Ladies, how would you like a chiropractor to deliver your baby? How about perform your annual well-woman exams, such as breast exam, bi-manual pelvic exam, speculum exam, recto-vaginal exam and Pap smear?
Sound out of their league? I thought so too. Way out. But, in some parts of the U.S., the law allows chiropractors to do all of these things and a great deal more. Including “adjusting” your basset hound.
A 2011 survey asked chiropractic regulatory officials whether their jurisdictions (all states, plus D.C., Virgin Islands and Puerto Rico, but I’ll refer to them collectively as the “states”) allowed 97 different diagnostic, evaluation, and management procedures. The results were recently reported and interpreted in the Journal of Manipulative and Physiological Therapeutics, in an article authored by Mabel Chang, DC, MPH, who was primarily responsible for the survey. Missouri allows the most procedures (92) and Texas, the fewest (30). A handful of states did not respond or did not respond to all questions, but the overall response rate was 96%. Results from a survey of Canada, Australia and New Zealand will be reported in a separate article.
One wonders whether there was some stagecraft at work in deciding which procedures to include. Although the survey was willing to ask about homeopathic products and colonic irrigation, other quackery is nowhere to be seen. For example, diagnostic techniques such as applied kinesiology, contact reflex analysis and various EAV devices are not mentioned. And although “subluxations” were mentioned, the fact that their detection and correction is the centerpiece of all chiropractic state practice acts was not. For example: “In Michigan, procedures . . . are permitted if they relate to the subluxation complex.” (This would include “glandular supplementation” in that state, according to the survey.)
So, how many states allow chiropractors to perform much, perhaps all, of your well-woman exam or deliver your baby? (We’ll get to the rest of surveyed procedures in a minute.) Here are the results:
- Obstetrics: 9 states (2 require additional training); can order an obstetrical exam in 2 states. Chiropractors can sign birth certificates in 10 states.
- Breast exam: 29 states (2 with additional training); can order in 3. Mammography was not included in the survey, but thermography, which is used (but shouldn’t be) for diagnostic breast imaging, can be performed by chiropractors in 32 states (6 with additional training) and can be ordered in 9.
- Bi-manual pelvic exam: 24 states (1 with additional training); can order in 5.
- Speculum exam: 24 states (2 with additional training); can order in 6.
- Recto-vaginal exam: 23 states (2 with additional training); can order in 5.
- Pap smear: 17 states; can order in 10.
I mention these procedures not to be titillating, but because they are extremely invasive and can be embarrassing and painful for women. They should never be performed by anyone without proper medical training. Yet chiropractic schools offer, at most, only the most cursory classroom instruction in these subjects. I would hazard a guess that chiropractic in-school clinics, where the vast majority of their clinical training takes place, do not include any OB/GYN training. Chiropractic post-graduate training generally consists of weekend lectures in hotel conference room settings. They do not do residencies before going into practice.
Regulators in a few states themselves seem to question the inclusion of these services in chiropractic scope of practice. Some recommended referral to “a more appropriate professional.” Others said “documentation of appropriate setting and clinical rationale” is recommended, adding that a chiropractor could be subject to investigation and sanctions without same. Which makes me wonder: why don’t these regulators ask their legislatures to remove these procedures from chiropractic scope of practice by statute?
The survey provides a list of all 97 procedures and tells us, state by state, whether a chiropractor can perform it, can perform with additional training/certification, can order it, or cannot order/perform. The survey also calculates what percentage of the states consider each procedure within the scope of practice, whether it be performing (with additional training or not) or ordering. The article divides these procedures into 3 groups, presented in three tables:
- Diagnostic and examination certifications
- Physical examination, gender-specific services, physiotherapeutics, and specialty training techniques
- Adjunctive and specialty service
While overall this information is valuable, how the author groups them is not. As is true of chiropractic scope of practice, these groupings don’t necessarily make any logical sense, and most certainly do not conform to any medical taxonomy. I’ve discarded in them in my analysis, because how a chiropractor would group them doesn’t matter. What matters is whether they should or should not be included in their scope of practice. I include the percentage of states allowing chiropractors to perform or order procedure, in parentheses. Here is my determination. Your results may vary.
Appropriate for chiropractic scope of practice, if limited to musculoskeletal conditions and evidence-based:
Impairment ratings (100), extremity exam (100), orthopedic exam (100), neurological exam (100), hydrocolation (hot packs, etc.) (100), cryotherapy (cold packs, etc.) (100), massage (98), traction (100), orthotic supports (100), spinal supports (100), lifestyle counseling (100), rehabilitation (98), recommendation of OTC (63)
May be appropriate to order, with adequate clinical rationale, but not perform:
Full spine X-rays (100), skull x-rays (98), soft tissue X-rays (98), tomography (85, most order only), CT scan (100, most order only), MRI (100, most order only), diagnostic ultrasound (95, most order only), surface scanning EMG (100), needle EMG/NCV (93, many order only)
Appropriate with limitations to insure against overuse or use in inappropriate circumstances:
TENS (100), electrical stimulation (100), shortwave therapy (95), vitamin supplementation (100), diet formulation (100), botanical therapy (100), intrarectal manipulation of coccyx (83)
Not appropriate for chiropractic practice:
Barium studies (74), cholecystography (X-ray visualization of gallbladder after administration of radiopaque substance) (80), thermography (95), electrocardiography (88), venipuncture (98), blood analysis (100), urinalysis (98), sputum analysis (95), fecal analysis (95), semen analysis (84), throat swab (92), skin scrape (92), school physicals (86), US DOT physicals (98), pre-employment physicals (95), pre-marital physicals (77), sign birth certificates (38), sign death certificates (50), EENT exam (90), abdominal exam (95), stethoscopic exam (98), sphygmomanometry (blood pressure) (95), bi-manual pelvic exam (73), speculum exam (72), recto-vaginal exam (72), Pap smears (79), female breast exam (80), rectal exam (85), male genital exam (85), prostatic exam (digital) (85), hernia exam (85), ultrasound (treatment) (100), IFC (interferential therapy) (100), microcurrent therapy (100), iontophoresis (not with prescription medication) (100), Russian stimulation (100), non-ablative laser therapy, nonadjustive treatment of female pelvic conditions (72), ear irrigation (83), TMJ (100), oral chelation therapy (76), IV chelation therapy (39), vitamin injection (43), limited prescription privileges (7), oxygen therapy (57), dry needling of trigger points (64), minor surgery (9), obstetrics (22), extremity casting sprains (71), extremity casting uncomplicated fractures (58), hypnosis (66), electrolysis (44), hyperbaric chamber (62), manipulation under anesthesia (71)
Hair analysis (93), magnetic therapy (90), extremity adjusting (assuming “adjusting” is related to “subluxations”) (98), soft tissue manipulation of the abdominal viscera (95), craniopathy (98), glandular supplementation (desiccated animal glands) (98), homeopathic preparations (95), colonic irrigation (74), endonasal technique (84), nasal specifics (75), needle acupuncture (70), electro-acupuncture (75), veterinary chiropractic (63)
What should the scope of practice be?
If you are startled, as I was, by the breadth of the procedures allowed, keep in mind that the opinion of chiropractic regulators is not the last word. Many of the procedures surveyed are not explicitly included in the state chiropractic practice acts. Some are permitted by regulations, which are usually enacted by the chiropractic boards. Others are included in policy memos or other informal guidance issued by the boards. Yet others are not specifically mentioned at all in state statutes, regulations or policies. When asked, some regulators included them because they were not explicitly prohibited yet thought to be consistent with the statutory scope of practice.
State statutes are the ultimate authority on what chiropractors can and can’t do and all regulations and policy statements are subject to challenge on the ground that they are outside the authority granted by the legislature. This occurred recently in the Texas Medical Board’s court challenge to the Texas Chiropractic Board’s rule allowing chiropractors to perform vestibular-ocular-nystagmus testing, manipulation under anesthesia, and needle electromyography. The Medical Board won. Nor does the fact that a chiropractic board says a procedure is within chiropractic scope of practice prevent a chiropractor from prosecution by the authorities or another board which feels the practice poaches on their territory, a scenario that played itself out when two chiropractors practiced “functional endocrinology.”
The author, to her credit, cautions that interpretations are subject to the ever-changing regulatory authority members (such as chiropractic boards). She also cautions that where a statute does not address a particular procedure, “upon challenge there may be a possibility of sanctions depending on interpretation.” There also were several comments by regulators that, even though “DCs are qualified in the procedures, the procedures must be related to a spinal condition as stated in the statutes.” For the life of me, I can’t see how many of these could possibly be “related to a spinal condition” unless one takes the extreme view of the straight chiropractors that everything is related to the spine.
In an understatement one can only agree with, the author concludes that “chiropractic practice in the United States can vary widely between jurisdictions.” She also advises “studies to assess whether quality or safety of health care is jeopardized in states with broader scopes.” I agree, although the time to research the possible implications for safety would be before enacting statutory practice expansion or liberal interpretation of scope of practice, which never seems to occur to state legislators or chiropractic regulatory authorities. I would add that research into whether the proposed practice is quackery, unsupported by evidence of effectiveness, or is the subject of adequate education and training in chiropractic schools is also appropriate, another area of inquiry which seems to regularly escape the notice of legislators and regulators.
Unfortunately, citing the presumed physician shortage, the author makes an argument for greater use of chiropractors:
to accommodate the demands for health care, especially in states that are already experiencing health care workforce shortages. Using all health care providers to the fullest extent of their training is one solution that will provide timely relief to these problems.
This comment appears to be based on the same deeply flawed premise as Section 2706 of the Affordable Care Act: state practice acts are based on a reasoned determination that adequate education and training underlies scope of practice. In fact, the author seems to believe that the practice acts underrepresent what chiropractors are actually educated and trained to do.
Education and training of limited scope health care providers is broader than what state practice laws allow. For instance, as part of The Council of Chiropractic Education [CCE] 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.
Some states have bought into the idea that the CCE should have the final word in what the legal scope of chiropractic practice should be. As the article notes:
Kentucky and Montana affirm that DCs may perform procedures as long as they were taught them at an accredited chiropractic school.
Chiropractic scope of practice should never be conflated with adequacy of education and training. Nor should the CCE be allowed to determine scope of practice. But as long as warring chiropractic factions, overreaching chiropractic regulators, and credulous legislators are allowed to form a three-ring circus whose main event is deciding what chiropractors should and should not be allowed to do, we’ll likely be stuck with the current system.