The first paper, "Family Physicians, Chiropractors and Back Pain," was authored by:
Peter Curtis, MD, with the Department of Family Medicine at the University of North Carolina, Chapel Hill. Dr. Curtis was also one of the members of the RAND multidisciplinary panel on low back pain.The other two papers were editorials supporting the paper by Drs. Curtis and Bove: one by well known researcher Daniel Cherkin, PhD, who has done a great deal of survey work reviewing the attitudes of patients to chiropractors and family physicians; the other by three Israeli MDs who supported the conclusions of Drs. Curtis and Bove.Geoffrey Bove, DC, a PhD candidate in the Department of Cell Biology and Anatomy at the University of North Carolina. Dr. Bove is also a fellow of the Foundation for Chiropractic Education and Research (FCER).
Most DCs will be very surprised at the tone of the first paper. The last part of the introduction says it all:
"In this country, low back pain, dysfunction, and work disability are moving toward epidemic proportions, and the context in which back problems occur most often results in presentation to primary care physicians, particularly family physicians. However, another discipline, chiropractic, is playing an increasing role in the primary care of musculoskeletal problems. Family physicians should therefore re-evaluate their relationship with these health care providers."The paper continues:
"Back pain is the second leading reason reported by patients for visiting physicians.1,2 Every year nearly 13 million visits are made to physicians for chronic low back pain, and it is the second leading cause of work days lost.2,3 From 1971 to 1981, the number of disabled people and the cost of care for low back pain increased at a rate 14 times that of the population growth.2 In medical settings, family physicians care for 38.6% of the patients with acute and chronic back pain, compared with 36.9% seen by orthopedists, 16.9% by osteopaths, and 7.6% by internists.4 Back symptoms are the third most common reason for visiting a family physician."5The authors discussed the ignorance that most family physicians have regarding chiropractic: "Fifty percent of family physicians surveyed believed they were only slightly or not at all informed about the clinical scope and skills of chiropractors, although 26 percent saw them as an excellent source of care for certain musculoskeletal problems." Greater patient satisfaction of chiropractic patients versus those of family physicians was also discussed.6
The discussion led to why family physicians were reluctant to refer to DCs, with an open admission that it took a lawsuit, Wilk et al., to solve the problem. Ultimately, there appears to be three reasons why family physicians don't refer to chiropractors:
Suspicion regarding the extent, depth, and validity of manipulative training:Manipulative therapy (the term the authors use when speaking of chiropractic adjustment) is discussed at length. The paper is very educational to the uninformed family practitioner.The authors gave a very solid description of chiropractic education, ending with this statement: "Doctors of chiropractic are highly trained practitioners, qualified and licensed to diagnose disease entities and to refer patients when the treatment necessary is out of their scope of practice."
Perceived lack of basic scientific evidence:
The authors admitted that: "Basic scientific evidence and clinical trials dealing with this topic are scarce, as they are for other modalities used in the treatment of musculoskeletal ailments."
Manipulation is a dangerous intervention:
This argument is addressed in a straight forward manner with the authors providing actual reports of the incidence of vascular accident: "between 1:400,000 and 1:1 million procedures."
"Guidelines for Identifying a Competent Chiropractor" are also included:
- Treats mainly musculoskeletal disorders with manual manipulative techniques
- Does not do routine radiographs on every patient
- Does not extend duration of treatment unnecessary
- Writes a response to a referral and outlines evaluation and therapy
- Does not charge "front end" lump sum for whole treatment program
- Graduated from a school accredited by the Council on Chiropractic Education
- Is willing to have the physician visit the office to observe treatment
- Good feedback from patients on care given
The summary is just as positive. It not only reviews the value of chiropractic care, but also which patients should be referred. Considering the incredible number of patients a family physician might refer if they were able to locate a DC they were comfortable with, it would be very beneficial for every member of this profession to read these articles and understand how to best begin working with family physicians.
References
- Cypress BK. Characteristics of patient visits for back syndromes: a national perspective. Am J Public Health 1983; 73:389-95.
- Frymorer JW. Magnitude of the problem. In: Weinstein JN, Wiesel SW, eds. The Lumbar Spine. Philadelphia: WB Saunders. 1990:32-8.
- Cunningham LS, Kelsey JL. Epidemiology and musculoskeletal impairments and associated disability. Am J Public Health 1984; 74:574-9.
- Deyo RA, Tsui-Wu YJ. Descriptive epidemiology of low-back pain and its related medical care in the United States. Spine 1988; 12:264-8.
- Deyo RA, Diehl A, Rosenthal M. Reducing roentgenography use. Can patient expectations be altered? Arch Intern Med 1987; 148:141-5.
- Cherkin DC, MacCornack FA. Patient evaluations of low back pain care from family physicians and chiropractors. West J Med 1989; 150:351-5.
Dynamic Chiropractic editorial staff members research, investigate and write articles for the publication on an ongoing basis. To contact the Editorial Department or submit an article of your own for consideration, email
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