In February, 2015, the American Chiropractic Association House of Delegates ratified “Six Key Elements of A Modern Chiropractic Practice Act.” For what it’s worth, this means that the “Six Elements” are part of the official “Public Policy” of the ACA.
1. “Chiropractic Physician” and “Chiropractic Medicine” as the Regulatory Terms of Licensure.
2. Scope of Practice Determined by Doctoral and Post-Doctoral Education, Training and Experience Obtained Through Appropriately Accredited Institutions.
3. Full Management, Referral and Prescription Authority commensurate with contemporary chiropractic education for Patient Examination, Diagnosis, Differential Diagnosis and Health Assessment.
4. Full Management, Referral and Prescription Authority commensurate with contemporary chiropractic education for the Care and Treatment of Neuromusculoskeletal and Other Health Conditions or Issues.
5. Full Authority for the Delivery of Information, Advice, Recommendations and Counseling Regarding General Health Matters, Wellness and Health Optimization.
6. Full Authority and Adaptable Requirements for the Management and Training of Health Care Teams and the Participation in Collaborative or Integrative Health Care Groups.
At the same time, the ACA announced the creation of a “College of Pharmacology and Toxicology of the American Chiropractic Association.”
The Six Elements are backed by a Resolution that is chock full of self-serving and evidence-free assertions such as:
Chiropractic patients and the general public are best served when the Chiropractic scope of practice is dynamic and determined by doctoral and post-doctoral education, training and experience so that a Chiropractic Physician can provide safe, best practice patient care and avoid unnecessary duplication of services.
Chiropractic patients and the general public are best served when a Chiropractic Physician can fully manage the process of examination, diagnosis and health assessment including referral to other physicians and specialists for consultation and the prescription of specific tests or procedures such as diagnostic imaging, laboratory tests, home testing equipment for blood pressure or glucose monitoring, etc.
I think we can all question who is actually being “best served” by this proposal for practice expansion.
Although not specifically couched in these terms, this is part and parcel of their scheme to rebrand chiropractors as primary care physicians, a subject we’ve covered on SBM many times before. (See the series “ DC as PCP“.) What the ACA implicitly recognizes with this latest effort is the need to amend the state chiropractic practice acts to conform to their PR campaign promoting DCs as PCPs.
Even though the proponent of science-based medicine might not otherwise agree with them on anything else, the “straight” chiropractors have proven to be a valuable resource and important counter-balance to the promotion of chiropractors as primary care physicians, including bids for prescription privileges.
The “Foundation for Vertebral Subluxation Research” informs us that the reason for the Six Elements is the ACA’s frustration with the Federation of Chiropractic Licensing Boards (FCLB), which has been working on a Model Practice Act (MPA) for chiropractors since 1993. FCLB recently finalized its MPA and says it’s undergoing legal review but it has not been otherwise released for review or comment. Maybe it is frustration, or maybe it’s a preemptive strike.
I do have to agree with the ACA that the current state chiropractic practice acts are inconsistent and permit chiropractors to offer a startling range of diagnostic services and treatments, from delivery of babies to treatment of back pain. What is entirely unclear is what the scope of practice should be. After all, the only thing chiropractors offer with any proven benefit is spinal manipulation for acute low back pain, a service that other professions offer without the heaping helping of quackery thrown in.
Dynamic Chiropractic interviewed two ACA Delegates who were present at the creation of the Six Elements and the College of Pharmacology and Toxicology. They had very different takes on the subject. So different, in fact, that one delegate announced his resignation over the controversy in the interview.
The interviewer asked both whether numbers 1 – 4 of the Six Elements didn’t suggest that chiropractors should have the authority to prescribe drugs. The newly re-elected president of the ACA was of the view that it did not because no chiropractic organization promoted the inclusion of prescription drug rights, as set forth by a group called “The Summit.”
But the straight faction has a way with words when cutting through the rhetoric of those who promote a broad scope of chiropractic practice. Here’s what the delegate from Kansas, the one who declared he was resigning from the ACA House of Delegates, had to say on the matter:
There is a saying in the Midwest: “If it looks like a pig, acts like a pig and smells like a pig … it probably is a pig … and no matter how much lipstick you put on it … it is still a pig.” In my opinion, it would be hard to draw any other conclusion than to suggest that these elements are there explicitly for the purpose of furthering the agenda towards acquiring prescription authority.
I’m with the Kansas delegate on this one. It’s extremely hard to reconcile the statement that chiropractic practice acts should include “Full . . . Prescription Authority commensurate with contemporary chiropractic education for the Care and Treatment of Neuromusculoskeletal and Other Health Conditions or Issues” with the statement that they are opposed to prescription rights, especially considering the fact that the ACA is also creating a new specialty called chiropractic pharmacology and toxicology. It looks a lot like lipstick on a pig to me too.
The interviewer also asked this revealing question:
The “Rational” for this Resolution #12 (that creates the College) states, “And the ACA Wellness Model Policy under Health Information Resource (Primary Prevention) whereby typical health promotion activities performed by a DC serving as a health information resource includes Drug Alerts, Immunization, and Drugs Used in Pain Relief;” Do you believe doctors of chiropractic should be equipped to be an “information resource” in “Drug Alerts, Immunization and Drugs Used in Pain Relief?”
To which the ACA delegate supporting these measures cryptically replied:
The ACA supports education of our profession in all matters related to public health.
Other than advice regarding OTC pain medications that may be recommended within their scope of practice, any advice regarding pain medications would necessarily intrude on the practice of physicians, PAs and Nurse Practitioners who recommended or prescribed pain meds. Chiropractors have no business going there, ACA “College” or no ACA “College.” And we certainly don’t want them giving immunization advice, considering their well-documented anti-vaccine ideology.
Apart from prescription authority and related issues, the most troublesome aspect of the Six Elements is the underlying premise that chiropractic educational institutions should be the sole arbiter of chiropractic scope of practice, as expressed in Elements 2, 3 and 4. Combined with all-inclusive phrases like “full management,” “patient examination, diagnosis, differential diagnosis and health assessment” and “care and treatment of neuromusculoskeletal and other health conditions or issues” we are left with the distinct impression that the Council on Chiropractic Education and the chiropractic colleges could cooperate to include just about any diagnostic method or treatment in the chiropractic college curricula and thereby, ipso facto, include them in the state chiropractic practice acts.
Given the fact that chiropractic education and practice is not bound by the strictures of science or the scientific method, this would mean virtually unlimited authority to dump any quackery they wished into the legal scope of practice. This is, in fact, what naturopaths have done, by the use of vague language in their practice acts. For example, Maryland’s new licensing act permits:
patient education and naturopathic therapies and therapeutic substances recognized by the Council on Naturopathic Medical Education.
Idaho’s defeated licensing bill included similar language.
Perhaps taking a page from the naturopathic playbook, bills introduced in New Mexico and Hawaii in both this and the last legislative session would have allowed a scope of practice that depended on whether a particular practice was taught in chiropractic school. Fortunately, none of these measures passed.
To fully understand the import of the Six Elements, one must realize how divorced chiropractic education and training is from the mainstream American educational system and the education and training of physicians and other health care professionals. Chiropractors are taught in small colleges that have no affiliation with the rest of the American post-high school educational system. These colleges have no entrance exam and are staffed mainly by faculty who are also chiropractors. Unlike physicians, they don’t do residencies after graduation. And unlike physicians, nurses, PAs and other allied health professionals, they do not engage in interprofessional training. Most of their clinical work is done in small chiropractic school clinics. This education pales in comparison to that of family practitioners.
These schools are accredited by a private organization run by chiropractors, the Council on Chiropractic Education. The Department of Education grants accreditation authority to the CCE, but that depends solely on its having met certain criteria related largely to administrative matters It has absolutely nothing to do with whether their education is sufficient to meet the requirements of a particular scope of practice. Chiropractors must pass an exam created solely by chiropractors to practice, an exam that, to my knowledge, no one outside of chiropractic has ever seen. Their practices are regulated by state chiropractic boards, which are also controlled by chiropractors.
In sum, chiropractic is a closed loop system, created by, and for the benefit of, chiropractors. Thus, to suggest, as the ACA does, that chiropractors can suddenly emerge, fully equipped to practice primary care and become an integral part of the mainstream American healthcare system by managing health care teams is ludicrous. (This “team” reference is an obvious allusion to the Affordable Care Act and the ACA’s ham-fisted attempt to fit chiropractic square pegs into the round holes of the ACA’s provisions for patient-centered medical homes.)
Fortunately, it does not appear that anyone other than the ACA thinks the “Six Key Elements” should be included in “A Modern Chiropractic Practice Act.” That does not mean we shouldn’t be vigilant in watching for these “Elements” to show up in proposals to amend the state chiropractic acts. They have already. No one other than chiropractors accepts the premises behind the chiropractic subluxation. And yet that concept made it into all 50 state chiropractic practice acts. It may be lipstick on a pig, but some legislators seem attracted to ruby-lipped sows.