Health Insights Today ~ Sept 2011; 4 (5)
By Daniel Redwood, DC
For at least as long as any living doctor of chiropractic can remember, our profession has engaged in ongoing and sometimes heated debate about the proper role of its practitioners. Should our primary or sole focus be the spine? The nervous system? Vertebral subluxation? Back and neck pain? Should we be musculoskeletal pain specialists? Complementary care generalists? Primary care physicians?
Two new papers, one by Donald Murphy and colleagues in Chiropractic and Manual Therapies  and the other by Jan Hartvigsen and colleagues in British Medical Journal,  simultaneously point in the same direction—toward the role of primary spine care practitioner. The lead authors of both articles are chiropractors, Murphy from the United States and Hartvigsen from Denmark. Neither proposes the primary spine care practitioner role as the only option for DCs; both make a persuasive case that developing this role on a much more widespread basis will significantly enhance the effectiveness of the health care system’s neuromusculoskeletal (NMS) care delivery. In the process, they demonstrate why many practitioners may find work as a primary spine care practitioner attractive. To the extent that deeper integration of chiropractic is one of the profession’s primary goals, this may be one of the best vehicles for its achievement. At the very least, it’s a possibility worthy of serious examination.
World Federation of Chiropractic Identity Statement
The Murphy and Hartvigsen proposals are wholly consistent with the 2005 professional identity statement from the World Federation of Chiropractic, which grew out of an extensive consultation and consensus building process among the WFC’s membership, comprised of the national chiropractic associations of over 80 nations, including both ACA and ICA from the United States.
How do the world’s chiropractors, speaking through the WFC, define themselves? First, with a phrase summarizing the primary identity of chiropractors: “The spinal health care experts in the health care system.”
Next, with a series of qualifying statements:
Ability to improve function in the neuromusculoskeletal system, and overall health and quality of life.
Specialized approach to examination, diagnosis and treatment, based on best available research and clinical evidence, and with particular emphasis on the relationship between the spine and the nervous system.
Tradition of effectiveness and patient satisfaction.
Without use of drugs and surgery, enabling patients to avoid these where possible.
Expertly qualified providers of spinal adjustment, manipulation and other manual treatments, exercise instruction and patient education.
Collaboration with other health professionals.
A patient-centered and biopsychosocial approach, emphasizing the mind/body relationship in health, the self-healing powers of the individual, individual responsibility for health, and encouraging patient independence.
This WFC definition does not limit what DCs can do. Its goal is to identify and define the common ground we all share and to speed the day when patients going to a chiropractor anywhere in the world can enter that doctor’s office with a reasonable expectation of receiving certain basic diagnostic and treatment/management procedures, delivered with a high level of patient-centered professionalism. Depending on licensure laws and personal choices by individual chiropractors, some chiropractors will continue to develop expertise in additional areas and utilize these skills in patient care. But whatever worthwhile “extras” a particular practitioner might provide, he or she would be expected to deliver the core procedures that constitute the essence of chiropractic care.
Primary Spine Care Practitioners
The new commentaries by Murphy et al and Hartvigsen et al apply this spine-focused perspective in ways that meet current and emerging health care system needs. It is now obvious to virtually all informed observers that primary care physicians (PCPs) in the medical profession have neither the focused expertise nor the time to effectively serve as the first step or entry point in the management of NMS pain patients. The primary expertise of these PCPs lies elsewhere, while the highest-level diagnostic and therapeutic expertise for NMS conditions can be found among practitioners whose training strongly emphasizes it and whose NMS skills are continuously honed by interactions with virtually every patient. Chiropractors are well-positioned to fill this need.
Hartvigsen et al’s BMJ commentary expressly advocates shifting non-pathologic NMS cases away from medical doctors to chiropractors, physiotherapists and osteopaths. (The osteopathic scope of practice in Britain is similar to that of U.S. chiropractors, not U.S. osteopaths). Notably, the article’s authors include both Hartvigsen, a DC who is research director at the Institute for Sports Science and Clinical Biomechanics in Odense, Denmark, and Peter Croft, a medical physician and epidemiologist best known among chiropractors for his landmark 1998 BMJ study that permanently debunked the myth that 90% of patients seeing MDs for low back pain recover fully within several weeks. (After 12 months, only 25% had recovered, but 90% had stopped seeing their MDs for low back pain.) Hartvigsen and Croft are not the first to advocate shifting musculoskeletal care of non-pathologic origin away from MDs. The importance of their article is that it is published in BMJ, which is the journal of the British Medical Association.
In the United States, this would be comparable to having such a commentary published in the Journal of the American Medical Association or perhaps the New England Journal of Medicine, something that has never happened and remains almost unimaginable at this point. The potentially groundbreaking significance of the Hartvigsen article is that the United Kingdom may be moving toward becoming the first nation to shift first-contact responsibility for NMS cases away from medical general practitioners to chiropractors, physiotherapists and osteopaths. Within the UK’s nationalized system of universal health care, such changes could potentially go system-wide relatively quickly, should such a policy shift be enacted.
Limits of the Supermarket
The commentary by Murphy et al addresses similar issues in an American context, focusing on the Affordable Care Act’s deeply embedded emphasis on strengthening primary care. In their abstract, the authors aptly note, “Costs of medical care for SRDs [spine-related disorders] have skyrocketed in recent years. Despite this, there is no evidence of improvement in the quality of this care. In fact, disability related to SRDs is on the rise. We argue that one of the key solutions to this is for the health care system to have a group of practitioners who are trained to function as primary care practitioners for the spine.”
They continue, “A variety of physicians and other providers have traditionally been involved with the diagnosis and treatment of these patients. This includes primary care physicians, chiropractic physicians, orthopedic surgeons, neurosurgeons, physiatrists, osteopathic physicians, physical therapists, psychologists, massage therapists, kinesiologists, naprapaths and acupuncturists. This has resulted in what has been termed the “supermarket approach” to the management of SRDs. That is, the SRD patient is faced with an environment in which there is a large number of practitioners, each offering a solution to SRDs, with the patient left to sort out which of these disparate approaches is best for his or her particular problem. Oftentimes this determination is based more on salesmanship and marketing than on science, clinical benefit and cost-effectiveness.”
Their solution is to carve out a role along the lines of the general dentist, who provides primary care for oral health. Primary spine care would involve “comprehensive first contact and continuing care for persons with any undiagnosed sign, symptom, or health concern … not limited by problem origin (biological, behavioral, or social), involving the spine.” This would be provided by practitioners specifically trained to diagnose and manage the majority of patients with SRDs with evidence-based methods. The primary spine care practitioner would function as the first contact for patients with SRDs and could also function as a resource for traditional PCPs (family practice physicians, general internal medicine physicians, pediatric, obstetrical/ gynecological physicians, primary care nurse practitioners or physician’s assistants) to refer patients who present with SRDs.
Murphy and colleagues explain that chiropractors and others serving in this newly defined role as primary spine care practitioners would in some ways need to stretch beyond their current roles, particularly with regard to understanding the complex interplay between physical and psychological factors in the chronic NMS pain patient. They would also have to understand, respect, and be fully prepared to appropriately utilize the full range of options available to patients, directly or through referral, including “intensive rehabilitation, interventional treatments and surgical procedures.” Some DCs already possess this knowledge base and are currently filling a primary spine care role; others would need further training. In a health care system reordered along the lines proposed by Murphy and Hartvigsen, those who pursue the primary spine care practitioner role as their defining career path would be integrated into mainstream health care delivery in ways that few chiropractors have yet experienced.
Is this our profession’s future? Most likely, it will be a part of our future. Some chiropractors may find great fulfillment in such a role, while others may gravitate toward other models of practice. These visionary proposals explicitly do not seek to force all chiropractors into the same mold but instead to allow professional evolution to proceed along multiple paths. Whether or not we as individual practitioners choose this particular path, we all can celebrate the opening of new doors.
Murphy DR, Justice BD, Paskowski IC, Perle SM, Schneider MJ.
The Establishment of a Primary Spine Care Practitioner and its Benefits
to Health Care Reform in the United States.
Chiropr Man Therap. Jul 21 2011;19(1):17.
Hartvigsen J, Foster NE, Croft PR.
We need to rethink front line care for back pain.
BMJ. 2011 (May 25); 342: d3260
Daniel Redwood, DC, is a Professor at Cleveland Chiropractic College–Kansas City. He is the Editor-in-Chief of Health Insights Today and The Daily HIT, and serves on the editorial boards of the Journal of the American Chiropractic Association, Journal of Alternative and Complementary Medicine, and Topics in Integrative Healthcare.