This is a synopsis of a recent article by Craig F. Nelson DC in The Journal of Manipulative and Physiological Therapeutics (JMPT) 1993; 16:488-97 which addresses the question of whether or not chiropractors are primary care physicians.

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Based on the definition of primary care developed by the National Academy of Sciences which identifies a number of conditions that must be met to qualify as a PC physician, he states that one of the conditions, comprehensiveness of services, cannot be met by chiropractors. Explicitly mentioned is the management of infectious diseases, providing immunizations and managing minor trauma (lacerations).

Who goes to see chiropractors and what do chiropractors do in their offices? Nelson's commentary points to several studies. From 1977- 1989 (no survey in 1978), the American Chiropractic Association conducted an annual survey ( Journal of the American Chiropractic Association 1990; Feb: 80-1) that asked its members what percentage of their practices involved the treatment of neuromusculoskeletal (NMS) disorders. The percentage has increased steadily since 1977 and seems to have leveled off at about 87%. Another survey (Phillips R. Survey of chiropractic in Dade County, Florida JMPT 1982; 5:83-9) asked patients to fill out a form on which they recorded their primary complaint.

Response from Phillips
Pain (head and neck, thoracic, low back-pelvis, peripheral) 90.4%
Restricted motion (neck, thoracic, lumbar pelvic, extremities) 2.9%
Neurological (paresthesia, hyperactivity, paralysis, numbness)1.3%
Organic (cardiovascular, GU, GI, endocrine, respiratory) 2.1%
Prevention or maintenance 1.4%
Other 2.3%

The first three categories would fall under the heading of NMS complaints. Collectively they total 94.6% of the patient population. Nelson cites a number of other studies which follow much the same pattern.

For the purposes of his commentary Nelson reviewed the last 4 years (1988-1991), inclusive of the JMPT, and identified all original articles, case studies and reviews of the literature where a particular clinical entity was the primary focus of the paper. One hundred and twenty-nine such papers were identified. Of these, 108 (84%) dealt with NMS problems (back, neck, extremities) while 21 (16%) dealt with all other conditions (dysmenorrhea, colic, asthma).

Nelson concludes, "One could keep piling on redundant statistics from public opinion surveys and insurance company information, all of which show that what chiropractors do and how we are perceived is consistent with that of a NMS specialist. At this point it seems that the best case that can be made for the DC/PC is that while chiropractors currently do not practice as PC providers, they aspire to."

Nelson also points to a comparison of curricula of several chiropractic and medical schools. (Foundation for Chiropractic Education and Research 1991: 23-4). The University of Minnesota Medical School and Northwestern College of Chiropractic were used as exemplars of their respective professions. Both DC's and MD's receive their degrees after four years of training totalling about 4500 hours. The first two years of instruction are roughly equivalent being spent mostly on the basic sciences and on introductory clinical courses. Chiropractors can actually boast of having more instruction in several of the basic sciences (anatomy, physiology, etc.) than their medical counterparts. Additionally, in the first 2 years the chiropractic curriculum includes classes on various adjusting techniques and classes relating to specific orthopedic, spinal and neurological problems. The medical curriculum offers significantly more training in pharmacology.

The last 2 years of medical school are usually spent in a series of clinical externships in fields such as internal medicine, obstetrics, gynecology, pediatrics, psychiatry and other primary care specialties. The last 2 years of a chiropractic education offers a continuation of technique classes, adjustive and otherwise, and a continuation of the NMS-related classes. The balance of the didactic instruction is in the classroom equivalent to those primary care specialties mentioned above. The key word here is classroom. These are essentially lecture classes that may or may not have a lab component. The lab component typically consists of demonstrating and practicing exam procedures, videos of patients or patient simulations. These classes do not usually offer any contact with patients. Nelson says, "How could one argue that a 30 hr. lecture class (no lab) in pediatrics, or a 67.5 hr class (no lab) in infectious disease is in any way the equivalent of spending 6 weeks in a patient care facility in each of these areas." It must also be pointed out that nearly all chiropractors go directly into practice following their 4 years of training, whereas nearly all MD's including family practitioners, internists, etc spend an additional 3-4 years in residency training.

"The MD/PC training is directed at creating a generalist. The content and duration of that training is a reflection of that. Quite sensibly, chiropractic training focuses on those conditions and problems that most commonly present in the DC's office, as well as providing enough generalist background to function competently. You might say that chiropractors major in NMS and minor in PC"

Nelson concludes by saying, "Chiropractic cannot have it all. We cannot claim concurrently to be generalists in the family practitioner mode, and NMS specialists and that we achieved all this in 4 years of professional training. There is no evidence that chiropractors either function as, are trained as, are perceived by the public as, or are recognized by other health professionals as primary care providers."

Submitted by
John Wiens, DC

Oct 94