A recent three-part article published in ACA News advocates turning chiropractors into “conservative primary care providers” who would be the initial point of contact for patients, would serve as gatekeepers for referrals to medical doctors and specialists, and would co-manage patients with those specialists on a continuing basis: essentially, family doctors. I think that’s a terrible idea. It might benefit chiropractors by increasing their market share, but it wouldn’t benefit patients. There is no evidence to indicate that chiropractors are capable of filling that role effectively or safely.
NUHS. The article was co-authored by several chiropractors on the faculty of the National University of Health Sciences, a school noted for integrating quackery with medicine. The “sciences” this school teaches are listed at the top of its website: chiropractic medicine, naturopathic medicine, oriental medicine, acupuncture, biomedical science, and massage therapy. The only one of those that even sounds like science, “biomedical science,” offers a bachelor of science degree with an integrative medicine focus and with no required core courses whatsoever!
Their doctor of chiropractic degree program says:
National University prepares students to become first-contact, primary care physicians fully qualified to diagnose, treat and manage a wide range of conditions.
Background. The authors say proposals to classify chiropractors as primary care physicians date back to at least 1967, with the Comprehensive Health Planning Councils. Arguably, the concept of chiropractors providing comprehensive health care dates back to the origin of chiropractic, since its founder asserted that all human disease was attributable to subluxations, 95% in the spine and 5% elsewhere. On the other hand, chiropractors used to claim they didn’t diagnose or treat illness, but only kept the spine in proper alignment so that the vitalistic force they called “Innate” could take care of anything and everything. In essence, doesn’t their aspiration to become “family doctors” amount to an admission that chiropractic is not the panacea they once held it to be? Doesn’t their wish to branch out demonstrate the failure of their discipline?
Their Arguments. They argue that more primary care providers are needed, and that chiropractors can fill the gap. They argue that using chiropractors as gatekeepers will reduce costs.
When chiropractic physicians functioned as primary care gatekeepers, pharmaceutical costs fell by 58.1 percent and hospital admissions by 43 percent. These are statistics that clearly support the value of the chiropractic physician in the primary care, gatekeeper position.
These statistics, even if correct, do not support the value of the chiropractor as gatekeeper. Cheaper is not better if it reduces quality of care. Of course pharmaceutical costs went down, because chiropractors can’t prescribe pharmaceuticals and they typically discourage patients from using them. They discourage surgery and conventional medical care, so it’s not surprising that hospital admissions fell; but maybe some of those patients would have been better off in the hospital. And I would guess that vaccination costs dropped too, since only around half of chiropractors support vaccination. We need to know the health outcomes for those patients, not just how much money was saved. Parents who belong to faith healing cults and never take their children to a doctor can cut medical costs to zero, but sometimes the children die.
Apart from the question of costs, the ability of chiropractors to function effectively as gatekeepers has not been tested in any formal study. It is questionable, to say the least. There is anecdotal evidence that occasionally a chiropractor makes a diagnosis that MDs have missed and that many chiropractors refer appropriately, but there is at least as much anecdotal evidence that chiropractors have missed diagnoses that would be obvious to any MD, and that they have failed to send patients to the emergency room for medical emergencies such as classic heart attack symptoms or fevers in very young infants.
They recognize that not all chiropractors are willing or able to carry out their vision:
Among the challenges is the diversity of our colleagues—those wanting to participate in primary care who order technical diagnostic procedures and clinical laboratory tests versus those who want to remain subluxation based. There are those who want to treat the whole person versus those who want to treat only musculoskeletal conditions. There are those of us who want to use treatment modalities beyond the adjustment, as well as those who feel we should adjust only the spine.
Managing Chronic Disease
“Conservative primary care physician” is language intended to clarify that as chiropractic physicians we do not address the complex primary care disease states that require pharmaceutical intervention and management.
Unfortunately, many do. I am increasingly hearing about chiropractors who profess to cure diabetes. They call themselves “doctors” and many of their patients don’t realize they are seeing chiropractors.
Chiropractors aspire to being part of a health care team, managing musculoskeletal problems and “co-managing” chronic diseases by counseling on lifestyle, diet, and exercise. They want to manage psychosocial issues such as anxiety and depression, and they want to use preventive management strategies to reduce the incidence of cancer and dementia. They want to. But that doesn’t mean they can.
A Primer on the History and Physical. After saying in part 1 that chiropractors should provide primary care, they proceed in part 2 to a primer on how to take a history. The fact that they feel a need to explain this implies that chiropractors don’t already understand the basic principles. They proceed to explain how to ask about chief complaint, history of present illness, past medical history, family history, social history, and review of systems. They even feel a need to explicitly remind chiropractors to ask if the patient smokes!
Even their attempt to instruct chiropractors is flawed. For instance, they recommend simple lab tests, but their recommendations for sedimentation rates and CRP testing are not evidence-based and do not correspond to standard medical practice.
In part 3, they describe an office visit and comprehensive physical exam in great detail, with many recommendations that are non-standard and not evidence-based:
- Routine pulse oximeter readings on every patient. (This may be routine in the ER, but it is not and should not be a routine part of every visit to a doctor’s office.)
- If any vital signs are abnormal, instead of taking prompt and appropriate action, they recommend that “they should be tracked on a regular basis to determine if a specialist consultation and/or further medical intervention is needed.”
- For trauma patients, they recommend assessing the patient’s short and long term memory and considering a mini-mental status test. (For most trauma patients this would be a waste of time.)
- As part of the chest exam, they recommend testing tactile fremitus. Abnormal tactile fremitus is a sign of lung consolidation in patients with pneumonia. It is only appropriate as part of a directed physical to pin down a suspected diagnosis, and even then it is not a particularly useful test. It’s one of those things doctors learned in medical school but rarely if ever use in practice because there are far better ways to make the diagnosis.
- “The role of testing for H. pylori infection in GERD (gastrointestinal reflux disease) remains controversial.” No, it doesn’t. There’s no controversy: there’s a clear consensus that such testing is not indicated. Some patients can be treated on the basis of symptoms alone; others will need endoscopy. H. pylori testing is done for suspected ulcers, not for GERD.
What really surprised me was their extensive coverage of the musculoskeletal exam. This is their particular area of expertise; surely chiropractors don’t need to be reminded about how to evaluate joint motion, muscle strength, and tender points. They ask “Is there any indication that the patient would be at increased risk for spinal manipulation of the neck?” It seems they recognize that neck manipulation can precipitate a stroke; unfortunately, there is no reliable way to rule out risk, and implying that chiropractors can do so is misleading and dangerous.
This whole exercise struck me as silly, condescending, and embarrassing. If chiropractors were already qualified to be primary care providers, they wouldn’t need to be given this information. If they are not qualified, a simplistic tutorial like this isn’t enough to educate them.
Legislation and Other Developments. Legislation has been proposed to expand the scope of chiropractic and even to authorize limited prescribing privileges. Government programs and insurance companies are considering expanding reimbursement policies. In some places chiropractors are authorized to do sports physicals as well as drug testing and DOT physicals for commercial drivers licenses. National University is even offering what they call a family practice residency.
Other Non-MDs Do It. It could be argued that other non-MD providers carry out primary care and gatekeeper functions. Physician assistants are one example whose training equips them to do the job well. My main concerns about chiropractors assuming these functions are:
- Their thought processes and clinical judgment have developed in the context of a discipline that was originally based on erroneous ideas and that is still lacking in scientific rigor. (These authors still speak of the “subluxation.”)
- Their training has not exposed them to seriously ill, hospitalized patients, which I think is essential to developing judgment about situations requiring emergency care or referral.
- Many chiropractors espouse nonsensical tests and treatments. Just one example: according to an American Chiropractic Association survey, an appalling 38% of US chiropractors use applied kinesiology, one of the most ridiculous travesties in all of alternative medicine.
- Patients under the care of chiropractors are less likely to get vaccinations; only around half of chiropractors recommend them.
- Chiropractors should not be treating children, but many do so.
Bottom line: Some chiropractors are family doctor wannabes, but they are not equipped to fill that role.
This article was originally published in the Science-Based Medicine Blog.