In my January article, "Scope of Chiropractic Practice: Is It Time for Change?" I discussed the use of the term primary spine care practitioner, the loss of privileges to diagnose in Texas, and the fact that the definition of "chiropractic" varied from state to state.
It is my opinion that the profession should consider the use of the terms chiropractic medicine and Doctor of Chiropractic Medicine (DCM) in order to enhance cultural authority. Based upon the fact that the University of Bridgeport and its chiropractic college teaches students the importance of evidence-based practice, patient-centered care, differential diagnosis and high-quality care for patients suffering with diseases, I am very comfortable with the following definition:
The evidence-based practice of differential diagnosis, patient-centered treatment and prevention of pain and human disease as taught by CCE-approved chiropractic colleges / institutions / schools.
Take Charge or Others Will
Peter Diamandis, co-author of Abundance: The Future Is Better Than You Think, warns us: "You either disrupt your own company [insert practice act/profession] or someone else will." He is referring to the exponential age and the need to change or suffer the repercussions of a static position. The exponential age is upon all health care professions and we must change and take control of our future. If not, others will determine our future for us.
You should know by this time that the Texas Medical Association disrupted the practice of chiropractic in Texas when it attacked the antiquated chiropractic practice in Texas and declared a victory.1 No longer are chiropractors in Texas permitted to make a diagnosis. In fact, they may not claim the right to diagnose vertebral subluxation complex. The TMA declared that legislation is necessary to change scope of practice.
Antiquated practice acts that mention specific restrictions, such as the need to detect and correct subluxations, will permit future attacks on chiropractic scope of practice in other states. It is time to address any antiquated language that narrows the scope of chiropractic practice. All 50 states should modernize their chiropractic practice acts with legislative action that expands scope.
Resisting Change – But at What Cost?
To my knowledge, the chiropractic profession is the only health care profession in the U.S. not expanding scope of practice and scope of reimbursement with a unified strategy. Certain schools and chiropractic organizations fight to maintain status quo and avoid the use of the term chiropractic medicine. While the nurses expand their training, credentialing and integration into medicine as primary care providers, with increasing reimbursement and salaries, the chiropractic profession resists progressive changes.
Expanded scope of practice and integration would increase the value of our services and provide more access to chiropractic care. It is my opinion that the chiropractic leaders and the Federation of Chiropractic Licensing Boards should utilize the APRN template for integration and expansion of scope of practice / reimbursement:2
Advanced practice registered nurses (APRN) are a vital part of the health system of the United States. They are registered nurses educated at Masters or post Masters level and in a specific role and patient population. APRNs are prepared by education and certification to assess, diagnose, and manage patient problems, order tests, and prescribe medications.
Certified Nurse Practitioners (CNPs) are educated and practice at an advanced level to provide care, independently, in a range of setting and in one of six described patient populations. CNPs are responsible and accountable for health promotion, disease prevention, health education and counseling as well as the diagnosis and management of acute and chronic diseases. They provide initial, ongoing and comprehensive care to patients in family practice, pediatrics, internal medicine, geriatrics, and women's health. CNPs are prepared to practice as primary care CNPs or acute care CNPs, which have separate national competencies and unique certifications.
Why do chiropractic management groups, chiropractic associations and select chiropractic colleges continue to promulgate cash practices and expensive, long-term treatment plans in order to detect and correct subluxations? This strategy ensures the chiropractic profession will be referred to as the "other" health care profession, one that lacks the cultural authority of medical physicians and nurse practitioners. Isn't it time for changes that will integrate chiropractic medicine into health care systems with non-discrimination, as described in Section 2706 of the Affordable Care Act; and as valuable members of the primary care team?
A Team Approach Requires Qualified Team Members
The U.S. is adopting a new model of primary care built around patients and delivered by teams.3 Primary care physicians are required to complete resident training and become board certified in a medical specialty. If the chiropractic profession wants to achieve the status of a primary care provider, the training and credentialing of chiropractic graduates must include resident training and board certification.
For more than 10 years, nurse practitioners have enhanced their clinical skills and become primary care providers. The Community Health Center of Middletown, Conn., has been offering resident training for nurse practitioners since 2007:4
Community Health Center, Inc. (CHCI), a multi-site, federally qualified, health center (FQHC) in Connecticut, implemented a one-year-residency program for new nurse practitioners (NPs) in 2007. This residency program is specifically designed for family nurse practitioners intending to practice as primary care providers in federally qualified health centers.
Recall also that recently, the CCE recognized the one-year, chiropractic resident training program within the Veterans Health Administration:5
The VA chiropractic residency program focuses on Integrated Clinical Practice, with training emphasizing the provision of chiropractic care in an integrated healthcare system, collaborating with primary care Patient Aligned Care Teams (PACTs), specialty care, and other medical and associated health providers and trainees.
The residencies provide advanced clinical training in complex case management, allowing recent graduates to increase their scope and depth of clinical knowledge, experience and acumen. Residents are mentored by senior VA chiropractors who are national leaders in integrated chiropractic practice. These clinicians share their expertise in patient care, academics and research to provide a robust educational experience.
These hospital-based training programs expand the residents' ability to collaborate with other healthcare professionals in team care, as trainees learn with and from other healthcare providers during interdisciplinary rotations. Residents develop their knowledge of hospital practice, policies and procedures, and are better prepared for future positions in VA, other healthcare systems, and/or academic settings.
The University of Bridgeport has offered a three-year, full-time chiropractic resident training program in neuromusculoskeletal medicine since fall 2013. This advanced clinical training takes place in Federally Qualified Health Centers and community health centers, and permits chiropractic specialists and residents to function as members of their primary care teams.
Upon completion, the chiropractic residents are qualified to sit on the chiropractic orthopedic board with the Academy of Chiropractic Orthopedists, which leads to board certification as a chiropractic specialist in nonsurgical orthopedics. A fellowship will be offered to interested residents upon board certification. This program was made possible because of the funding of the Affordable Care Act.
With all that said, I repeat, now is the time to expand the scope of chiropractic practice!
Editor's Note: For additional information regarding ongoing legal actions in Texas, read Parker University President Dr. William Morgan's front-page article in the March issue: "Chiropractic in Texas Is Under Attack."
References
- "Court Sides With TMA in Final Ruling on Chiropractic Scope of Practice Lawsuit." Texas Medical Association, Nov. 1, 2016.
- APRNs in the U.S. National Council of State Boards of Nursing.
- Primary Care for the 21st Century: Ensuring a Quality Physician-Led Team for Every Patient. American Academy of Family Physicians white paper, Sept. 18, 2012.
- Flinter M. "New Nurse Practitioner to Primary Care Provider: Bridging the Transition through FQHC-Based Residency Training." Online J Issues in Nursing, January 2012;17(1).
- U.S. Department of Veterans Affairs: Rehabilitation and Prosthetic Services.
Click here for previous articles by James Lehman, DC, MBA, DIANM.