Issue #9: Chiropractic Job Market
Today's chiropractic student is being led down a "primrose path" without a glimmer of the realities of obtaining gainful employment as a chiropractor.25 There is one reality that must be realized by the chiropractic profession. There is no job market. There are only three things you can do in chiropractic: teach at a chiropractic college, become an associate,or set up your own practice. How many job offerings are there in the want ads that are looking to fill the position of assistant director of chiropractic services at XYZ hospital? Employment opportunities that could easily be performed by the DC are denied to us for no other reason than possession of a chiropractic education.26
Chiropractic associateships are substandard to other professions. Law, medicine, dentistry, psychology, and physical therapy are structured to absorb new licentiates in ways chiropractic is not. In other professions, positions are structured to pay a respectable salary and benefits. New licentiates can get entry-level positions that don't require cash investments.27
Let's take for example a chiropractor who gets a first position as an associate. A $2,000/month salary seems reasonable, but let's break it down with today's student loan burdens factored in. A base salary of $2,000 nets $1,300. A student loan payment of $700 leaves the new graduate with $600 to live on. So this is what they call financial security.
New MDs, first as interns, then as residents, immediately earn in the $20,000-30,000 per year range. New MDs can work part-time and earn up to $75,000 per year. The DC does not have access to these jobs.28 But one advantage about medical doctors and their earning power and internship is that they can defer the loan while in training. Deferment means you don't pay your loans nor does the interest accumulate. Forbearance puts more time on your side, but interest accumulates.
Terry Rondberg points out one item that needs to be clarified to chiropractors and potential chiropractors.
"If people want to make an MD's wage by doing an MD's job, then let them become MDs. If you want to make an MD's wage by doing a DC's job then let's create a bigger more lucrative market for the DCs."28
Issue Thirteen: Optional Limited Pharmaceuticals
The "optional limited pharmaceutical" question will be the most debated question that chiropractic will have in the next century. Although a lengthy discussion could be made on the topic alone, serious discussion needs to be examined on the impact of clinical and economic status of the chiropractic profession.
But several questions need to be answered by the profession. Why is the typical knee-jerk reaction to pharmaceutical inclusion a philosophical response and not one of "reasonable clinical rationale"? Another answer that needs rationalization is "it's not chiropractic." We must take into consideration that we have two national organizations and 50 states. Each of these entities have their own definition of what chiropractic is.
Another reaction is, "If you want to give drugs, go to medical school." Who has the emotional energy and financial capabilities of attending another eight years of school after completing five to seven to become a chiropractor?
Yet another reaction: "You have no faith in chiropractic." Are those who use this referring to the philosophy of chiropractic as described to us by the present day doctrine, or is it a lack of confidence in the clinical approach of objective data for positive patient outcome? Or is it the frustration and confusion of trying to fit and understand a philosophical premise into a clinical model?
Statements such as these have had no effect on the question of pharmaceutical inclusion. But the inclusion question also draws another anti-inclusion response. Gerard Clum's statement raises a point on the "confusion" argument.
"In fact, there would be considerable disservice to the public through the diminution of alternative to medical care and increased confusion as the care the public may receive from a given provider."30
But Fred Barge clouds that argument:
"The influence of those who practiced mixed (chiropractic) practice obfuscated the identity of chiropractic until, increasingly today, public confusion exists as to what chiropractic really is."31
There already exists in the public mind confusion of what a chiropractor does. The new buzz-word that is appearing in the literature is the term "alternative." Have we ever thought that this term may in fact be causing patients not to come to the chiropractor? The word "alternative" may conjure images of "new age," "unproven speculation," or "fringe" in the minds of the general public. The word "alternative" should really be replaced with the word "complementary." Chiropractic should be a complement to reasonable clinical rationale for the treatment of neuromusculoskeletal problems.
But what would pharmaceutical inclusion do for the profession economically? We must realize that the chiropractor is limited.28 The competition between the MD, DO, and physical therapist could be neutralized if we could handle more difficult cases with extensive pathologies.28 If we could prescribe, our professional image would be enhanced, and our patient population would expand.32 This expansion of patient volume means one thing also besides increasing clinical rationale. By giving DCs an enlarged scope of practice, they will be able to pay back huge loans in a short period of time so that they can concentrate on getting sick people well.28
Issue Fourteen: The Doctor of Chiropractic Medicine
The doctor of chiropractic medicine is another hot topic in the profession currently. By applying this title, inclusion into programs that were closed to chiropractic would open. The title of DCM means advantages in another area. The DCM will provide the legal authority needed for a chiropractor to offer primary care and to function on the same basis as other PCPs. Without the legal authority to prescribe, we do not have the authority to discontinue or modify drug use. These are measures for total clinical authority.33
What this broad scope practice will allow is the inclusion of chiropractic into hospitals and mainstream clinical thinking.
Issue Fifteen: Inclusion into Mainstream Clinical Practice
"Let's open those 'closed' areas (like the military, hospitals, and Department of Health) to the DC."28
But Fred Barge counters:
"Remember the osteopathic profession? They bowed and scraped to medicine, they wanted to belly up to the bar with the MDs, and where are they today? Oh, you say they are in the hospitals! La De Da. How are they really viewed by the public?34
According to the charts, the public must have confidence in the osteopaths. They possessed a low default rate in almost all categories as compared to DCs and MDs. They are serving as PCPs with the right to refer to where patients should go for referral related services. They have specialty groups and have their own hospitals. It would seemingly appear to anyone that osteopathy enjoys considerable professional respect. The concept of a DO being a second rate MD is not only false but one conceived out of ignorance. But did the osteopaths know something that we are starting to learn now?
But chiropractic inclusion into hospitals could open up a new potential job market for chiropractic. The access to lab facilities, use of advanced diagnostic imaging such as MRI and CT would help us to be more of a complement to reasonable clinical rationale instead of a new age alternative. One of the injustices McAndrews referred to was:
"Chiropractic graduates must frequently purchase highly expensive x-ray equipment when they would rather have referred their patient to a hospital-based radiology facility."10
But has the traditional view of chiropractic being able to only detect, locate, analyze, control, reduce, and correct the vertebral subluxation limited our advancement of clinically sound and legally defensible chiropractic? This limitation of chiropractic does not allow for advancement in economics or clinical rationale. The inclusion of pharmaceuticals into clinical practice could open the doors to hospitals, HMOs, insurance-based PCPs, which would equate into an increased job market and decrease in the struggle of private practice and student loan defaults.
Issue Sixteen: Public Funding for Chiropractic
Another issue I wish to discuss is how medical doctors get an advantage over chiropractors. The University of Kansas School of Medicine, for instance, has a program called the Kansas Medical Student Loan Program (KMSLP). The text of the program reads:
"The state legislature has established the KMSLP to assist students ... in return for agreements to provide medicine in Kansas. The KMSLP provides payment of tuition, living expense up to $1,500/month for each month enrolled in the Kansas School of Medicine."35
The only requirement that this public-funded legislation has is that the new MD must enter a primary care residency (family practice, general internal medicine, general pediatrics, or emergency medicine) for each year the loan was granted.35 There are 105 counties in Kansas, of which 100 are classified as medically underserved. If these counties are medically underserved, could they be chiropractically underserved?
But James Gregg, president of the ICA confuses the matter:
"Issues of competition, validating research, public funding and education that we face in chiropractic differ little from those faced by other professions."11
It appears that public funding is being made available to medical students but not chiropractic students. Jerome McAndrews deciphers the disparages of DCs versus MDs:
"Over the past two decades medical practitioners have developed large group practices; new medical graduates are invited to join these practices for guaranteed and virtual overnight success. In contrast, chiropractors go into solo practice, having to develop a line of credit in addition to their educational indebtedness."10
But another public-funded program is the Health Profession Student Loan (HPSL). This loan program has the federal government subsidizing the interest. Chiropractic students are not eligible for this program.10
But the Kansas program for medical students raises an interesting question. If medical students can get state funding, why can't chiropractic students who are citizens of Kansas by birth and wish to stay in Kansas?
Issue Seventeen: Reasons for Public Nonfunding
There are several reasons for this discrepancy: 1) Archaic chiropractic principles dictate to us that chiropractic is not medicine. But if we were doctors of chiropractic medicine, this funding might be opened to us. 2) Our anti-immunization position and stance against antibiotic therapy for infectious processes might be closing the door on us. 3) As I spoke of early, our philosophy may be causing discrimination due to interpretation. 4) There's confusion of what really chiropractic practice is.
Finally, in Kansas, chiropractors are not classified as physicians.36 The attorney general's opinion No: 87-42 states:
"Chiropractors are specifically prohibited by statute from practicing medicine and surgery. Thus, the term "chiropractic physician" is misleading to the public as it implies that a chiropractor is licensed to practice beyond the scope of the statutory definition of Chiropractic. Therefore, it is our opinion that Doctors of Chiropractic cannot use the term 'Chiropractic Physician.'36
There are two catch-22s that need to be pointed out. In Kansas, a chiropractor as reaffirmed by policy by the Board of Healing Arts, can use the term "chiropractic physician," and that no disciplinary action will be sought against a chiropractor for using this term.36 But in reality, Kansas chiropractors are not physicians.
What this interpretation has done for chiropractic in Kansas has limited us from the economics of PCP referral, workers' compensation cases, school physicals, and other insurance related matters. With this interpretation any attempt to get on board with any type of public funding programs may be futile.
The second catch-22 is under the federal government guidelines on provisions of health care under Medicare. Provision number 2250 states:
"The term 'physician' under Part B includes a chiropractor who meets the specified qualified requirements set forth in S2020.26."37
The big question remains: the federal government says we are physicians, but Kansas says we are not; are chiropractors in violation of the law if they accept Medicare reimbursement within Kansas borders? This federal government interpretation could have precedence for chiropractic to be involved in the HPSL program and other federal programs. These interpretations of the law need to be checked by every state. By getting the definite legal interpretation chiropractic may be able to hold off other attempts to change the economics of the profession. I hope this will allow the profession to progress beyond its present state into full inclusion as a mainstream health profession.
Conclusion
But the question remains, "Is chiropractic doing much to reform itself?" Does it care that large numbers of its graduates are driven to bankruptcy with unjustifiable student loan debts?"38 Can we continue to fight for the rights of our students to borrow large sums of money for their education if we don't fight as aggressively to remove the obstacles that prevent graduating chiropractors from making a living adequate to service this debt?39
To conclude this subject matter, the words of Hannibal come to mind. The chiropractic profession must either find a way to change what is happening internally and externally or we must make a way. But Gerard Clum points out:
"As the public demands clinical accountability and financial soundness of health care procedures, we will see the strength of chiropractic grow and medicine decline."40
But when will chiropractic grow? Are statistics, graphs, and referenced quotes, as we have seen throughout this paper, indicating growth of a profession or a profession in need of change? Dr. Clum also states:
"The order of the day is to stay the course, tell our story, advocate our care, motivate our people, and inspire our patients. Our brightest day is about to dawn!"40
In reviewing the graphs, the quotes, the statistics, the Federal Register, and the problem(s), the most viable option to divert certain economic collapse is to change course. Especially while we have the opportunity to control and direct it ourselves before it is forced upon us.
To end this discussion, each chiropractor should reflect upon a simple question. Ronald Reagan, in his presidential debates in 1980 and 1984, asked one question. "Are you better off now than you were four years ago?"
Special note: Many thanks are in order to my many colleagues for providing much of the research. Your letters and telephone calls offered insight and awareness about this topic.
References
10. McAndrews, J. HEAL update: ACA says correction of inequities will allow DCs to pay up. Special Report, American Chiropractic Association, ACA/FYI, Sept/Oct 1993 page 11.
11. Gregg J. Chiropractic: A timeless science, Today's Chiropractic Vol. 24, #1, Jan/Feb 1995 pg 68-72.
25. Lynn M. Widen the scope, Letter, Chiropractic Journal, Volume 6, #7, April 1992.
Rondberg, T. Publishers Response to "Widen the scope," Chiropractic Journal, Vol. 6, #7, April 1992.
26. O'Berence T. Limited options await new DCs, Letter, Chiropractic Journal, Vol 6, #9, June 1992.
27. Elyad L. Article on Ethics, Dynamic Chiropractic Oct 23, 1992.
28. Blumberg L. Limited scope-limited income, Letter, Chiropractic Journal, Vol 6, #5. Feb. 1992.
Rondberg T. Publishers Response to "Limited scope- limited income." Chiropractic Journal, Vol 6, #5 Feb, 1992.
30. Clum G. Counterpoint to Western States doctor of chiropractic medicine program, Dynamic Chiropractic, Vol 12, #13, June 17, 1994.
31. Barge F. The history of that which is Truly philosophy, Today's Chiropractic, Vol, 24. #1. Jan/Feb 1995, pg. 75.
32. Reader Reaction, Should dcotors of chirorpactic be allowed to prescribe drugs, Chiropractic Journal, Vol. 1, #2, Nov. 1986.
33. Dallas W. The DCM: chiropractic primary care round II, Dynamic Chiropractic, Vol 12. #16, July 29, 1994.
34. Barge F. A message to the No-CAs, Chiropractic Journal, Vol 8, #5. Feb. 1994.
35. University of Kansas School of Medicine: The Kansas Medical student loan program, The Office of Admissions.
36. Stephen R. Attorney general's opinion no 87-42, Office of Attorney General, March 5, 1987.
37. Federal Government Guidelines on Provisions of Health Care: Medicare #2250, Coverage and Limitations, Section 2, pg 101, Rev, 1076. 2-85.
38. Culbert W. Equality, on babis of what, Letter, Dynamic Chiropractic, Vol. 10., #9. Sept. 1, 1993.
39. Nelson T. HEAL loans for some equals "sea of red." Letter, Dynamic Chiropractic, Vol. 10, #9, April, 24, 1992.
40. Clum G. Doctor of chiropractic medicine round II, Dynamic Chiropractic, Vol. 12, #17, Aug 12, 1994.
Timothy Mirtz, BA, DC
935 Iowa Street, Suite 2
Lawrence, KS 66049