Science-Based Medicine
by Jann Bellamy on February 20, 2014
Almost 10 years ago, a thoughtful article, entitled “Chiropractic as spine care: a model for the profession”, appeared in the journal Chiropractic & Osteopathy. The authors were a group of both academic and practicing chiropractors, as well as representatives from a health insurer specializing in coverage of CAM provider services. Another article, under different authorship, appeared the same year deploring some aspects of chiropractic education. In 2008, a third article came out with a similar theme, “How can chiropractic become a respected mainstream profession? The example of podiatry.” All three are open access and worth reading. The authors are to be commended for taking on an extremely contentious subject in their own profession.
The first article is a refreshingly honest look at the current state of chiropractic. The authors note the inability of chiropractors to consistently define who they are and what they do, which results in public confusion (including among those in the healthcare industry) about just what role chiropractors should play in the healthcare system. The authors deplore the continued existence of the “subluxation” in chiropractic and it’s accommodation by no less than the Association of Chiropractic Colleges. And they thoroughly deconstruct any notion that such a thing exists. The idea that chiropractors are capable of acting as primary care physicians is given equally short shrift and debunked as well.
The article points out that, whatever the confusion among chiropractors about who they are and what they do, the public has decided on its own: the public perception of chiropractors is that of back pain specialists. Back-related problems account for over 90% of the reason patients see chiropractors. They also argue that chiropractic must embrace evidence-based healthcare and stop relying on their clinical experience, noting the many reasons (e.g., regression to the mean) that a chiropractor’s observations may be explained by something other than treatment effectiveness. They admit that the chiropractor’s stock-in-trade, spinal manipulation, might not hold up under an evidence-based standard. (A possibility that is becoming a reality.) They even quote Marcia Angel’s observation on “alternative” medicine:
There is only medicine that has been adequately tested and medicine that has not, medicine that works and medicine that may or may not work.
The article on chiropractic education is downright disturbing considering claims by chiropractors that they are qualified to serve as primary care physicians. Especially appalling is the lack of clinical training:
Our cumulative observations suggest that the obvious contrast in numbers of patient encounters in a chiropractic externship, when compared to a medical/osteopathic internship, are sadly disconcerting from the perspective of the volume and variety of patient exposures.
And this alarming observation:
Instruction in evidence based medicine (EBM) in American chiropractic schools also appears to be lacking.
In addition to improvements in chiropractic education, they propose stiffening chiropractic school admission requirements, which they note are the least stringent among all professional degree healthcare disciplines.
The third article holds up podiatry as a template for necessary change to chiropractic: university-based education and training, a commitment to improving podiatry education via honest analysis of its weaknesses (including a Flexner Report-type analysis), collaboration with (not rejection of) medical doctors, commitment to public health (including proven public health measures like vaccination and fluoridation), and acceptance of a niche patient population (people with foot problems).
So why has nothing happened?
Summarizing all three articles, their solution is a professional model of chiropractic as portal-of-entry provider of “spine care,” improvements in chiropractic education, ridding chiropractic of the “subluxation,” acceptance and promotion of evidence-based healthcare, a conservative clinical approach, chiropractic as an integrated part of the healthcare system, and implementation of accepted standards of professional ethics.
As far as I can tell, their suggestions have been ignored by the chiropractic profession. This is due, at least in part, to a fatal flaw in their plan:
[T]he Spine Care model is completely consistent with current state licensing.
I’m afraid not.
As pointed out in an informative article by a physical therapist (also well worth reading) writing about the chiropractors’ incessant attempts to claim (falsely) that chiropractors alone have education and training to perform spinal manipulation:
In effect, the subluxation construct was and remains to this day central to the legal definition of chiropractic, its scope of practice, and reimbursement for chiropractic services, no matter how many factions within the profession decry defining the profession based on this outdated 19th century construct.
My own review of the 50 chiropractic state practice acts agrees with this conclusion.
The physical therapist notes that chiropractors have expanded the subluxation definition (while keeping it equally nonsensical) over the years, thereby automatically expanding the chiropractic scope of practice, as well as opportunity for insurance reimbursement, without ever having to amend the chiropractic practice acts. The subluxation is, quite conveniently, whatever they say it is.
(I’ve even wondered whether the chiropractic practice acts could be challenged in court on the basis that they exceed the state’s police power, that is, the power to regulate for protection of the public health, safety and welfare, reserved to the states via the Tenth Amendment to the U.S. Constitution. Certainly, allowing baseless diagnoses and treatments hardly meets this protective purpose. But we’ll leave that for another day and more research.)
Despite the widespread recognition that chiropractic desperately needs reform, after a search of both PubMed (which indexes a number of chiropractic journals) and the legal literature, I could find only one article discussing the need to amend the chiropractic practice acts to address this pressing problem. (In this journal, although the article, “Note: Adjusting the Role of Chiropractors in the United States: Why Narrowing Chiropractor Scope of Practice Statutes Will Protect Patients,” by Peter Morrison, is not available on online without a subscription service.) To his credit, the author recognized the need to rid chiropractic of the subluxation via reform of the chiropractic practice acts, although he did not make specific suggestions for statutory language.
If there is a movement afoot among chiropractors to limit their practice to the sort of model suggested in the three chiropractic journal articles, it is not evident in their current legislative efforts. Right now, for example, there is a bill pending in Hawaii that would simply default to the faulty chiropractic educational system to determine chiropractic scope of practice. And, as expected, chiropractors in New Mexico are again attempting to expand their scope of practice to include prescribing even more drugs, including dangerous drugs. (You can find out more about these bills and other unfortunate legislative efforts to expand the reach of CAM providers on the Society for Science-Based Medicine website, updated weekly. See how many pro-CAM bills are pending? Discouraging, isn’t it?)
I am not of the opinion that we necessarily need chiropractors at all. (As best I can tell,physical therapists can do everything evidence-based that chiropractors do, and more.) But I am concerned about the continued fleecing of the public with outlandish claims that the detection and correction of subluxations is not only beneficial, but necessary for good health (and so forth), forcing health insurance consumers and taxpayers to pay for unnecessary and, in some cases, frankly quack diagnoses and treatments. And yes, in anticipation of the irrelevant comments that will almost certainly appear, medicine needs reform too but for entirely different reasons. And medicine is paying attention to its problems and offering solutions, not ignoring them. Chiropractors are largely ignoring their problems. In fact, they are actively perpetuating them.
While it is all well and good to make frank assessments of the many deficiencies in chiropractic education, training and practice, the authors are not advocating for the one action that can have the most impact. In fact, they deny the need for a legislative solution. Reformers (some of whom have commented on SBM) must draft a new model chiropractic practice act and lobby for it. (Physical therapists already have a model act; see page 25.) Pick a state and start. I guarantee you will get a legislator’s attention if you, a group of chiropractors, tell him or her that the state’s chiropractic practice act is promoting quackery, not giving patients and third-party payers value for their healthcare dollar, and permitting unsafe practices. And I imagine this is one piece of chiropractic legislation that will find support in other businesses and professions, such as health and worker’s compensation insurers, employers, medical doctors, and doctors of osteopathy.
And we’re going to help you.
Here are my suggestions for the Model Chiropractic Practice Reform Act. (I’ve ventured into this territory before.) They would need to be drafted as a bill, in statutory language, a detail that can be left for later and with the help of experts in bill drafting. Reasons for the provisions follow in parentheses.
- Limit chiropractic scope of practice to diagnosis, treatment and prevention of musculoskeletal conditions related to the spine. (That is what they are educated and trained for, if imperfectly, and that is what their patients see them for.)
- Prohibit the administration, prescription or recommendation of drugs. (They are not sufficiently educated and trained to do this. And when given the privilege, they have employed it irresponsibly.)
- Forbid diagnosis and treatment based on the existence or clinical significance of the subluxation or any putative condition derived from the original subluxation “hypothesis.” (For obvious reasons.)
- Require that chiropractors practice evidence-based healthcare. (Should they be singled out among healthcare professions? Yes, because of their long history of what might be called “abuse of science.”)
- Require chiropractors to make clear to patients the limitations of their scope of practice and to refer all conditions outside their scope of practice to a medical doctor or doctor of osteopathy. Require a referral from an M.D. or D.O. for treatment of pediatric patients. (There is evidence that the public isn’t aware they are not medical doctors. As to pediatric patients, again, the issue is education and training, and the lack of reliable safety and effectiveness evidence.)
- Prohibit the sale of dietary supplements, vitamins, homeopathic products and other remedies by chiropractors to patients. (A terrible conflict of interest.)
- Starting in four years, require that all chiropractors applying for a license to practice have a baccalaureate degree prior to entering chiropractic college and a one-year post-graduation internship. (For the reasons stated in the journal articles.)
- Form a commission consisting of academic and practicing chiropractors, medical doctors, osteopathic physicians, and university-based academics who specialize in spinal anatomy, physiology and neuroscience. Chiropractors should choose their members and M.D.s and D.O.s should choose the rest of the group. This group should meet and in two years have recommendations ready for further amendments, if necessary, to the chiropractic practice act to ensure the health, safety and welfare of the public. This should include the administration of additional testing and post-graduation internship requirements prior to being licensed by the state. There should also be some mechanism for continued monitoring of how the new law is working.
- Require the state chiropractic board to issue regulations in accordance with the chiropractic practice act, as amended, within a specified period of time. (No foot-dragging allowed.)
There is certainly room for improvement in these suggestions. But someone has to start somewhere. Chiropractors who don’t like being lumped in with the subluxation or “DC as PCP” set need to step up to the plate and be proactive about reform. And without legislation chiropractors simply won’t make the sort of dramatic changes needed to bring them into the 21st century.