, including primary care definitions, the definition of chiropractic, education, licensure, intraprofessional consensus, and clinical practice, the CCA Ad Hoc Committee concluded the Connecticut-licensed DC is qualified to provide primary care.
Definition of primary care
While the committee's analysis of 7 primary care definitions revealed some terms which may bring into question the primary care qualifications of the DC, a review of those terms and the context in which they are used was not considered to preclude the DC from practicing primary care.
Medicine. “…the science and art of diagnosing, treating, curing, and preventing disease, relieving pain, and improving and preserving health.…” [59] While some DCs argue that chiropractic does not seek to diagnose, treat, cure, and prevent disease, or is even interested in addressing disease, the mission statements and curricula of CCE-accredited colleges are clear in establishing that the DC is trained to address the diagnosis, treatment, cure, and prevention of diseases or conditions affecting the human being. The term is not specific to the allopathic discipline and arguably may include all disciplines of the healing arts. The most contemporary and comprehensive definition from the IOM does not make the distinction of practicing medicine. [37]
Comprehensiveness. This term is addressed in the Starfield definition. [34] She points out that the provider need not render a broad range of services but rather recognize problems presented by the patient, give explicit notification of the services provided in the facility, and arrange for appropriate patient care. Furthermore, as Bowers and Mootz52 observe, “no physician, chiropractic or medical, is truly comprehensive in delivery of primary care.”
Widest possible range of common conditions. According to the IOM, this phrase connotes the provider act as a patient advocate. [37] A full range of patient concerns are addressed and managed in the primary care practice, the scope of which includes acute care, chronic care, early detection and prevention, and coordination of referrals. To “manage” the patient throughout the scope implies the clinician “…direct[s] or control[s] the use of…” [60] health care services.
The definitions of primary care and primary care provider have undergone periodic refinement over the last 30 plus years as a result of ongoing study by government agencies, academic and allopathic groups, insurance associations, philanthropic interests, private industry, and individuals. Little contribution has been made by health care consumers. Furthermore, the chiropractic profession has not participated in any group studies involving formulation of a definition. Thus, without significant input from the health care consumer and active involvement of the chiropractic profession, a definition would be limited to the predominant allopathic model of health care. The inclusion of consumer opinion for determining the type of primary care discipline and specific provider is a highly regarded concept revealed in studies of this kind.
Definition of chiropractic
Established by the CCE and largely adopted by all CCE-accredited colleges, the definition of chiropractic adds support to the position that the DC qualifies as a PCP. “The application of science in chiropractic concerns itself with the relationship between structure, primarily the spine, and function, primarily coordinated by the nervous system of the human body as that relationship may affect the restoration and preservation of health. Further, this application of science in chiropractic focuses on the inherent ability of the body to heal without the use of drugs or surgery. The purpose of chiropractic professional education is to provide the doctoral candidate with a core of knowledge in the basic and clinical sciences and related health subjects sufficient for the doctor of chiropractic to perform the professional obligations of a primary care clinician. As a gatekeeper for direct access to the health delivery system, the doctor of chiropractic's responsibilities as a primary care clinician include wellness promotion, health assessment, diagnosis, and the chiropractic management of the patient's health care needs. When indicated, the doctor of chiropractic consults with, comanages, or refers to other health care providers.…The accreditation criteria indicate the minimum education expected to be received in the accredited programs and institutions that train students as primary health care providers.” [28]
Describing chiropractic as a neuromusculoskeletal or musculoskeletal profession is counter to the character of chiropractic in caring for the human being as a whole rather than the illness or a particular physiological system. This reduces the profession and fractionates health care, which is precisely what the first study on primary care sought to avoid. [32] The terms neuromusculoskeleta and musculoskeletal are vague with little to no descriptive support in the literature. Some DCs may choose to limit their practice to neuromusculoskeletal conditions, yet this does not fully describe the chiropractic discipline. This description limits the opportunity for patients in the health care system to fully benefit from chiropractic care. In general, it limits consumer choice for a naturally based approach to their primary health care needs and would run counter to the IOM's goal to assure a patient-centered health care system that is “respectful of and responsive to individual patient preferences, needs, and values.” [37]
The CCE clearly structures chiropractic education to establish competencies in the “primary care role of the doctor of chiropractic.” [28, 61] With this mission to prepare the student in primary care, the CCE assures the Doctor of Chiropractic Degree Program accreditation encompasses an adequate number of instructional hours, a curriculum consistent with whole body health care study, competent clinical skills, and quality care with instruction provided by instructors with credentials in their respective fields of study. Accordingly, achievement of these goals helps assure the DC is prepared to answer the call to primary care. Postgraduate education to improve primary care qualifications may be pursued in pediatrics, family practice, behavioral health, neurology, and nutrition.
Connecticut general statutes
The Connecticut General Statutes clearly recognize the CCE as the accrediting body for establishing standards of chiropractic education. In fact, these statutes dictate that candidates for licensure must have graduated from a CCE-accredited (or equivalent) chiropractic college. Review of those chiropractic college mission statements reveals that their training includes the application of current scientific knowledge of health and disease in preparing the DC to render primary care. Thus, Connecticut credentials the DC consistent with his or her professional training, that is, as a PCP.
Intraprofessional consensus
Based on the results of the second survey, the majority of Connecticut-licensed DCs consider themselves qualified to practice primary care. Additionally, only 12% consider the DC to be a neuromusculoskeletal provider only. In clinical practice, the majority of these respondents report that up to half of their time is spent providing primary care service.
The majority of chiropractic college presidents, association leaders, and Connecticut-licensed DCs who responded to the surveys felt chiropractic practice closely fits most of the given definitions of primary care. There was also general agreement that the profession should be involved in the formulation of any definition of primary care, and the patient should have the right to choose an MD or DO, as well as a DC or ND, as their PCP. This illustrates a need for our health care system to be more responsive to and inclusive of other healing arts practitioners and health care consumers.
Historically, the chiropractic profession, by virtue of its distinct naturally based paradigm of health care, evolved independent of allopathic medicine. As such, it has made every effort to establish itself as a first-contact health care discipline capable of addressing the total health care needs of the patient, recognizing that providers from all disciplines serve important positions on the health care team. This practice is evident in the varied and generalist health care services provided by DCs throughout the twentieth century. These services included obstetrics, pediatrics, minor surgery, general health care, and care for the handicapped in the outpatient and inpatient setting. [62-64] This chiropractic primary care role is carried forward into the managed care system with the establishment and successful utilization of the chiropractic primary care network, Alternative Medicine, Inc. [65]
With a formal recognition of chiropractic primary care, the profession may further its scientific development with research directed at the effect of chiropractic care on the whole individual rather than musculoskeletal conditions only. It provides the profession with the impetus to develop its natural and holistic approach to health care with the opportunity to develop specialties within the profession. It is illogical to develop primary care from a specialty base. A naturally based healing art provides choice and opportunity for the nation to reduce its reliance on pharmaceutical and surgical intervention, often shown to be detrimental to the individual and environment. Furthermore, the chiropractic profession, as a primary care discipline, may ably contribute to the full spectrum of dialog for much needed improvements in the United States health care system.
This choice of primary care is consistent with society's values of self-responsibility, self-determination, and self-empowerment and supports the IOM's goal in 1996 to assure a patient-centered health care system that is “respectful of and responsive to individual patient preferences, needs, and values.”37 This goal is important enough to be reaffirmed by the IOM in its 2001 report calling for a patient-centered health care system that is “respectful of and responsive to individual patient preferences, needs, and values and ensuring patient values guide all clinical decisions.” [66]
Conclusion
The committee set out to apply the terms primary care, neuromusculoskeletal care, or musculoskeletal care to the practice of chiropractic, particularly in Connecticut. The evidence supports chiropractic as a primary care profession and the Connecticut-licensed DC as qualified to provide primary care. The study also revealed the DC's interest in providing neuromusculoskeletal or musculoskeletal specialty care. It was very clear that health care consumer/patient choice is very important, if not essential, when the type of primary care discipline and the specific provider is to be determined by the individual.
We propose that all primary care healing arts professions, including chiropractic, should be included in the formal study and practice of primary care at the governmental, industrial, interprofessional, and consumer levels. A partisan authoritarian system fails under its own weight and self-indulgence. Our health care system may improve only when all healing arts professions are respected and able to contribute to the formulation of health care policy for the present and future. This respects the citizen's liberty to choose a primary health care approach consistent with their way of life.
Further study should be conducted to determine the economic effects of chiropractic primary care throughout all types of communities within the health care system. For instance, chiropractic treatment effects on pharmaceutical and hospital utilization and cost per diagnostic episode should be investigated. Investigation of allopathic primary care from the chiropractic perspective and chiropractic primary care from the allopathic perspective are suggested. Finally, investigating patient or health care consumer perspectives of chiropractic and allopathic primary care and the reasoning of such perspectives should be undertaken. [67]
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