Coming soon, to a chiropractor's office near you?

Coming soon, to a chiropractor’s office near you?

Chiropractors are once again engaged in intra-fraternal warfare over the chiropractic scope of practice, a saga we’ve chronicled before on SBM. (See the references at end of this post.) Every time it looks like the warring factions have buried their differences, they come rising to the surface like zombies.

The International Chiropractors Association (ICA), representing the “straight” faction, wants chiropractic to continue as a drugless profession. They are happy to detect and correct subluxations, thereby removing “nerve interference” and “allowing the body to heal itself” in the tradition of Daniel David Palmer. But the American Chiropractic Association (ACA) has bigger fish to fry.

This time, the ICA is upset that the ACA House of Delegates up and decided to establish a “College of Pharmacology and Toxicology,” which would operate under the auspices of the ACA Council on Diagnosis and Internal Disorders. The ACA’s announcement of the “College” is rather vague on details:

The purpose of the College is to further educate the chiropractic profession on clinical matters related to the widespread use of both prescription and over-the-counter medications and nutritional supplements.

I e-mailed the ACA several days ago asking for more information but have yet to receive a reply.

The ICA sees this move as yet another attempt by:

forces at work within some organizations actively promoting incorporating drugs into the chiropractic scope of practice.

The ICA thought it had worked all of this out in 2013, at “The Chiropractic Summit,” when the warring parties met in Seattle to hammer out a deal settling their differences over the CCE and it’s troubles with the Department of Education. A treaty from those efforts declares:

The drug issue is a non-issue because no chiropractic organization in the Summit promotes the inclusion of prescription drug rights and all chiropractic organizations in the Summit support the drug-free approach to health care.

(We should note here that the Summit didn’t include all the warring parties. There was another faction – improbably named the DaVinci Group – made of other, non-Summit straights, such as the International Pediatric Chiropractors Association, who didn’t participate.)

So, as things stand now, the ICA and the ACA are officially at odds, once again, over drugs.

Chiropractic “internists”

Let’s spend a few minutes on this Council on Diagnosis and Internal Disorders, under whose jurisdiction the College will operate, because it gives us some indication of the, um, quality of education chiropractors can expect regarding said “clinical matters.” If educating chiropractors about these “clinical matters” follows the modus operandi of the CDID, I suspect what we’ll see are weekend hotel conference room courses leading to some sort of ersatz certification in prescribing drugs.

The CDID is one of the ACA’s “specialty councils” and is “certified” by the American Board of Chiropractic Internists. (Yep, that’s right, chiropractic “internists.”) Its mission statement is:

To maintain and promote the chiropractic profession as primary health care providers, support the advancement of chiropractic, influence full scope practice within the profession and in current and future health reform legislation.

So I think you can see where things are going with the new “College.”

Their particular brand of “primary health care” looks a lot like naturopathy, but with even less education and training. According to their website, their practices include blood laboratory studies, electrocardiograms, spirometry, salivary assay hormonal and neurotransmitter tests, IgG food allergy testing, stool analyses “and many other diagnostic tools.” Treatments include dietary supplements, homeopathic remedies, botanical medicine, natural hormone replacement and “pharmacologic counseling.”

To earn this coveted status, one must take a 300 hour “post doctorate course,” pass an exam and have 12 hours of continuing education per year. One becomes a “Diplomate” with this effort and earns a “post-graduate degree.” (I don’t know how one earns a “degree” unless it’s from an educational institution, but perhaps my definition of “degree” is too narrow.) There is also the 100-hour “Chiropractic Family Practice Functional Medicine” course sponsored by the CDID and the National University of Health Sciences. (As you will see below, chiropractors have really warmed up to the idea of functional medicine.)

I’ve written about the CDID before, and its weekend hotel conference room courses, most (all?) of which seem devoid of any clinical training. (Who knew you could learn everything about primary care pediatrics or dermatology in a single weekend?) This is cargo-cult specialization – all the trappings and titles of an American Board of Medical Specialties certification, with none of the education or training.

As if the ACA’s announcement weren’t enough for the ICA, the Wisconsin Chiropractic Association (WCA) recently put forth yet another iteration of the chiropractor in a White Paper with the unwieldy title: “Filling the Shortage of Primary Care Health Care Providers in Wisconsin: The Primary Spine Care Physician, a new class of health care provider.” In a nutshell, the proposal sounds a lot like the “Chiropractic as Spine Care” model we’ve discussed before on SBM except with prescription privileges.

The WCA proposes a “M.S. Degree in Advanced Clinical Practice: Board-certifed Primary Spine Care Physician,” (they seem to like long titles), with a 500 hour clinical training component including “neuro/orthopedic spine surgery, pain management, orthopedic and neurology practices.” It doesn’t say what institution would offer these degrees, but I think you can guess after reading the next few paragraphs. It isn’t clear where these clinical rotations would take place either. There would be a Board exam after that, but they don’t say under whose auspices this Board would operate.

The ICA was incensed that the WCA would suggest chiropractors weren’t already Primary Spine Care Physicians. And further incensed that anyone would suggest that drugs are necessary to provide competent spine care. This led to dueling letters from different chiropractic colleges published in the ICA’s Chiropractic Choice.

On the anti-drug side were Palmer Chiropractic College and the ultra-straight Life Chiropractic College. On the pro-drug side were the National University of Health Sciences (NUHS) and University of Western States. NUHS has been at the forefront of gunning for chiropractic prescription privileges and a broad scope of practice. A few years back, it announced establishment of a “Masters of Science degree” in “Advance Clinical Practice,” to prepare chiropractors for prescription privileges, but apparently that didn’t pan out, at least that I can find on its website. There was no entrance exam, the only requirements being a 2.5 GPA and graduation from a “first professional degree” program.

NUHS, which also grants naturopathy and acupuncture degrees, published a study a couple of years ago claiming it was nearing its goal of training chiropractic students as primary care practitioners, a study totally demolished by Harriet Hall. The NUHS was also co-author of an earlier ACA attempt to promote DCs as PCPs with a different white paper. Dr. Hall demolished that one too. The NUHS’s recently-retired president, James Winterstein, is a longtime cheerleader for a broad scope of practice.

Western States, although it is located in Portland, OR, had three representatives (of eight) on the “Authors/Contributors” attribution page of the WCA White Paper. While it doesn’t offer naturopathy or acupuncture degrees, it did recently sign an agreement that will lead to “further collaboration” with the Institute for Functional Medicine, the Jeffrey Bland initiative, on whose Board Dr. Mark Hyman sits. I had to chuckle when I read that Western States would include integration of what it called “IFM’s novel patient assessment criteria.” “Novel” hardly begins to describe it. (Of course, the Cleveland Clinic also recently expanded its descent into integrative medicine with the Institute.) I note with interest, therefore, that one area of training for the Primary Spine Care Physician model is “Nutrition for Musculoskeletal Health.”

Let me make a suggestion to the Wisconsin Chiropractic Association: dump the subluxation and all the quack diagnoses treatments chiropractors are famous for, concentrate on establishing yourselves as evidence-based profession specializing in back problems, and then maybe come back and ask for limited prescription privileges. Until then, no one should trust this proposed scheme.

Another strategy

Adding insult to the ICA’s injury was this year’s perennial attempt by New Mexico chiropractors to expand their prescription privileges. (NM is the only state with the dubious honor of having so-called “advanced practice chiropractors” as well as garden variety chiropractors.) With the help of their ever-reliable friend in the NM Legislature, Sen. Cisco McSorley, the pro-drug faction hatched quite an elaborate statutory scheme. Of course, this too is but part of a larger effort to rebrand chiropractors as “primary care physicians.” Sen. McSorley’s bill took care of that aspect as well, but let’s deal with the drugs first.

The state’s existing “advanced practice” chiropractors would be divided into two tiers, “Level One” and “Level Two.” Both could prescribe any drugs approved by the chiropractic board. Level Ones currently have 90 additional hours of training after chiropractic school, and they would be grandfathered in, but requirements are changed to a “postgraduate degree in a clinical specialty” from a chiropractic school, with no minimum standards for such a course set.

According to the NM Chiropractic Association “advance practice” chiropractors can already perform:

IM injections (B12, homeopathic, magnesium, trigger point, etc.), neural therapy injections Intravenous procedures (meyer’s cocktails, H2O2, chelation, ascorbates, amino acids, minerals, etc.)

Under the bill, if the chiropractic board, in consultation with (but not necessarily the approval of) the pharmacy board, gives its ok, other drugs could be added. The medical board wasn’t given a say. Level Twos would require, in addition, 650 hours in a supervised “clinical rotation,” which could take place at a chiropractic college. Level Twos could prescribe, inject and dispense all dangerous drugs (as defined in by state law) except Schedule I and II controlled substances, that are used in standard primary care practice.

Bill amendments would have required that instruction for Level Two be okayed by the medical board and the existence of a collaboration agreement with a physician or certified nurse practitioner for first five years of practice for Level Two chiropractors who want to prescribe dangerous drugs, including chart reviews.

Fortunately the ICA descended on the legislature to oppose the bill and reports that it was defeated, although I’ve not been able to confirm that on the NM legislature’s website.

Arizona chiropractors made a more modest attempt to gain prescription privileges, limited to prescription-strength doses of ibuprofen, naproxen, methocarbomol and cyclobenzaphrine. They would need 75 hours of instruction and 300 hours of practical experience under the supervision of an M.D. or D.O. The bill is marked as “held” on the Arizona legislature website.

A second provision of the NM bill supporting efforts to rebrand DCs as PCPs is a bit sneakier in its language. And it is similar to language we are seeing pop up in bills in other states. This year, chiropractors in NM and Hawaii wanted a scope of practice including all diagnoses and treatments for which they have been “educated and trained.”

Hawaii’s bill, which also had a provision allowing chiropractors to call themselves “physicians,” was limited to education and training provided in an accredited chiropractic school. (Mississippi already defines chiropractic scope of practice this way.) What’s wrong with this? It defaults to the Council on Chiropractic Education to determine what the scope of chiropractic practice should be, because the CCE decides what chiropractic schools must teach their students. Fortunately, the bill failed a deadline for further consideration.

And what does the CCE itself say about this? In an apparent effort to please its various constituencies, the CCE’s accreditation standards state that:

An accredited DCP prepares its graduates to practice as primary care chiropractic physicians, and provides curricular and clinical evidence of such through outcome measures. CCE applies the understanding that in order to competently practice as a primary care chiropractic physician, DCP education trains its graduates to:

Practice primary health care as a portal-of-entry provider for patients of all ages and genders focusing on the inherent ability of the body to heal and enhance function without unnecessary drugs or surgery.

So if chiropractic students are trained as “chiropractic primary care physicians” who focuses on vitalism?

NM’s bill (it changed chiropractic to chiropractic “medicine”), on the other hand, did not contain the same limitation – the education and training presumably could come from other sources. And who would decide if a certain level of education and training had been achieved? The chiropractor?

Which brings us to another intriguing resolution just passed by the ACA, touting:

The identification of six key elements that should be considered or included in a modern chiropractic practice act. Variability of state chiropractic regulations has created uncertainty and confusion for the general public, chiropractic patients and chiropractic physicians, impeding development and progress of the profession.

It would be most interesting to find out exactly what these “key elements” are but my guess is that language along the lines of the failed NM and Hawaii bills will be included. Again, the ACA did not respond to my request for more information.

Finally, a third ACA resolution continued the “DC as PCP” theme:

The resolution, adopted by the House members, emphasizes the importance of allowing chiropractic physicians to practice and be reimbursed for the fullest extent of their licensure, training and competencies.

According to ACA President Anthony Hamm, DC, “The ACA will develop and implement a comprehensive strategy to ensure that doctors of chiropractic are recognized as being able to provide all existing Medicare services, as allowed under their state scope of practice, to beneficiaries.”

This would involve dumping the limitation on chiropractic coverage to detection and correction of subluxations (Congress having gone along with the fiction that subluxations exist when adding chiropractors as providers). If this scheme works, they would have to be reimbursed for whatever their state practice acts allow them to do, if it is covered by Medicare. No wonder they are so interested in having the CCE or, even better, individual chiropractors, determine their scope of practice.


The DC as PCP? Series (and related posts)

 

 

Posted by Jann Bellamy

Jann J. Bellamy is a Florida attorney and lives in Tallahassee. She is one of the founders and Board members of the Society for Science-Based Medicine (SfSBM) dedicated to providing accurate information about CAM and advocating for state and federal laws that incorporate a science-based standard for all health care practitioners. She tracks state and federal bills that would allow pseudoscience in health care for the SfSBM website.  Her posts are archived here.