THE CHIROPRACTIC SCOPE OF PRACTICE IN THE UNITED STATES: A CROSS-SECTIONAL SURVEY
 
   

The Chiropractic Scope of Practice in the United States:
A Cross-sectional Survey

This section is compiled by John Wiens, D.C.
Send all comments or additions to:
    Frankp@chiro.org
 
   

FROM:   J Manipulative Physiol Ther. 2014 (Jul);   37 (6):   363–376 ~ FULL TEXT

Mabel Chang, DC, MPH

National University of Health Sciences-Florida,
Pinellas Park, FL.
mchang@Nuhs.edu


OBJECTIVE:   The purpose of this study was to assess the current status of chiropractic practice laws in the United States. This survey is an update and expansion of 3 original surveys conducted in 1987, 1992, and 1998.

METHODS:   A cross-sectional survey of licensure officials from the Federation of Chiropractic Licensing Boards e-mail list was conducted in 2011 requesting information about chiropractic practice laws and 97 diagnostic, evaluation, and management procedures. To evaluate content validity, the survey was distributed in draft form at the fall 2010 Federation of Chiropractic Licensing Boards regional meeting to regulatory board members and feedback was requested. Comments were reviewed and incorporated into the final survey. A duplicate question was imbedded in the survey to test reliability.

RESULTS:   Partial or complete responses were received from 96% (n = 51) of the jurisdictions in the United States. The states with the highest number of services that could be performed were Missouri (n = 92), New Mexico (n = 91), Kansas (n = 89), Utah (n = 89), Oklahoma (n = 88), Illinois (n = 87), and Alabama (n = 86). The states with the highest number of services that cannot be performed are New Hampshire (n = 49), Hawaii (n = 47), Michigan (n = 42), New Jersey (n = 39), Mississippi (n = 39), and Texas (n = 30).

CONCLUSION:   The scope of chiropractic practice in the United States has a high degree of variability. Scope of practice is dynamic, and gray areas are subject to interpretation by ever-changing board members. Although statutes may not address specific procedures, upon challenge, there may be a possibility of sanctions depending on interpretation.

KEYWORDS:   Chiropractic; Health Resources; Health Services; Legislation; Licensure



From the FULL TEXT Article:

Introduction

Chiropractic is the third largest health profession in the United States and the largest and most recognized of the complementary and alternative professions. [1] Chiropractors in all 50 states, the District of Columbia, Puerto Rico, and the United States Virgin Islands provide direct access care to patients. [1]

Scope of practice is the regulation of professionals in a specific jurisdiction and is used to legally create boundaries by restricting the allowed activities for a specified profession. [2] Its purpose is to protect the public by setting legal limits for what a provider can do, and it can be used as a means to define a profession in a particular locale. [3–5] Some scholars counter that practice laws have failed to protect the public but have been used as a tool to limit competition. [6–12]

Practice laws are the responsibility of each state, and this has caused variations in scopes of practice for a wide variety of health professionals. [3, 13–17] The United States does not have a unified scope of practice for most health care professionals. This has contributed to fragmentation of health care across jurisdictions. The only health care professionals that have a unified scope of practice across state lines are medical doctors and doctors of osteopathy. [2] The medical profession was the first to have licensure standards, and because they were the first to become licensed, their scope of practice is uniform and broad. [4, 5, 18] As each health care profession sought licensure, the American Medical Association aggressively defended their practice rights and ensured that limitations were put on other professions. [7, 18–21] It should be noted that all health professional organizations have followed the same tactics in defending their practice rights. [22, 23]

In addition to the prior 3 surveys, there have been several surveys that were located in the gray literature performed by state associations, student research projects, and the World Federation of Chiropractic. The state surveys explore local attitudes of their members on issues of chiropractic unity, drugs, and scope expansion. [24, 25] “The Legal Status of Chiropractic Practice Internationally” is a survey of association members from 85 countries. Data from 49 countries were collected pertaining to legal status, direct access to patients, protection of titles, presence of regulations for licensure, imaging rights, prescription rights, laboratory tests, ability to authorize sick leave, and reimbursement climate. The report was completed in June 2011. [26] The student research project surveyed alumni practicing in the states of Alabama and Florida. [27] None of the respondents to these surveys were members of regulatory boards.

Data from the Congressional Budget Office indicates that the Patient Protection and Affordable Care Act will expand health care coverage to 33 million nonelderly Americans. [28] Twenty-seven million people are expected to gain health insurance by 2017. [29] In addition to the increase in the number of insured, the senior population has been growing at an exponential rate. One of 5 in the US population will be older than 65 years by 2030. [30] The fastest growing segment of this group is the oldest of the old—those 85 years and older. [31] With society's longevity comes the associated increase in chronic diseases. Those with chronic disease require more health care resources. [32]

Full-scope physicians have not been able to address the needs of our population's growing health care demands. They are working fewer hours, [33] restricting their practices by opting out of Medicare, [34] and setting up boutique practices to provide better quality care to fewer patients. [35–37] In addition, a substantial number of these providers will be retiring soon. [39, 39] This has caused public officials to worry about stretching an already thin workforce. [40–43] States are looking for ways to accommodate the demands for health care, especially in states that are already experiencing health care workforce shortages. [41] Using all health care providers to the fullest extent of their training is one solution that will provide timely relief to these problems.

In addition to the workforce shortage, the Patient Protection and Affordable Care Act is encouraging the formation of Accountable Care Organizations and the Patient Centered Medical Home in an effort to improve health outcomes through integration and cross-communication between providers. [44] Clarification of the chiropractic scope of practice will help to facilitate referrals and participation in these organizations.

Legislation relating to the scope of practice of health professionals is increasing in the United States because of these factors. There were 1,795 scope of practice-related bills proposed in 54 states, territories, and the District of Columbia between January 2011 and December 2012, but only 349 have been adopted or enacted into law. [40, 45] The purpose of this study is to clarify regulations that guide chiropractic practice by updating and expanding the 3 original surveys conducted in 1987, [46] 1992, [47] and 1998. [48] The original 3 studies surveyed 78 services, whereas this study surveys 97 services. [46–48] To the author's knowledge, this update offers the most comprehensive survey of regulatory officials on specific services allowed in their jurisdictions.



Methods

The institutional review board at the National University of Health Sciences reviewed this study and exemption was granted. Following the procedures of the 3 previous surveys, spinal manipulation and regional spine plain film radiography were not included in the survey. [46–48] The current survey was updated in consultation with the original investigator, the American Chiropractic Association, and the Federation of Chiropractic Licensing Boards (FCLB) to include the following items:

diagnostic ultrasound imaging,
surface electromyography (EMG),
National Department of Transportation Driver Physicals,
orthopedic and neurologic examinations,
hernia examinations,
magnetic therapy,
traction,
oxygen therapy,
dry needling of trigger points,
hyperbaric chamber,
manipulation under anesthesia, and
veterinary chiropractic.

Electrotherapy was broken down to specific therapies. Applied kinesiology and intervaginal uterine manipulation were removed from the survey. Ninety-seven services were evaluated compared with 78 services in the prior surveys. A comment section was added to the survey to allow for commentary after each set of questions.

To evaluate content validity, the survey was distributed in draft form at the fall 2010 FCLB regional meeting to regulatory board members, and feedback was requested. Comments were reviewed and incorporated into the final survey. In addition to surveying Canada, the United States, and the District of Columbia, the survey was expanded to include Puerto Rico, and the Virgin Islands, Australia, and New Zealand. Results from Australia, Canada, and New Zealand will be reported in a separate article.

The sample frame used included regulatory officials who were a part of the FCLB e-mail list. Officials were asked to respond with their name, contact information, and position on the board. If the official was no longer a member of the board, he/she was asked to contact the investigator and provide contact information for an alternate official. The officials were asked to choose a single response indicating the extent that a health care service was within the chiropractic scope of practice in their jurisdiction.

Structured answers included the following:

(1)   can perform (includes can order),
(2)   can perform with additional training/certification,
(3)   can order (or refer), and
(4)   cannot order/perform.

After each section of the survey, officials were given an opportunity to clarify their responses in an essay box. If a jurisdiction left an item blank, it was not counted in the percentage totals. Reminders were sent each month to those who had not completed the survey. Portable document format of the survey was made available to the board members as well.

In late January 2011, the study began data collection using the Form Creation Module for the DotNetNuke Content Management System (v 1.6.4 Code 5 Systems; LLC, Aberdeen, SD). Because of the magnitude of the survey, the survey instrument was migrated to SurveyMonkey (SurveyMonkey Inc, Palo Alto, CA) in late March 2011, so that respondents could save their responses and return to the survey later. The survey was closed in January 2012, and the process of reconciling the data continued.

If there were inconsistencies within the same jurisdiction, the respondents were contacted by telephone, e-mail, or both; advised of the inconsistencies; and asked to review their answers. If the inconsistencies were not able to be resolved by this method, it had been decided a priori that rank of the responding official would determine which response was deemed correct. This decision was based on the assumption that higher-ranking officials have more responsibility within the organization and therefore will be more familiar with practice law in their jurisdiction than lower-ranking officials.

During the data analysis, it was discovered that some of the inconsistent responses were made by the same official. Upon further inquiry, it was revealed that administrators had filled out their surveys using the president's or chair's demographic information. It was decided that the certifying official's responses would be considered accurate. Because of the length of the study, if multiple replies from the same jurisdictions were received, the most recent data were considered correct if the responses were greater than 6 months apart. If neither of the above applied, the question was considered unanswered.

A duplicate question was imbedded in the survey to test reliability. If validation failed, respondents were notified that they had failed the duplicate question test and they were asked to review the survey in its entirety. In June 2013, all respondents were given a copy of their answers and asked to review them and make changes accordingly. Percentage totals were made for each item. The percent within scope reflects the combined responses of “can perform,” “can perform with additional training/certification,” and “can order.” If an item was left unanswered, it was not included in the calculations.



Results

Partial or complete responses were received from 96% (n = 51) of the jurisdictions surveyed. Of these, Indiana provided demographic information only, Maryland opted out of SurveyMonkey, and Puerto Rico did not respond to our requests. Respondents held a range of titles including president, chairperson, executive director, director, general counsel, legal assistant, bureau manager, program manager, executive assistant, administrative specialist, and board administrator. The results are reported in Table 1, Table 2, and Table 3.


Table 1.   Diagnostic and Examination Certifications

Table 2.   Physical Examination, Gender-Specific Services, Physiotherapeutics, and Specialty Adjusting Techniques


Table 3.   Adjunctive and Specialty Services




The states with the broadest chiropractic practice laws determined by the number of services that could be performed were

Missouri (n = 92),
New Mexico (n = 91),
Kansas (n = 89),
Utah (n = 89),
Oklahoma (n = 88),
Illinois (n = 87), and
Alabama (n = 86).


The most restrictive states by the number of services that cannot be performed are

New Hampshire (n = 49),
Hawaii (n = 47),
Michigan (n = 42),
New Jersey (n = 39),
Mississippi (n = 39), and
Texas (n = 30).


Extremity examinations   (n = 48),
orthotic supports   (n = 48),
orthopedic examinations   (n = 47),
spinal supports   (n = 47),
lifestyle counseling   (n = 47), and
neurologic examinations   (n = 46)
may be performed by a chiropractor without additional education in every jurisdiction that responded.


Vitamin supplementation   (n = 46),
temporomandibular joint evaluation and treatment   (n = 45),
full-spine radiographs   (n = 48),
traction   (n = 45),
diet formulation   (n = 44),
electrical stimulation   (n = 43),
ultrasound   (n = 42),
tens   (n = 42),
botanical therapy   (n = 39),
IFC   (n = 41), and
microcurrent therapy   (n = 41)
may be performed in all jurisdictions that responded, but may require additional education.


Ninety percent or more of the jurisdictions report that limited prescription rights and minor surgery were not within the chiropractic scope of practice. There were a total of 97 services surveyed.

      Diagnostic Imaging

Full-spine radiographs (n = 46) can be performed in all jurisdictions without additional education, except in Delaware and Rhode Island, where they can only be ordered. It is legal for doctors of chiropractic (DCs) to order or perform the following services in all jurisdictions that responded: computed tomography (CT; n = 43) and magnetic resonance imaging (MRI; n = 45).

Idaho responded that thermography was under discussion during the time of the survey and that it may be allowed with additional training because it falls under diagnostic x-rays. Michigan qualified their answers to this portion of the survey by stating that DCs can order MRI of the spine only.

In Ohio,

“chiropractic radiologists are permitted to perform computed tomography (CT) scans, MRI, and fluoroscopy at free standing or mobile diagnostic imaging centers. A chiropractic radiologist must have diplomate status by the American Chiropractic Board of Radiology (ACBR) and those who perform CT and MRI must be credentialed by the ACBR.”

Oregon reports that they do have specific training and informed consent requirements for breast thermography but more information can be found on their Web site. In Texas, there are no clear rules or guidelines for CT scan, cholecystography, thermography, or diagnostic ultrasound. Needle EMG cannot be performed in Texas, but a nerve conduction study without needles is permitted. Iowa code/rules does not address needle EMG, but a policy statement from the board indicates that needle EMG and nerve conduction velocity studies are within the scope with additional training and certification. Vermont states that the board has no ruling on electrocardiography and has not contemplated this issue.

      Diagnostic Procedures

Doctors of chiropractic are able to order or perform surface EMG (n = 43) in all jurisdictions that responded.

      Laboratory Procedures

Blood analysis (n = 44) can be ordered or performed in all jurisdictions that responded. Arkansas reports that blood can be drawn for analysis; however, nothing can be injected into the body. In Oklahoma, venipuncture of the skin is limited to the injection of natural nutrients and vitamin compounds. In Texas, needles can be used only to draw blood for diagnostic purposes and for acupuncture.

      Examination Procedures

All of the jurisdictions that responded allowed DCs to perform extremity examinations (n = 43), orthopedic examinations (n = 42), and neurologic examinations (n = 41) without additional education.

Doctors of chiropractic may order or perform impairment ratings (n = 42) in all jurisdictions that responded. California law does not specify if signing birth certificates and performing electrocardiography are within the scope of practice. Hawaiian statutes do not address school physicals. In the District of Columbia, the survey was answered presuming that school physicals included giving vaccinations if needed/wanted for that age group, and thus, the official marked it as “cannot perform.”

In Kentucky, a chiropractor may perform these examinations if taught by an accredited chiropractic college; however, the board recommends that these examination procedures be referred to a more specifically trained medical doctor.

Tennessee statute allows for the performance of services such as impairment ratings, school physicals, sports physicals, and others, but there may be rules in place within the system (ie, Department Of Education, Worker's Compensation, and hospital) that bar chiropractors from performing them within that system. New Mexico states that premarital examinations are not required in their jurisdiction.

      Gender-Specific Services

An area of frequent commentary pertained to female- and male-sensitive examinations. Washington State qualified that the hernia examination is approved as external only. Several jurisdictions noted that the procedures themselves are within the chiropractic scope of practice, but the “appropriateness” of such examinations must be documented. Arizona, Kansas, Kentucky, Ohio, Oregon, and Vermont recommended referral to a more appropriate professional. They stressed that if performed, documentation of appropriate setting and clinical rationale for these examinations was important. Without them, a doctor would very likely be investigated, subject to a hearing, and potentially face sanctions. Nevada and Oregon noted that these procedures would require signed informed consent from the patient prior to performing the examinations. In rare cases in New York, a cursory breast examination may be done if there is referred spinal pain to the chest or a skin eruption, that is, shingles, but not as a routine/preventive screening. Tennessee reported that statute does not prohibit the performance of any of these tests, except if/when they constitute the practice of some other branch of the healing arts. If/when that is said to occur has not been tested.

      Physiotherapy

All jurisdictions that responded also allowed DCs to perform ultrasound (n = 43), transcutaneous electrical nerve stimulation (n = 43), interferential therapy (n = 42), micro–current therapy (n = 42), and electrical stimulation (n = 43), except for the state of Washington, where these services can be ordered.

Massage (n = 55) can be performed in all locales, except Hawaii. Hawaii notes, however, that DCs may perform trigger point therapy and paraspinal soft tissue work.

Traction (n = 44) can be performed without additional education in all jurisdictions, except the District of Columbia, Kentucky, and Wisconsin, where additional education is required.

It is legal for DCs to order or perform the following services in all jurisdictions that responded: ultrasound iontophoresis without prescription medication (n = 39), Russian stimulation (n = 41), nonablative laser therapy without tissue destruction (n = 40), and cryotherapy (n = 41).

Illinois states that laser therapy is allowed but does not include laser hair removal or other dermatological cosmetic procedures that cause tissue destruction. In Ohio, nonablative laser therapy can only be related to musculoskeletal conditions.

      Adjustive/Manipulative Procedures

Extremity adjusting (n = 56) can be performed in all locales, except Hawaii.

      Nutrition

Vitamin supplementation (n = 44), diet formulation (n = 43), and botanical therapy (n = 41) could be performed in all jurisdictions.

      Treatment Procedures

All jurisdictions that responded allowed DCs to perform orthotic supports (n = 44), spinal supports (n = 43), and lifestyle counseling (n = 43) without additional education. All jurisdictions that responded allowed DCs to perform temporomandibular joint evaluation and/or treatment (n = 43), except for the state of Washington, where these services can be ordered. All jurisdictions allow rehabilitation to be performed (n = 43), except Rhode Island.

      Specialty Procedures

Electrolysis is a minor surgery procedure that requires specialty certification in minor surgery to perform in Oregon. Alabama, Arkansas, Idaho, Illinois, Massachusetts, Michigan, Missouri, Nebraska, New Jersey, Ohio, Oregon, Pennsylvania, Utah, and Wisconsin state that a veterinarian and a chiropractor must work in conjunction with each other to deliver care to animals and the chiropractor must have training in animal chiropractic.

      Jurisdiction-Specific Information

Several jurisdictions stated that although a chiropractor has been trained in a procedure, because of the language of the law, these procedures would only be legally performed if it related to a spinal condition. For example, in New York, soft casts may be used in sprains to an extremity only if due to a primary spinal condition. New York also states that over-the-counter vitamins/nutritional supports can be recommended, but not over-the-counter medication. Endonasal technique is allowed if secondary to a primary spinal complaint.

In Utah,

“the Chiropractic Physician Practice Act and Rule permit examination, diagnosis and treatment using x-ray, and administration of physical agents, including light, heat, cold, water, air, sound, compression, electricity, and electromagnetic radiation except gamma radiation, provided the licensee has the education and training to competently practice a procedure. Specific diagnostic imaging procedures are not identified. Should questions arise concerning quality and adequacy of care, the Quality and Standards Committee will serve as an advisory peer committee to the Chiropractic Physician Licensing Board. This Committee is made up of five chiropractic physicians licensed and in good standing that are qualified by education, training and experience to competently act in quality care review to determine adequacy and appropriateness of care.

A chiropractic physician may not:

(a) perform incisive surgery;

(b) administer drugs or medicines for which an authorized prescription is required by law
except as provided in Subsection (2)(d);

(c) treat cancer;

(d) practice obstetrics;

(e) prescribe or administer x-ray therapy; or

(f) set displaced fractures.”


“Virginia law only mentions the 24 moveable vertebrae. The chiropractor may perform procedures necessary to practice his profession.” Virginia law states that “the practice of chiropractic does not include the use of surgery, obstetrics, or osteopathy.” Kentucky and Montana affirm that DCs may perform procedures as long as they were taught them at an accredited chiropractic school. In Michigan, procedures noted in Table 1, Table 2, Table 3, and 3 are permitted if they relate to the subluxation complex.

Washington State notes that “analysis is considered the interpretation of results of a test by a chiropractor and does not include the technical performance of taking, collecting, or testing of samples. Diagnostic procedures that are within the scope of practice are allowed for purposes of providing a chiropractic differential diagnosis. However, individuals should review Washington law to determine how the law may apply to their particular circumstance.”



Discussion

The number of jurisdictions that responded to this survey is higher than the past surveys possibly due to the increased number of requests for those who did not respond. [46–48] Similar to prior surveys, there appears to be a trend of increasing scopes of practice. [47, 48] Similar to prior surveys, [46–48] there were instances where one procedure was within the scope of practice, yet an associated diagnostically valuable procedure was not. [46–48] For example, 58% of the jurisdictions reported that DCs could perform bimanual examination of the female pelvis without additional training, but only 44% allowed Papanicolaou test to be performed.

There were several comments that should be discussed further. Respondents indicated that although procedures may be within the scope of practice, there may be other organizations such as insurers, employers, schools, and so on, that may not accept or reimburse for services provided. Some jurisdictions reported that although procedures were within the scope of chiropractic practice, they questioned whether they were “usual and customary.”

As Vermont elaborates, “presumably a person properly trained may be able to do this procedure, but should a complaint or charge be made against the doctor, there is nothing in the statute that expressly permits or prohibits this procedure.” Other jurisdictions commented that although DCs are qualified in the procedures, the procedures must be related to a spinal condition as stated in the statutes. Documentation of rationale, justification, and consent was cited by a number of jurisdictions. Tennessee cited specific language indicating that services were permitted as long as they did not infringe on the practice rights of another healing profession. Some jurisdictions were in the midst of challenges to the performance of some items on the survey and chose to leave those items unanswered. This highlights the ambiguity of the statutes.

Effective interprofessional and integrated health care requires that all providers understand each other's scope of practice. [49, 50] Most health care providers will not refer to another profession if they do not understand their scope of practice. Complementary and alternative medicine is often not well understood by other professions. This lack of information prevents referrals unless a patient requests one. One study found that this leads to feelings of self-consciousness and defensiveness by the complementary and alternative medicine practitioner and leads to further isolation. [49] A study of the inclusion of chiropractic in the Veterans Health Administration found that varying perceptions of chiropractic care by health care providers and administrators caused problems in effective use of chiropractic. [51]

Organizations that are considering integrative care are also concerned that limited scope providers make appropriate referrals when the situation arises. It is important that DCs know what is legally permissible in their states as well as organizationally created limitations to their scope of practice. This will allow for appropriate referrals. [50]

Education and training of limited scope health care providers is broader than what state practice laws allow. [42, 52–54] For instance, as part of The Council of Chiropractic Education accreditation process, chiropractic schools are to educate and train students to become a “competent doctor of chiropractic who will provide quality patient care and serve as a primary care physician,” yet the variances in practice regulation do not allow this to occur. [16, 55, 56] In addition, the language of state practice acts may be vague and may not be sufficient to answer whether a technique or procedure is within a particular scope of practice. [16] This can be very confusing for patients, health care providers, insurers, students, and policy makers.

Scope of practice is an important issue for patients, health care providers, health care organizations, and policy makers. Although scope of practice is important, there are many other factors that dictate whether procedures are used in practice. Some of these factors include organizational climate, [57–59] reimbursement, [7, 57–61] the philosophy of the doctor, doctor preference, patient demand, and societal perceptions as to appropriateness. A practice analysis of chiropractic radiologists showed that although trained to read advanced imaging, the majority read only or mostly plain films. [62] Even with practice laws that were favorable for nurse practitioners to practice primary care, there were many organizational factors that restricted this from happening. [57, 58]

Uniform practice models for health care professionals have been advocated for many health care providers. The National Highway Traffic Safety Administration has proposed a model of uniform scope of practice for emergency medical personnel to alleviate public confusion, improve professional mobility, decrease reciprocity challenges, and increase the efficiency of the health care workforce. [13] Duenas [16] has advocated for a uniform chiropractic practice act in the United States. Having a uniform model of practice would decrease confusion of the public, policy makers, and other providers and would facilitate the use of chiropractic services.

Limitations

Limitations to this study include the transitory nature of board membership; thus, these results may not reflect the views of future board members. Some administrative personnel completed the survey using the highest ranking official's demographic information. Although there were a handful of boards that choose to complete the survey together, most responses came from individuals with a wide range of rank leading to concerns about self-reporting and that answers may not be representative of the entire board. In addition, the length of the survey may have caused respondents to only complete part of the survey or to incorrectly answer the survey questions due to fatigue. Although a number of respondents were health care professionals, some were not. Several states had their attorneys interpret the statutes and fill out the survey. Non–health care professionals may not be familiar with the services that were surveyed. This may have caused services that were not understood to be skipped. This survey was administered electronically, and this may limit the number and type of respondent. Another limitation includes vague statutes and gray areas that licensing boards are charged with interpreting when challenges to scope of practice arise. The interpretation will depend on who sits on the board at the time. The boards regularly have membership changes, and this can affect the interpretation of the practice laws.

Future Studies

Areas of suggested research using this information include performing well-conducted studies on the adoption of expansion in scope by DCs, studies to assess whether quality or safety of health care is jeopardized in states with broader scopes. It would also be useful to look at health care costs in states with expanded chiropractic services. Lastly, because of the evolving nature of scope of practice, this survey should be repeated after health care reform has been implemented.



Conclusion

This study found that chiropractic practice in the United States can vary widely between jurisdictions. Although statutes may not address specific procedures, upon challenge there may be a possibility of sanctions depending on interpretation. Scope of practice is dynamic, and gray areas are subject to clarification by ever-changing board members.

This study should be helpful for providers, educators, patients, and policy makers in determining the limitations to chiropractic practice by jurisdiction and when addressing any changes that need to be made to the current scope of practice regulations. For more information about the statutes and rules for the study jurisdictions, please go to FCLB's Chiropractic Regulatory page found at
http://www.fclb.org/Boards.aspx


Practical Applications
  • Although chiropractic services are allowed, due to the language of the law
    in some jurisdictions, services must be related to the spine.

  • Although chiropractic services are allowed, there were questions to
    appropriateness that would expose the chiropractor to sanctions.

  • Although services are within the scope of chiropractic practice, there may
    be other organizations that restrict payment or would not accept services provided.

  • Similar to prior surveys, in some cases although one procedure was allowed,
    another associated, diagnostically valuable service was not allowed.

Funding Sources and Conflicts of Interest

No funding sources or conflicts of interest were reported for this study.


Acknowledgments

The author thanks Dr Lester Lamm for the use of his prior survey and advised in the updating of the survey. The author thanks the FCLB, Kelly Webb, and Donna Leiwer for the use of their mailing list, assistance in pretesting the survey, and their help in gathering responses. The author thanks Dr Susan Bedair for her assistance in data collection and editing the manuscript.



Appendix B.   Select Services Glossary and Abbreviations
(in order of appearance)


Diagnostic Imaging

Full spine: radiographs of the entire spine
Skull: radiographs of the head
Soft tissue: imaging of the muscles, ligaments, and tendons

1   “Tomography.” Barium studies/barium swallow (Ba): a small amount of barium paste or liquid administered orally and observed radiographically or by fluoroscopy for examination of swallowing and esophageal function

2   “Computed Tomography (CT) scan.” Tomography: the recording of internal body images at a predetermined plane by means of the tomograph

3   “Magnetic resonance imaging (MRI).” Computed tomographic scan: digitized, detailed, spatially accurate, serial, 3-dimensional body images, created by a narrow beam of x-rays delivered along a spiral trajectory (2–mm “slices” for foot and ankle), in which compact bone appears white, and air black; CT scans are especially useful for examination of cortical bone.

4   “Cholecystography.” Magnetic resonance imaging (MRI): the patient is placed in a magnetic field and radiofrequency signals are transmitted and received by surrounding coils. A computer processes the information and constructs cross–sectional images which provide detailed information on soft tissues.

5   “Thermography.” Cholecystography: visualization of the gallbladder by x–rays after the administration of a radiopaque substance

6   “Diagnostic ultrasound.” Thermography: a technique wherein an infrared camera photographically portrays the body's surface temperature, based on self–emanating infrared radiation; sometimes used as a means of diagnosing underlying pathologic conditions, such as breast tumors

7   “Electrocardiography.” Diagnostic ultrasound (US): the use of ultrasound to obtain images for medical diagnostic purposes, employing frequencies ranging from 1.6 to about 10 MHz Diagnostic Testing

8   “Doppler.” Electrocardiography (ECG): a commonly used, noninvasive procedure for recording electrical changes in the heart

9   “Electromyography—definition of electromyography in the medical dictionary—by the Free Online Medical Dictionary, Thesaurus, and Encyclopedia.” Surface scanning electromyography (sEMG): the recording of electrical activity generated in muscle for diagnostic purposes using surface recording electrodes

10   Ibid.

11   “Nerve conduction studies—definition of nerve conduction studies in the medical dictionary—by the Free Online Medical Dictionary, Thesaurus, and Encyclopedia.”

Needle electromyography and/or nerve conduction studies (EMG/NCS): the recording of electrical activity generated in muscle for diagnostic purposes using needle recording electrodes/a noninvasive method for assessing a nerve's ability to carry an impulse, which quantifies latency periods and conduction velocities; larger peripheral motor and sensory nerves are electrically stimulated at various intervals along a motor nerve

12   “Sphygmomanometry.” Doppler (Vascularizer): a diagnostic instrument that emits an ultrasonic beam into the body; the ultrasound reflected from moving structures changes its frequency (Doppler effect). Of diagnostic value in peripheral vascular and cardiac disease

Blood analysis: analysis of the blood
Urinalysis: analysis of the urine
Sputum analysis: (analysis of) matter coughed up and usually expelled from the mouth, especially mucus or mucopurulent matter expectorated in diseases of the air passages
Fecal analysis: analysis of feces
Semen analysis: analysis of semen
Throat swab
Skin scrape
Hair analysis

Examinations

School physicals
National Department of Transportation Driver Physicals
Preemployment physicals
Premarital physicals
Impairment ratings
Sign birth certificates
Sign death certificates
Eyes/Ears/Nose/Throat (EENT) examinations
Abdominal examinations
Extremity examinations
Orthopedic examinations
Neurologic examinations
Chest auscultations

13   “Pelvic exam.” Sphygmomanometry: determination of the blood pressure by means of a sphygmomanometer

14   “Speculum.” Bi–manual (pelvic) examination: a pelvic examination is a routine procedure used to assess the well–being of the female patients' lower genito–urinary tract

15   “Pap Smear.” Speculum examination: a speculum is an instrument that is used during the internal genitalia examination. It can be made of plastic or metal and is used to open up the vaginal cavity in order for the examiner to view the walls of the vagina and the cervix. Rectovaginal examination

16   {Citation} Papanicolaou test: a screening test for precancerous and cancerous cells on the cervix. This simple test is done during a routine pelvic examination and involves scraping cells from the cervix.

Female breast examination
Rectal examination
Male genital examination
Prostatic examination (digital)
Hernia examination

Physiotherapy

17   “Ultrasound therapy—definition of ultrasound therapy in the medical dictionary—by the Free Online Medical Dictionary, Thesaurus, and Encyclopedia.” Ultrasound therapy (UST): the application of ultrasound waves to soft tissue to heat and relax injured tissue and disperse edema

18   “Transcutaneous electrical nerve stimulation—definition of transcutaneous electrical nerve stimulation in the medical dictionary—by the Free Online Medical Dictionary, Thesaurus, and Encyclopedia.” Transcutaneous electrical nerve stimulation (TENS): a technique used for pain relief in which nerves are electronically stimulated to block transmission of pain information to the brain Interferential therapy (IFC): a form of electrostimulation therapy using 2 or 3 distinctly different currents that are passed from a tissue through surface electrodes

19   “Microcurrent—definition of microcurrent in the medical dictionary—by the Free Online Medical Dictionary, Thesaurus, and Encyclopedia.” Microcurrent therapy: an electrotherapeutic modality that uses low levels of electrical current (<1 mAmp) to facilitate circulation and cellular healing or to reduce pain or edema

20   “Magnetic therapy—definition of magnetic therapy in the medical dictionary—by the Free Online Medical Dictionary, Thesaurus, and Encyclopedia.” Magnetic therapy: an alternative medical therapy in which the placement of magnets or magnetic devices on the skin is thought to prevent or treat symptoms of disease, especially pain

Electrical stimulation

21   “Iontophoresis—definition of iontophoresis by the Free Online Dictionary, Thesaurus, and Encyclopedia.”

Iontophoresis (not with prescription medication): therapy that uses a local electric current to introduce the ions of a medicine into the tissues

Russian stimulation: uses medium frequencies to provide electrical stimulation to muscle groups and is used to reduce muscle spasms as well as for muscle strengthening

Nonablative laser therapy: laser therapy without tissue destruction

Short wave therapy: warmth is created in the tissue via electric and magnetic fields.

Hydrocolation: hot, moist pack used to treat bruises, sprains, and muscle spasms

22   “Cryotherapy—definition of cryotherapy by the Free Online Dictionary, Thesaurus and Encyclopedia.” Cryotherapy: medical treatment in which all or part of the body is subjected to cold temperatures, as by means of ice packs

23   “Massage—definition of massage by the Free Online Dictionary, Thesaurus and Encyclopedia.” Massage: the act of kneading, rubbing, and so on, parts of the body to promote circulation, suppleness, or relaxation

24   “Traction—Definition Of Traction In The Medical Dictionary—by the Free Online Medical Dictionary, Thesaurus, and Encyclopedia.”

Traction: the use of a pulling force to treat muscle and skeleton disorders Extremity adjusting: manipulation the extremities of the body including arms, legs, feet, hands

Soft tissue manipulation of the abdominal viscera

25   “Craniopathy—definition of craniopathy in the medical dictionary—by the Free Online Medical Dictionary, Thesaurus, and Encyclopedia.” Craniopathy (cranial adjusting): area of medicine concerned with the bones that encase the brain Vitamin supplementation

Glandular supplementation: thyroid, adrenal, thymus derived from cow or pig glands. Glandular therapy helps provide the exact nutrients that the gland needs to perform adequately.

Diet formulation

Botanical therapy: the use of plants or plant extracts for medicinal purposes (especially plants that are not part of the normal diet)

Homeopathic preparations: a system for treating disease based on the administration of minute doses of a drug that in massive amounts produces symptoms in healthy individuals similar to those of the disease itself

Orthotic supports

Spinal supports

Lifestyle counseling

Rehabilitation: a treatment or treatments designed to facilitate the process of recovery from injury, illness, or disease to as normal a condition as possible.

Nonadjustive treatment of female pelvic conditions

Intrarectal manipulation of the coccyx

Ear irrigation: a routine procedure used to remove excess earwax, called cerumen, or foreign materials from the ear

26   “Colonic irrigation—definition of colonic irrigation by the Free Online Dictionary, Thesaurus, and Encyclopedia.”

Colonic irrigation: a water enema given to flush out the colon

Temporomandibular joint evaluation and/or treatment

Digital manipulation of the Eustacian tube orifice (“Endonasal Technique”)

Nasal Specifics (balloon inflation into nasal passages)

27   “Chelation—definition of chelation by the Free Online Dictionary, Thesaurus, and Encyclopedia.” Oral chelation therapy: the process of removing a heavy metal from the bloodstream by means of a chelate as in treating lead or mercury poisoning—via mouth

28   Ibid.  

Intravenous chelation therapy: the process of removing a heavy metal from the bloodstream by means of a chelate as in treating lead or mercury poisoning administered into a vein Vitamin injection

Limited prescription writing privileges includes prescription writing
of medications pertaining to field of care


Recommendation of nonprescription items (over counter)

29   “Oxygen therapy—definition of oxygen therapy in the medical dictionary—by the Free Online Medical Dictionary, Thesaurus, and Encyclopedia.”

Oxygen therapy: treatment in which an increased concentration of oxygen is made available for breathing, through a nasal catheter, tent, chamber, or mask

Dry needling of trigger points the use of solid filiform needles for therapy of muscle pain, sometimes also known as intramuscular stimulation

30   “Minor surgery—definition of minor surgery in the medical dictionary—by the Free Online Medical Dictionary, Thesaurus, and Encyclopedia.” Minor surgery: surgical procedure for minor problems or injuries that are not considered life–threatening or hazardous

31   “Obstetrics—definition of obstetrics in the medical dictionary—by the Free Online Medical Dictionary, Thesaurus, and Encyclopedia.”

Obstetrics: the branch of medicine that deals with the care of women during pregnancy, childbirth, and the recuperative period after delivery

Extremity casting: sprains

Extremity casting: uncomplicated fractures

32   “Hypnosis—definition of hypnosis in the medical dictionary—by the Free Online Medical Dictionary, Thesaurus, and Encyclopedia.”

Hypnosis: an altered state of consciousness characterized by focusing of attention, suspension of disbelief, increased amenability and responsiveness to suggestions and commands, and the subjective experience of responding involuntarily

33   “Acupuncture—definition of acupuncture in the medical dictionary—by the Free Online Medical Dictionary, Thesaurus, and Encyclopedia.”

Acupuncture (needle puncture): practice in Chinese medicine in which the skin, at various points along meridians, is punctured with needles to remove energetic blockages and stimulate the flow of qi

34   “Electroacupuncture—definition of electroacupuncture in the medical dictionary—by the Free Online Medical Dictionary, Thesaurus, and Encyclopedia.”

Electroacupuncture: the application of electrical stimulation to acupuncture points

35   “Electrolysis—definition of electrolysis in the medical dictionary—by the Free Online Medical Dictionary, Thesaurus, and Encyclopedia.”

Electrolysis: destruction by passage of a galvanic current, as in disintegration of a chemical compound in solution or removal of excessive hair from the body

36   “Hyperbaric chamber—definition of hyperbaric chamber in the medical dictionary—by the Free Online Medical Dictionary, Thesaurus, and Encyclopedia.”

Hyperbaric chamber: an airtight chamber containing an oxygen atmosphere under high pressure. A patient may be placed in the chamber for the treatment of certain infections, tumors, and cardiovascular diseases in which atmospheric oxygen pressures up to 3 times normal may have therapeutic value.

37   “Manipulation under anesthesia—Encyclopedia article about manipulation under anesthesia.” Manipulation under anesthesia (MUA): multidisciplinary manual therapy treatment system which is used to improve articular and soft tissue movement using specifically controlled release, myofascial manipulation, and mobilization techniques while the patient is under moderate to deep intravenous sedation using monitorized anesthesia care (MAC)

Veterinary chiropractic: refers to animal chiropractic care



References:

  1. NBCE 2010 Practice Analysis
    [cited 2013 Aug 27]. Available from:
    http://www.nbce.org/practiceanalysis/

  2. Cassidy, A.
    Nurse practitioners and primary care (updated).
    Health Affairs, ; 2013 Available from:
    http://www.healthaffairs.org/healthpolicybriefs/brief.php?brief_id=92

  3. Institute of Medicine Committee on Quality of Health Care in America.
    Crossing the Quality Chasm:
    A New Health System for the 21st Century

    Washington, DC: National Academies Press; 2001

  4. Final report of the Commission on Medical Education.
    Calif West Med. 1933; 38: 112–113

  5. The National Council of State Boards of Nursing.
    Changes in healthcare professions' scope of practice: legislative considerations.
    cited 2013 Aug 23]. Available from:
    https://www.ncsbn.org/ScopeofPractice_09.pdf

  6. Bourgeault, IL and Grignon, M.
    A comparison of the regulation of health professional boundaries across OECD countries.
    Eur J Comp Econ. 2013; 10: 199–223

  7. Blevins, SA.
    The medical monopoly: protecting consumers or limiting competition.
    Policy Anal. 1995; 246: 1–36
    Available from:
    http://forhealthfreedom.org/Publications/Monopoly/CatoPA246MedMonopoly.pdf

  8. Folland, S, Goodman, AC, and Stano, M.
    The economics of health and health care. 7th ed.
    Pearson, Upper Saddle River, N.J; 2013

  9. Fuchs, VR.
    Who shall live? Health, economics and social choice. 2nd ed.
    World Scientific, Singapore; 2011

  10. Safriet, B.
    Impediments to progress in health care workforce policy: license and practice laws.
    Inquiry. 1993; 31: 310–317

  11. Feldstein, PJ.
    The politics of health legislation: an economic perspective.
    Health Administration Press Perspectives, ; 1988 ([276 p.])

  12. Havighurst, CC.
    The changing locus of decision making in the health care sector.
    J Health Polit Policy Law. 1986; 11: 697–735

  13. National Highway Traffic Safety Administration.
    National EMS Scope of Practice Model.
    National Highway Traffic Safety Administration, ; 2007
    cited 2014 Jan 30. Available from:
    https://www.nremt.org/nremt/downloads/Scope%20of%20Practice.pdf

  14. Gardner, D.
    Expanding scope of practice: inter–professional collaboration or conflict?
    Nurs Econ. 2010; 28: 264–266

  15. Wesorick, BR and Doebbeling, B.
    Lessons from the field: the essential elements for point-of-care transformation.
    Miscellaneous Article
    Med Care. 2011; 49: S49–S58
    Available from:
    http://ovidsp.ovid.com/ovidweb.cgi?T=JS&CSC=Y&NEWS=N&PAGE=fulltext&D=
    yrovftm&AN=00005650-201112001-00010

  16. Duenas, R.
    United States Chiropractic Practice Acts and Institute of Medicine
    defined primary care practice.
    J Chiropr Med. 2002; 1: 155–170

  17. Bellamy, JJ.
    Legislative alchemy: the US state chiropractic practice acts.
    Focus Altern Complement Ther. 2010; 15: 214–222

  18. Ronald Hamowy.
    The early development of medical licensing laws in the United States 1875-1900.
    J Libert Stud. 3(1):17–119.

  19. Ameringer, Carl F.
    The health care revolution: from medical monopoly to market competition—chapter 1:
    the professional regime. The Health Care Revolution:
    From Medical Monopoly to Market Competition.
    University of California Press, ; 2008
    cited 2013 Sep 30]. Available from:
    http://www.ucpress.edu/content/pages/10188/10188.ch01.pdf

  20. Baerlocher, MO and Detsky, AS.
    Professional monopolies in medicine.
    JAMA. 2009; 301: 858–860

  21. Baer, HA.
    Divergence and convergence in two systems of manual medicine:
    osteopathy and chiropractic in the United States.
    Med Anthropol Q. 1987; 1: 176–193

  22. Bodenheimer, TS and Smith, MD.
    Primary care: proposed solutions to the physician shortage
    without training more physicians.
    Health Aff (Millwood). 2013; 32: 1881–1886

  23. Huijbregts, Peter A.
    Chiropractic legal challenges to the physical therapy scope of practice:
    anybody else taking the ethical high ground?.
    J Manipulative Ther. 2007; 15: 69–80

  24. Alabama State Chiropractic Association:
    2010 Scope of Practice Survey.
    cited 2013 Aug 27]. Available from:
    http://www.mccoypress.net/subluxation/docs/ASCAscope.pdf

  25. NYSCA & New York Chiropractic College Conduct Scope of Practice Survey
    [Internet]. The Chronicle of Chiropractic. ([cited 2013 Jul 18]. Available from:
    http://chiropractic.prosepoint.net/64259

  26. World Federation of Chiropractic.
    The legal status of chiropractic practice internationally.
    World Federation of Chiropractic, Toronto ON Canada; 2011 ([Available from:
    http://www.wfc.org/website/index.php?option=com_content&view=article&id=213&Itemid=175&lang=en

  27. Hamill, Jeff, Lange, Chuck, and Schmaltz, Kim.
    A survey of practicing logan college of chiropractic doctors located in the southeastern
    states of Alabama and Florida on the utilization of procedures and treatments per
    the legislated scope of practice in these states.
    ([cited 2013 Aug 27]. Available from:
    http://www.logan.edu/mm/files/LRC/Senior-Research/1997-Aug-44.pdf

  28. Congressional Budget Office and Joint Committee on Taxation.
    Updated Estimates for the Insurance Coverage Provisions of the Affordable Care Act - CBO.
    Congressional Budget Office and the Joint Committee on Taxation, ; 2012 ([Available from:
    http://www.cbo.gov/publication/43076

  29. Congressional Budget Office.
    Effects of the Affordable Care Act on Health Insurance Coverage—
    February 2013 Baseline.
    ([cited 2013 Sep 1]. Available from
    http://cbo.gov/sites/default/files/cbofiles/attachments/
    43900_ACAInsuranceCoverageEffects.pdf

  30. He, W, Sengupta, M, Velkoff, VA, and DeBarros, KA.
    65+ in the United States: 2005.
    U.S. Dept. of Commerce, Economics and Statistics Administration,
    Bureau of the Census, Washington, D.C; 2005

  31. Colwill, JM, Cultice, JM, and Kruse, RL.
    Will generalist physician supply meet demands of an increasing and aging population?
    Health Aff (Millwood). 2008; 27: w232–w241

  32. Bodenheimer, T, Chen, E, and Bennett, HD.
    Confronting the growing burden of chronic disease: can the U.S. health care
    workforce do the job?
    Health Aff (Millwood). 2009; 28: 64–74

  33. Staiger, DO, Auerbach, DI, and Buerhaus, PI.
    Trends in the work hours of physicians in the United States.
    JAMA. 2010; 303: 747–753

  34. Stodd, RT.
    The Weathervane.
    Hawaii J Med Public Health. 2013; 72: 450

  35. French, M, Homer, J, Klevay, S, Goldman, E, Ullmann, S, and Kahn, B.
    Is the United States ready to embrace concierge medicine?
    Popul Health Manag. 2010; 13: 177–182

  36. Barr, P.
    On retainer.
    Mod Healthc. 2011; 41: 28–30

  37. Page, L.
    The rise and further rise of concierge medicine.
    BMJ. 2013; 47 ([f6465-f6465])

  38. Orkin, FK, McGinnis, SL, Forte, GJ et al.
    United States anesthesiologists over 50: retirement decision making
    and workforce implications.
    Anesthesiology. 2012; 117: 953–963

  39. Nusbaum, NJ.
    Commentary: physician retirement and physician shortages.
    J Community Health. 2009; 34: 353–356

  40. Scope of Practice Overview.
    ([cited 2014 Jan 10]. Available from:
    http://www.ncsl.org/research/health/scope-of-practice-overview.aspx

  41. Chadi, N.
    Breaking the scope-of-practice taboo: where multidisciplinary rhymes
    with cost-efficiency.
    MJM. 2011; 13: 44–52

  42. Reagan, PB and Salsberry, PJ.
    The effects of state-level scope-of-practice regulations on the number and growth
    of nurse practitioners.
    Nurs Outlook. ([cited 2013 Aug 23]; Available from:
    http://www.sciencedirect.com/science/article/pii/S0029655413000961

  43. U.S. Department of Health and Human Services:
    Health Resources and Services Administration - Bureau of Health Professions.
    The Physician Workforce: Projections and Research into Current Issues Affecting
    Supply and Demand. U.S. Department of Health and Human Services:
    Health Resources and Services Administration -
    Bureau of Health Professions, ; 2008 ([Available from:
    http://bhpr.hrsa.gov/healthworkforce/reports/physwfissues.pdf

  44. Patient Protection and Affordable Care Act. 42.
    Sect. 18001. ; 2010: 111–148

  45. Scope of Practice Legislation Tracking Database.
    ([cited 2013 Aug 26]. Available from:
    http://www.ncsl.org/issues-research/health/scope-of-practice-legislation-tracking-database.aspx

  46. Lamm, L and Wegner, E.
    Scope of practice: what the law allows.
    AJCM. 1989; 2: 155–159

  47. Lamm, L, Wegner, E, and Collord, D.
    Chiropractic scope of practice: what the law allows—update 1993.
    J Manipulative Physiol Ther. 1995; 18: 16–20

  48. Lamm, L and Pfannenschmidt, K.
    Chiropractic scope of practice: what the law allows—update 1999.
    J Neuromusculoskel Syst. 1999; 7: 102–106

  49. Soklaridis, S, Kelner, M, Love, RL, and Cassidy, JD.
    Integrative health care in a hospital setting: communication patterns
    between CAM and biomedical practitioners.
    J Interprof Care. 2009; 23: 655–667

  50. Gray, B and Orrock, P.
    Investigation into factors influencing roles, relationships, and referrals
    in integrative medicine.
    J Altern Complement Med. 2014; 17 ([140117124141004])

  51. Khorsan, R, Cohen, AB, Lisi, AJ et al.
    Mixed-Methods Research in a Complex Multisite VA Health Services Study:
    variations in the implementation and characteristics of chiropractic services in VA.
    Evid Based Complement Alternat Med. ([cited 2014 Feb 6];2013. Available from:
    http://www.hindawi.com/journals/ecam/2013/701280/abs/

  52. Fairman, JA, Rowe, JW, Hassmiller, S, and Shalala, DE.
    Broadening the scope of nursing practice.
    N Engl J Med. 2011; 364: 193–196

  53. Dower, Catherine, Christian, Sharon, and O'Neil, Edward.
    Promising scope of practice models for the health professions.
    Center for the Health Professions University of California,
    San Francisco; 2007 [cited 2013 Oct 8]. Available from:
    http://futurehealth.ucsf.edu/Content/29/2007-12
    _Promising_Scope_of_Practice_Models_for_the_Health_Professions.pdf

  54. Dill, MJ, Pankow, S, Erikson, C, and Shipman, S.
    Survey shows consumers open to a greater role for physician assistants and
    nurse practitioners.
    Health Aff (Millwood). 2013; 32: 1135–1142

  55. Standards for Doctor of Chiropractic Programs and Requirements for Institutional Status,
    January 2007. The Council on Chiropractic Education, ; 2007
    [cited 2014 Jan 27]. Available from:
    http://www.cce-usa.org/uploads/2007_January_STANDARDS.pdf

  56. Duenas, R, Carucci, GM, Funk, MF, and Gurney, MW.
    Chiropractic–primary Care, Neuromusculoskeletal Care, or Musculoskeletal Care?
    Results of a Survey of Chiropractic College Presidents, Chiropractic Organization
    Leaders, and Connecticut-licensed Doctors of Chiropractic

    J Manipulative Physiol Ther 2003 (Oct); 26 (8): 510–526

  57. Poghosyan, L, Nannini, A, Stone, PW, and Smaldone, A.
    Nurse practitioner organizational climate in primary care settings:
    implications for professional practice.
    J Prof Nurs. 2013; 29: 338–349

  58. Poghosyan, L, Nannini, A, Smaldone, A et al.
    Revisiting scope of practice facilitators and barriers for primary care nurse practitioners:
    a qualitative investigation.
    Policy Polit Nurs Pract. 2013; 14: 6–15 [cited 2013 Aug 23]; Available from:
    http://ppn.sagepub.com.proxy.cc.uic.edu/content/early/2013/03/21/1527154413480889

  59. Gaumer, GL.
    Regulating health professionals: a review of the empirical literature.
    Milbank Mem Fund Q Health Soc. 1984; 62: 380–416

  60. Cooper, RA.
    Health care workforce for the twenty-first century: the impact of nonphysician clinicians.
    Annu Rev Med. 2001; 52: 51–61

  61. American Medical Association.
    Digest of Official Actions. 1969-1978, Reimbursement in Federal Programs [Internet]. ;
    1980: 248 ([Available from:
    http://ama.nmtvault.com/jsp/viewer.jsp?doc_id=Digest of Official Actions%2
    Fama_arch%2FAD100001%2F00000003

  62. Smith, SD and Beran, TN.
    Practice analysis of chiropractic radiology: identifying items for part I of the
    clinical competency examination.
    J Manipulative Physiol Ther. 2012; 35: 710–719



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