The chiropractors at our hospital here in New Jersey have been serving on-call for over eight years and have assisted in the care of more than 3,000 patients. It is a successful program because it is based upon a foundation of ethics. From its inception, we insisted on being called at any hour, day or night, regardless of the probability of reimbursement. Each one of us has taken our turn to be awakened at 3 a.m. to treat an unreimbursable patient. Being on-call sometimes involves dragging yourself out of bed, driving to the hospital, taking care of the patient, thanking the staff for the call, and then hoping to return home quickly enough to catch a couple hours of sleep before getting up for the next morning's office hours.

The chiropractors in our hospital make it clear that we do not treat car accidents, work injuries or insurance plans; we do not treat wallets, we treat patients. As should any specialist called for consultation, we provide care because it is needed, regardless of reimbursement probability. Fortunately, a substantial number of emergency-department patients are either covered by insurance or are willing to pay for their care. While one should not expect to get rich from working in a hospital, it is certainly worthwhile.

The chiropractors in our hospital have been very fortunate. We have not had any staff members place financial reward before patient care. The result is high patient satisfaction. Perhaps an equally important result is respect from the hospital administration and emergency-department staff. That respect was recently demonstrated when the hospital administration organized a dinner. The purpose of the dinner was to encourage the new emergency-department physicians to use the on-call chiropractors to treat patients with neck and back pain. Listening to pain management specialists, orthopedists, spine surgeons, administrators and the director of medicine as they encouraged the new director of emergency medicine to utilize chiropractic services would bring chills to the spines of even the most cynical chiropractor.

Our hospital chiropractic program has been good for the patients, good for the hospital, great for the chiropractors and an excellent reflection upon our chiropractic profession. The success of our program is ample reason to believe that all U.S. hospitals should have hospital chiropractic programs. To achieve the goal of a chiropractor in every hospital, we became involved in training chiropractors. We developed a hospital protocols program based on what we had learned through years of experience that was sometimes trial by ordeal. The many topics covered are always based upon a foundation of ethics.

In addition to teaching hospital protocols, I became involved in teaching manipulation under anesthesia (MUA). Aside from having performed MUA for many years, I was involved in MUA utilization review. Years of reviewing medical records provided a plethora of information of both proper and improper practices and documentation. My years of MUA records review made it very clear that the same emphasis on ethics that helped our hospital chiropractic program thrive is needed to help MUA thrive; the goal being to create MUA practitioners who practice in a manner that helps not only to preserve MUA, but makes it more available to those patients who could benefit.

Unfortunately, not all MUA practitioners in my home state of New Jersey have followed an ethical path. Some appear to have earned a degree in "entrepreneurial medicine" rather than chiropractic. In reacting to excessive MUA billing, the state appears to have adopted Newton's third law of motion: "For every action there is an opposite and equal reaction." The state of New Jersey reacted to the excessive billing by enacting a new personal-injury fee schedule in which reimbursement for MUA was reduced to an embarrassingly low fee. The new MUA fee is so low that a provider is likely to lose money by leaving the office to travel to and from a surgical center to perform the MUA procedure. If MUA had not been billed at such high rates, there would have been no need for the extreme overreaction by the state.

In New Jersey, the MUA well that has been nourishing some is quickly drying up. Those practitioners will likely be looking for other sources of income soon. Some may start charging excessive fees for services not covered by the fee schedule. My fear is that some will look to hospital chiropractic as another goose to lay golden eggs.

If a provider's primary motivation were financial, the provider would likely not be successful in the hospital setting. Working in a hospital is like working in a fishbowl made of magnifying glass: Everyone can see what you are doing. There are documentation requirements that surpass those of office practice. Patients are seen by varied professionals, each answering to a different authority. In the emergency room, the hospital governs the nursing staff; the emergency department physician typically works for an outside group; and the chiropractor is a consultant who answers to a department of the medical staff. Those who pursue selfish or improper agendas are much more quickly discovered in the hospital than they would be in a more isolated environment, e.g., a private office. Unlike working in the office, a hospital provider's actions reflect upon and affect many others working in the hospital. There are many who will quickly point out wrongdoing to protect their own place in the hospital.

Old sayings persist because of their undeniable truth. "Moderation in all things" is as true now as when it was first described as a philosophical truth by Aristotle. MUA is certainly a valuable procedure that, at least in New Jersey, has been unfairly devalued to control those who do not understand the importance of moderation. Hospital chiropractic is likewise a very important service from which many have benefitted and many, many more have yet to benefit. Reimbursement for hospital-related services should be fair, but as Aristotle might say, moderate.

Hospital chiropractic should not be thought of as a new source of income, but rather as a means of expanding chiropractic delivery so more patients can obtain the benefits chiropractic provides in the hospital setting. Those who would rather slaughter geese are invited to find a path that veers clear of the hospital system.

For more information on hospital chiropractic, visit the American Academy of Hospital Chiropractic Web site at www.hospitaldc.com.