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The DC as PCP?

Subluxation-free Chiropractic?

The long-simmering internecine wars among various factions of chiropractic recently reached a full boil when the Council on Chiropractic Education (CCE) had the audacity to eliminate the word “subluxation” from its draft 2012 “Standards for Doctor of Chiropractic Programs.” The CCE is the official U.S. Department of Education-approved accreditation agency for chiropractic colleges. It intends to adopt the revised Standards in January 2011and asked for comment from those affected.

“Totally unacceptable,” is the response of James Edwards, DC, in a recent article in Dynamic Chiropractic entitled “What Is the CCE Trying to Pull?

Perhaps taking up the spirit of this election season, Edwards defines the problem in terms of conservative vs. liberal ideologies: “After beating back and defeating the ridiculous ‘subluxation only, no diagnosis’ position of the extreme right-wing minority of the profession, we are now faced with the equally unacceptable ‘ivory tower’ position of the extreme left-wing minority of the profession.” Later in the article he refers to the proponents as the “left-wing fringe.”

Edwards is further exercised by the CCE’s plans to remove the phrase “without the use of drugs or surgery” from its description of chiropractic practice. As well, the CCE proposes, somewhat cryptically, to accredit any program which it deems to be “equivalent” to the D.C. degree program.

The proposed changes prompted the International Chiropractic Pediatric Association to send out an “URGENT! Action Needed!” e-mail requesting that members fax in objections because “the CCE has a few proposals that will drastically affect the future of chiropractic.”

Gerald Clum, DC, in a memo expressing concern from his faculty position at Life Chiropractic College West, opined that this meant the CCE might approve a “Doctor of Chiropractic Medicine” degree “or any other creative reconfiguration of a chiropractic curriculum.” Clum also noted the removal of references to the “Purpose of Chiropractic Education” from the Standards, with no replacement language in the new version. The following language was deleted:

The application of science in chiropractic concerns itself with the relationship between structure, primarily the spine, and function, primarily coordinated by the nervous system of the human body, as that relationship may affect the restoration and preservation of health.

Readers familiar with chiropractic will recognize this as a reference to the vertebral subluxation complex.

Finally, Clum noted “the change in the definition of chiropractic primary care physician [by the proposed Standards] removes any definitional elements that would cause the statement to be unique to the practice of chiropractic. The definition as proposed would apply to any primary care medical doctor, nurse practitioner, physicians assistant, etc.”

Parker College of Chiropractic officially expressed its concern in the on-line publication ChiroAccess, although it took a more subdued approach, saying only that it would like “to see additional clarity or further expansion” of the changes.

Another change is escalation of the required GPA for admission to chiropractic colleges from a 2.5 to 3.0. Parker asked for a more gradual change “because a drastic change could negatively impact admissions and institutions need the opportunity to mitigate this change through other means.”

The “Certified Advance Practice Chiropractic Physician”

So, What Is the CCE Trying to Pull in sanitizing its accreditation requirements so they appear less, well, “chiropractic?”

I don’t know, but it may have something to do with a prototype of the future chiropractor set forth in a law passed in New Mexico last year.

You may recall that New Mexico is one of the few states to allow anyone to practice medicine despite having no license, no education and no training. So it is no surprise that New Mexico is the first state to create a new iteration of chiropractic known as “Chiropractic Advanced Practice.”

The New Mexico Legislature created this new class but left the details to the NM State Board of Chiropractic Practice. The Board, while retaining the subluxation-based definition of chiropractic, added a category of “certified advanced practice chiropractic physician,” defined as an “advanced practice chiropractor who shall have prescriptive authority for therapeutic and diagnostic purposes.”

All you have to do to register as an advance practice chiropractor is (1) fill out an application, (2) complete 90 “clinical and didactic” hours of education provided by an approved institution, and (3) pass a competency exam. In other words, take the equivalent of a little over two standard work weeks of instruction and a test and — voila! — you’re “certified” for “advanced practice.”

The rules prescribe a formulary that consists of “those substances that are natural or naturally derived.” The initial formulary and any changes to it must be approved by three boards: medical, pharmacy and chiropractic. This smells like a compromise on the part of medicine and pharmacy, and the smell is not a pleasant one.

SBM contributor Scott Gavura, BScPhm, MBA, RPh, provided some insight into the formulary as prescribed by rule in NM. It includes estradiol, progesterone, and testosterone, all of which are used as hormone replacements, as well as desiccated thyroid, which alt med practitioners believe is effective for thyroid replacement, although it is rarely used nor is it recommended by evidence-based guidelines. Also included are drugs widely disparaged for years by chiropractors: muscle relaxers and NSAIDs. There is also sarapin, a dubious treatment for neuropathic pain, and glutathione for inhalation, an alt-med treatment for lung disease. Of course, homeopathic preparations “requiring prescription” and “for injection” are included. And, even more inexplicably, caffeine for injections.

It sounds like the perfect formulary for increased chiropractor income.

The origin of the “certified advanced practice physician” requirements is explained in a press release put out by the National University of Health Sciences (NUHS), in Lombard, IL, and posted on ChiroAccess. (In addition to its DC program, NUHS offers degree programs in naturopathy, acupuncture and massage.)

As the press release explains:

The United States is experiencing a shortage of primary care family doctors. That’s why over the last 8-10 years, chiropractic associations in states with severe shortages of primary care physicians have sought to expand the scope of practice for chiropractic physicians… . By granting [chiropractors] the ability to prescribe select medications, specially trained and licensed DCs can help a significant number of patients who would otherwise be forced to seek simultaneous care from an already overburdened and limited pool of MDs in general practice.

Those state chiropractic associations! Always looking out for the best interests of patients and overburdened MDs.

Thus, the state associations contacted “experts at [NUHS]” and asked them to “assess what additional training would be necessary.” The experts decided on 90 hours in pharmacology “in addition to the prerequisite physiology and biochemistry courses already required by accredited chiropractic education programs.”

NUHS is, helpfully, offering these additional hours in New Mexico to those who want to become advanced practitioners. In addition to an instructor who has a Ph.D. in pharmacology and pharmocognosy, the NM students “are receiving training in injectible [sic] nutrients and drugs from Dr. Michael Taylor, a chiropractic physician who also holds a diplomate [sic] from the American Board of Chiropractic Internists.”

And what better way to beef up the ranks of family practice doctors, pediatricians and internists than with chiropractors wielding syringes full of “injectible nutrients?”

The E-Z Way to Primary Care Practice

But here is the really interesting part of the NM law: After December 31, 2012, the examination requirement can be met by “successfully complet[ing] a graduate degree in a chiropractic clinical practice specialty.” And where might one get this degree?

As it turns out, NUHS is also offering a “Master of Science degree (MS) – Advanced Clinical Practice” (or “MSACP”) which is “An Advanced Degree designed for the Chiropractic Profession” beginning in September, 2011. The only requirements  are a minimum 2.5 GPA in a “first professional degree” program.

The MSACP program consists of weekend courses spanning two years, 18 in the classroom and 8 in “distance learning” format, plus one “case defense” and one “capstone defense” (whatever that is).

The program conveniently includes the 90 hours of pharmacology required by New Mexico and is presumably the origin of the chiropractic board’s decision to skip the exam if a chiropractor has the “advanced clinical practice” degree. Thus, if you take this course, you’re in, at least as far as New Mexico is concerned.

But chiropractors promoting this new degree obviously have bigger fish to fry. The NUHS course descriptions give a hint as to what those fish might be. Weekend and “distance learning” courses include clinical neurophysiology, clinical problem solving for the primary care physician, clinical neurology, advanced diagnostic imaging, psychological issues of illness, pediatrics, women’s and men’s health/geriatrics, inflammatory mechanisms, dietary prescription, and advanced clinical laboratory medicine.

Hmmm. Why would anyone go to this much trouble when he can just as easily qualify for NM’s “certified advanced practice chiropractic physician” registration by taking 90 hours of classes in pharmacology and a test? In fact, NUHS already incorporates this 90 hours into its regular D.C. program, so all those graduates would have to do to register is take the test.

Here’s why. As the NUHS press release continues:

Because of this growing interest (in expanding the scope of chiropractic practice) NUHS is also thinking about offering its MSACP (Master of Science in Advanced Chiropractic Practice) in New Mexico as well, and is strategizing how to deliver similar programs in other states in the future.

(Emphasis mine.) 

The press release ends with this sunny prediction by James Winterstein, president of NUHS:

Chiropractic physicians are already licensed as primary care doctors in most states … As health care policy-makers wrestle with the scarcity of general practice physicians, expanding the scope of chiropractic care to qualified chiropractic physicians makes good economic and strategic sense. New Mexico’s citizens will undoubtedly benefit from broadening health care delivery by chiropractic physicians, and we anticipate that more states will see the wisdom in this as well.

Let’s hope not.

The MSACP course descriptions illustrate just how far they would like to venture. All of the courses described below take place over one weekend. (All emphasis in quotations mine.)

Clinical Skills for the Primary Care Physician:

… present and demonstrate clinical skills including comprehensive history taking and regional physical examinations skills in the context of common and complex internal disorders. The student will be enabled to effectively integrate these skills and formulate an accurate differential diagnosis and integrative treatment approach.

Clinical Problem Solving for the Primary Care Physician:

The purpose of this distance learning course is to refine and expand upon clinical problem solving skills with an emphasis on internal medicine. The student will be able to effectively integrate patient history and physical examination findings into an accurate differential diagnosis with consideration of appropriate diagnostic testing.

And, I must comment, certainly there is no more effective way for the physician to learn patient history taking, physical examination, and differential diagnosis that watching these things on a computer screen.

Clinical Nutrition I – Inflammation Mechanisms and Dietary Prescription:

… a detailed understanding of the altered biochemistry that underlies the expression of most inflammatory related diseases. Current evidence-based nutritional literature will be presented as a foundation for the clinical application of appropriate dietary changes and key nutritional supplements.

Pediatrics:

… an overview of common pediatric disorders and effective methods for approaching evaluation and management of the pediatric patient. Well infant and child examinations will also be discussed and demonstrated. Students will gain an understanding of normal growth and development and discuss scheduled vaccinations and their associated risks and benefits.

Women’s & Men’s Health/Geriatrics:

… illustrates common and complex conditions impacting the health of women and men, including the geriatric population [including] pathophysiology, differential diagnosis and effective integrative and allopathic treatment strategies will be discussed.

So that’s it! They want to be real doctors who make “differential diagnoses” and “evaluate and manage the patient” and prescribe “dietary changes,” “nutritional supplements,” and “integrative treatment strategies.” Wait, no, that’s naturopathy. They want to be naturopathic doctors?

As it turns out, the American Chiropractic Association (ACA) has its own “Council on Diagnosis and Internal Disorders:”

… an educational Board that endorses and coordinates a post doctorate degree; Diplomate in Diagnosis and Internal Disorders (DABCI). Our Doctors are trained in the most advanced forms of modern medical diagnosis and natural medicine. Our Doctors diagnostic training far exceeds the current standards of health care practice utilizing many current and specialized diagnostics such as: blood chemistries, orthomolecular evaluation, electrocardiograms, vascular ultrasounds, lung function studies, bone density testing, hormonal evaluations, delayed food allergy testing, and much more. Treatments may include; nutritional recommendations, dietary modification, supplement recommendations, homeopathic and naturopathic remedies, natural hormone replacement, etc. Most conditions if diagnosed properly can be resolved naturally and our doctors and the most qualified to provide this service.

Training far exceeds the current standard? Most properly diagnosed conditions can be resolved naturally? Where do they get this stuff?

The ACA’s program, called “The Natural Approach to Family Medicine,” also takes place over a series of 26 weekend sessions (Saturday, 9AM-5 PM; Sunday, 8AM-Noon), although the student can take only one session per month to get credit. Some session titles: Diseases and Exam of the Pelvis & Associated Pathology; Urinary Disorders and Hair Biopsy Assessment; Malignant Diseases, AIDS, & their Management & Treatment; and Upper Gastrointestinal Disease.

So, in sum, chiropractic’s leading organizations — or, depending on your point of view, the pointy-headed, ivory-tower liberals — have seen the future of chiropractic and it is not chiropractors!

The International Chiropractors Association(ICA) is having none of it. Through an article in “Chiropractic Choice,” Stephen P. Welsh, DC, Fellow of the ICA, saw right through NUHS and its grandiose plans:

“A wolf in sheep’s clothing” is the phrase that comes to mind… . The arguments of the moment asserting needs due to provider distribution and availability and the extension of nutritional approaches into the arena of nutraceutical therapies are red herrings. The goal of the advocates of these changes is to practice primary care medicine, without fully qualifying at the appropriate standard to do so. It is disingenuous to assert that these changes are being made to address a sudden deficiency in providers in New Mexico or elsewhere or a spectacular new advantage to some form of nutritional therapy.

Couldn’t have said it better myself.

Posted in: Chiropractic, Legal

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