Dr. Sokoloff states that he is a firm believer in chiropractic as a science and in its primarily responsibility to educate the public as to the depth and scope of practice that a chiropractic physician is educated in, so they can be the direct beneficiaries.
The practice of chiropractic is undergoing a renaissance, the outcome of which will require the profession as a whole to make some tough decisions. Unfortunately, the time is rapidly approaching when past and present delays in making such decisions will lead to consequences that affect the private practitioner's access to the health care consumer. Yet for this renaissance to come to fruition, the profession as a whole must re-evaluate and realign a number of its priorities.
Changes in Education
The process of chiropractic education is undergoing some profound changes. However, the politics involved in many of these changes have developed some "malignant" characteristics. In reality, many of the components of the training of a chiropractic student are no different (nor should they be) than those for a medical, osteopathic, dental or podiatric student.1 Each is responsible for an entire body of anatomical, biochemical and pathophysiologic knowledge in order to prepare for the general needs of a portal-of-entry practitioner. Basic and clinical sciences are integral components of becoming a health provider and need to be perceived by all professions as much more than a "right of passage" or a necessary evil needed to stand toe to toe with the rest of the health care community.
The chiropractic colleges must collectively have a vision that embodies the characteristics of just what a chiropractic graduate should be in the context of the greater health care delivery system. As a result of fewer health care dollars and the increased activism on the part of consumers and third party payers, more attention is given to procedures and practices that offer the greatest benefit to the patient in the most cost effective way. As a result of this and efforts by chiropractic academies and politicians to gain mainstream acceptance, chiropractic is coming under the most objective scrutiny in its history.
One essential characteristic required of the contemporary chiropractic graduate is the ability to maintain an open mind and participate in a reasonable fashion with the rest of the health care team. The day is past where students can choose whether they're going to be a "straight" or "mixer" or the practitioner of one particular technique. Traditionally students have come into chiropractic for a variety of reasons: family influences, personal experiences with a chiropractor, or from a frank desire to be a proponent of wellness and prevention, and natural lifestyle modification through the care of neuromusculoskeletal conditions. Only after a thorough educational program consisting of a strong didactic and clinical curriculum is a student equipped to make decisions regarding appropriateness of the variety of treatments available to the practicing chiropractor.
An essential but sadly neglected aspect of chiropractic training involves exposure to a wide variety of problematic patients representative of those seen in practice by a variety of specialties.2,3 Clerkship and residency rotations must become a standard component of chiropractic clinical training programs.4 Without exposure to the multiplicity of clinical situations,5 the student is destined to encounter difficulty in interactions with multidisciplinary and hospital-based opportunities that are becoming more significant options for chiropractors. Only after full and appropriate exposure to classroom and clinical encounters can students intelligently consider which approach and practice scopes are right for them.
While chiropractic still finds itself debating techniques,6 practice management, insurance, federal programs and the like, the real issue of addressing definable characteristics of incoming chiropractic students has not been given the priority and importance it deserves. This is just the first step in clarifying the identity of chiropractic in the eyes of society.
There is a need for organizations such as the Association of Chiropractic Colleges (ACC) and the Council on Chiropractic Education (CCE) to address these issues in earnest and establish position papers along these lines. Further, the mission and purpose statements of the chiropractic colleges need to address the role that quality care has in the education of chiropractic students.
A Changing Perspective on Licensure and Certification
By the year 2000, licensing in all of the health services is likely to be completely revisited and revised. The Estes Park Healthcare Forum, a nationally know organization that educates leaders in the field of medical education and hospital administration, made a presentation regarding the philosophy of licensing and privilege granting at hospital levels.7 This organization suggests that by the year 2000, those trained and established in providing particular skills in the most cost effective manner will be those certified to do so. At the Estes Park Project meeting the group went even further by prescribing details of implementation on a national level.
Chiropractic's Identity Crisis
The average "consumer" whether a patient, a third party payer, or government agency has a very skewed, unclear, biased, or confused view of what services a doctor of chiropractic can provide. This problem originates from within the profession itself. A patient going to one dentist is exposed to a similar method of evaluation and care as that which is provided by another. Although there may be variations in the exact equipment and details of the techniques used, there is little doubt in the consumer's mind concerning scope of practice or nature of procedures to be employed. The same cannot consistently be said of chiropractors. Scope and philosophies of practice, specialization, and types of techniques provided from one DC to the next are unclear, poorly standardized, and occasionally "weird" in the mind of the uninitiated. This likely stems from the profession's difficulty in embracing standard assessment methodologies.8
A chiropractor is capable of being a family doctor. Serving in the capacity of a portal-of-entry physician, the DC is trained to evaluate and manage a variety of patient situations including those requiring co-management with our MD and DO counterparts. Yet most of the public is unaware that chiropractic students are trained to screen for major health concerns including oral, breast, colon, and prostate cancer. Early detection and referral for appropriate care are critical issues in contemporary health care.
Issues of wellness and health promotion and disease prevention have been traditional components of the chiropractic perspective. In recent years the entire health delivery system has begun to emphasize prevention even at the presidential cabinet level.9 The chiropractic profession needs to take a more active role in addressing and promoting the chiropractor's role in this vital aspect of entry level health care.
When issues come before such governmental agencies as the Health Care Financing Administration (HCFA), few if any administrators and legislators recognize the valuable manpower available within chiropractic to assist in these vital public health concerns. The profession has a significant task ahead of itself: informing the public that the chiropractor is not an isolated practitioner without the same body of knowledge all other physicians possess.
Health care consumers have made it clear that they are tired of needless medication, surgery, and impersonal and expensive care. Recent articles in the Journal of the American Medical Association and the New England Journal of Medicine have concluded that wellness is not something that internists and family practitioners promote or even feel comfortable with. In fact, the task of routine wellness screening often falls in the hands of the physician's assistant or nurse practitioner.
Another field in which chiropractic has much to offer is industrial medicine. Low back pain itself is a 40 billion dollar a year business. DCs are well-equipped to serve as gatekeeper, and case manager, as well as treating clinician in this arena. There is much to offer in the pre-employment arena as well. Yet the profession needs to develop serious pre and/or postgraduate multidisciplinary residencies in this important area in order to establish and maintain credibility with industry and government. At present there are only approximately 1000 board-certified occupational medicine physicians in the United States. Chiropractic is positioned at the helm to fill a void in health care. However, proper terminology, and communication skills (for the purpose of letting industry understand the chiropractic approach) are of the utmost importance.
The Interdisciplinary Approach
Contemporary Western medicine has rebuffed anything that was not procedural, both from a medical/surgical or diagnostic point of view. High tech, high touch medical care is definitely coming to the forefront as is illustrated at educational programs such as the American Back Society's Bi-annual Multidisciplinary Symposium. Non-invasive techniques for musculoskeletal problems are gaining not only more acceptance but there is an earnest interest in the medical community to develop more skill in these kinds of approaches. It is essential for the chiropractors to position themselves to be perceived as expert providers.
As cognitive skills are typically reimbursed at a higher level than technical skills (i.e., gastroscopy, colonoscopy, etc.), chiropractic needs to rise to its deserved level of knower, not just doer. The chiropractic approach is very cognitive; if chiropractic physicians function as diagnosticians and portal of entry providers, they are capable of fitting into the evolving health paradigm.
Integration Versus Selling Out
Some old-timers and young-timers may say that amalgamating with the allopathic or osteopathic professions is selling out. I say it's putting chiropractic on an equal level and saying and performing the functions that the public desires and is ready to consume. Neuromuscular disease may very well be a specialty of chiropractic but its foundation is the preparation of an individual to be a primary care provider who happens to come from a different philosophy than the osteopathic and allopathic physician. If one carried that further, the DC is indeed a non-operating orthopedist or the equivalent to a physiatrist when it comes to neuromuscular disease in a non-invasive manner. In fact, there is more skill from the chiropractic point of view in dealing with these neuromuscular problems from a hands-on mechanical treatment, a physical therapy approach, or a rehabilitation process. The chiropractic philosophy takes care of the entire individual, not just the injured part.
When the profession allows our educational institutions to define the mission statement, then no longer will management seminars become the predominant factors to instill confidence in our students; no longer will they educate them in systems of treatment that produce income and patient flow rather than quality of care based on high educational, ethical, and scientific precepts. The students will have a better picture of their self-worth as physicians because they will see themselves as equals to the MD primary care physicians and the osteopathic primary care physicians. If one looks at the daily practice of these people, it doesn't take a genius to see that most of the presenting complaints are somatoviscerval or viscerosomatic in origin. The rest of their time is spent dealing with psychological problems, stress-related disorders, dietary concerns, and a large number of musculoskeletal maladies which they are ill-prepared to deal with; they opt for physical therapy and unnecessary medications. If one puts that into perspective, the chiropractic physician is not only an equal level with the MDs, but on a higher level to address these everyday problems.
There are many specialists within allopathic and osteopathic medicine who deal in life and death situations and their roles are well-defined; thank God they are there. But the chiropractic family physician is capable of referring such cases to appropriate specialists when the skills and talents of MDs are needed.
Our future is very bright, but we don't have the luxury of a tremendous amount of time to set our sights and devise the plans to achieve our goals. The process must begin now and it begins with each and every one of us assuming the responsibilities for the health and welfare of our patients. We should all be applying for hospital privileges to better serve our community for certain types of pathologies. We can very well adjoin the current hospital system and appropriate specialists in the best interest of our patients.
Our institutions must be affiliated with teaching hospitals to allow DCs to rotate through primary care services, emergency room services, pathology services, gynecology services etc. Our students should be exposed to basic wellness patterns, see pathology and be given the confidence, knowledge, and skills necessary to confront patient needs and better serve the public. It's not that many years ago that osteopathic medicine did not have enough outside rotations to educate their students; they indeed spent three years of hard didactic time in the classroom because they only had enough pathology to have one year of hospital or outside rotations in private practice offices. The osteopaths saw this need and filled it. They have done well in many parts of this country in fulfilling the role of a family practitioner. Unfortunately, they have abdicated a lot of the basic skills that the public today is desiring, which only pushes chiropractic into the forefront.
Our institutions can no longer object to the teaching of basic pharmacology in the curriculum. We choose to be drugless practitioners based on philosophy, but we don't want students ignorant of the actions of medications that their patients are taking. This is a very large statement: Many of the patient that we are seeing are completely over-medicated, and present with complaints that may indeed be brought on by medication. The chiropractic physician must be capable of understanding the actions of medications.
On the other side of the coin, there may be medications that would expedite the healing process of many of our patients, and we should feel free to consult with appropriate specialists that can provide that medicine to hasten the healing process. Our educational institutions need a more global perspective. We cannot close our eyes to the entire gamut of health care. We can choose to be the best that we can, but we must do that based on solid educational foundations in both basic and clinical sciences and in the graduate specialties that we choose to pursue. We must all take a positive action and gear ourselves for a speedy trip. Time is flying; we must start the process now.
References
- Ratcliff CR, Rogers SR, Richardson KD: Comparison of core curriculum courses common to chiropractic medical, and osteopathic schools in Missouri. J. Chiro Ed 4(3): 76-80, 1990.
- Mootz RD, Souza TA, McCarthy KA: The apprenticed-based clinical experience. ICA Review May/June 1988: 28-32.
- Mootz RD, Coyle BA: Students and the clinical experience: the mentor model. J. Calif. Chiro. Assoc. 14(10): 28-33, 1989.
- Mootz RD, Cohen PC: Chiropractic Clinical Teaching (in press).
- McCloud PJ, Harden RM: Clinical teaching strategies for clinicians. Medical Teacher 7(2): 173-189, 1985.
- Cooperstein, R: Brand name techniques and the confidence gap. J. Chiro Ed 4(3): 89-93, 1990.
- Estes Park health care meeting, October 1990.
- Keating JC, Mootz RD: Five contributions to a philosophy of the science of chiropractic. J Manip Physical Therapy 10(1): 25-29, 1987.
- Sullivan LM: Keynote address, annual meeting of the American Public Health Association 1990.
Tilden H. Sokoloff, D.P.M., M.S., D.C.
San Leandro, California