A faction of the chiropractic profession has been advocating for prescription rights for its members.1-2 This proposed break from chiropractic tradition and definition has become a source of significant controversy and debate.
The Physician Shortage Rationale
Often the rationale for seeking drug prescription rights for chiropractors is based upon the assumption that there is a shortage of primary care physicians in the U.S. According to a March 2015 physician work force project report, The Complexities of Physician Supply and Demand: Projections From 2013 to 2025, released by the Association of American Medical Colleges (AAMC), the likelihood of a shortage is an accurate assumption.3
The report estimates a shortage of 12,500 to 31,000 primary care physicians and a shortfall of 28,200 to 63,700 non-primary care physicians by 2025. The report indicates that the shortage will be especially acute among rural populations, where there is not only a shortage of family practice doctors, but of specialists as well.
Chiropractors seeking prescription rights believe that attaining this privilege would allow the DC to assist in filling the doctor shortage gap by effectively assuming the duties and responsibilities of primary care physicians. However, it is important for chiropractors to carefully consider the practical implications of this belief.
As an example, consider a hypothetical community in rural North Dakota, Kentucky or perhaps Mississippi. Visualize a town with a population of 1,800 residents served by two aging family physicians, a 20-bed hospital and a nursing home with a 40-resident capacity. The nearest community of more than 20,000 with a broader range of doctors and specialty services is over 40 miles away.
The town's only surgeon left several years earlier to practice in an adjacent state, and attempts to replace him have been futile.
At age 68, one of the town's overworked physicians suffers a stroke and becomes permanently disabled. Suddenly the national shortage of primary care physicians is an acute reality for the citizens of this community. A search committee is promptly formed.
Now let's consider the role and responsibilities of the replacement doctor the search committee is seeking. Such a doctor must be proficient in:
- Emergency care for acute myocardial infarctions, stroke and other vascular conditions such as venous thrombosis, varicose ulcers, etc.
- Emergency care for severe lacerations, stab, puncture and gunshot wounds
- Care of fractures, dislocations, crushing injuries, etc.
- Emergency care for major vehicular accidents and industrial trauma
- Emergency care for severe burns, toxic chemical exposure, accidental poisonings, etc.
- Non-complicated surgical procedures such as appendectomy, tonsillectomy, gall bladder surgery, hernia repair, etc.
- Pre- and post-natal obstetric, maternal and gynecological services
- Appropriate clinical case management of acute and chronic, often life-threatening disorders such as cancer, diabetes, digestive, genito-urinary, neurologic, hepatic and respiratory disorders
- Fulfillment of required public health mandates including childhood and adult immunizations and reportable communicable diseases
- Comprehensive knowledge of pharmacological agents and ability to accurately and safely prescribe life-saving and life-extending drugs
A Thought-Provoking Scenario
Regarding the last item above, let me share a story that should give every chiropractor pause: In January 2013, I received an email letter from one of my cousins announcing the sudden death of another cousin's husband. For the sake of confidentiality, I will refer to him as Stan and his wife (my cousin) as Rebecca. Stan was a veteran of the Vietnam war and had struggled with bouts of depression and post-traumatic stress disorder.
Stan was often unemployed, and because of health problems, Rebecca had not worked for over a year and was on medical disability. The combined effect of their health issues resulted in a severe economic hardship for the family.
The day before Stan took his own life in desperation, Rebecca had been hospitalized for kidney failure that was the result of the adverse effects of 30-plus prescription drugs currently used to treat her migraine headaches. We were told that nine of the prescriptions were to counter the side effects of the originally prescribed drugs.
While this represents a single, perhaps isolated case, the reality is all of her local doctors had given up in their efforts to help her. The most recent clinical management of her disorder was through the services of a famous headache clinic they referred her to in Chicago. Does this not remind us of the old saying, "If the only tool one has is a hammer, then everything begins to look like a nail"?
Spending Billions to Offset the Side Effects of Prescription Drugs
A1995 report by Johnson and Bootman titled "Drug-Related Morbidity and Mortality – A Cost of Illness Model," published in the Archives of Internal Medicine,4 reported that on average, Americans spend approximately $75 billion for prescription drugs annually, and during that same year, spend another $76 billion for the problems caused by drugs (drug problems – DRPs).
Five years later, the Johnson and Bootman study was updated by Ernste and Grizzlein in "Drug-Related Morbidity and Mortality: Updating the Cost-of-Illness Model," published in the Journal of the American Pharmaceutical Association.5 Their findings indicated that during the five years following the original study, the annual cost for DRPs had more than doubled, with the average cost of drug-related problems rising to $177 billion.
They reported that the vast majority of those costs were the result of required hospitalization of those affected by DRPs. Of note, these figures reflected only the drug-related problems incurred by patients in the ambulatory, outpatient setting.
Table 3 on page six of the study summarized the findings of the investigation, reporting that in addition to the costs, an average of 218,113 deaths resulted from prescription drug-related problems each year.
The Reality: No Shortage of Drug-Prescribing Providers
While the future medical doctor shortage is real, statistics would indicate there is no shortage of health professionals currently licensed to prescribe drugs.
According to the nonprofit Henry J. Kaiser Family Foundation,6 whose role is to provide trusted information on national health issues, the following represent the April 2016 numbers of licensed care providers among the various disciplines that have prescription rights:
- Primary care and specialists (MDs and DOs): 908,508
- Advanced nurse practitioners (ANPs): 222,000
- Physician assistants (PAs): 91,994
- Total: 1,222,502
The United States Census Bureau reported that as of July 2016, the total U.S. population was 321,604,44.7 These numbers translate to one primary or specialty clinician available to prescribe drugs for approximately every 300 citizens. In addition, the Kaiser Foundation statistics indicate there are 210,030 dentists in the U.S., and according to the American Podiatric Medical Association, there are currently approximately 15,000 licensed podiatrists practicing in the U.S.8 The figures represent a grand total of 1,447,532 medical professionals in the U.S who can provide consumers with prescription drugs.
Editor's Note: In part 2 of this discussion, Dr. Sweere discusses the "help get patients off medications" rationale, among other topics. Part 2 is scheduled to appear in the August digital issue and will feature complete references for both parts.
Click here for previous articles by Joseph J. Sweere, DC, DABCO, DACBOH, FICC.