Chiropractors are trying to rebrand themselves as primary care physicians, a topic both Harriet Hall and I have addressed (here and here) on SBM. Toward this end, they are seeking the expansion of their scope of practice, via the magic of legislative alchemy, to include the prescription and administration of drugs. Not drugs that any self-respecting M.D. would use, but drugs nonetheless. That effort succeeded to an extent in New Mexico. Recently Colorado got into the act. Other states have followed suit.
Chiropractors have claimed from the very beginning they are primary care physicians. Chiropractic was born in 1895 with the notion that virtually all diseases could be resolved with chiropractic treatment. This was Daniel David Palmer’s original contention, that the interruption of “nerve flow” by “subluxations” caused disease which could be remedied by spinal adjustment to restore the flow, thereby allowing the body to heal itself.
State chiropractic practice acts have always given chiropractors a broad scope of practice which allows them to diagnose and treat virtually any condition as long as they can squeeze the treatment into the “chiropractic paradigm.” If they can pretend the condition is amenable to chiropractic treatment via the detection and correction of subluxations, they can diagnose and treat it legally. This is how they are able to claim, falsely, that asthma, allergies, colic, and many other health problems can be resolved by chiropractic care. This is how “straight” chiropractors still practice.
Over time, to the chagrin of the “straights,” “mixer” chiropractors sought to expand their treatment options. They’ve succeeded in all 50 states to some extent. This liberalization of their practice acts includes the right to use acupuncture and to give nutritional advice, including the sale of dietary supplements and homeopathic products. Now some of the mixers want to dump the subluxation altogether and become, by legislative fiat, real primary care doctors who use the same diagnostic methods and treatments as primary care M.D.s and D.O.s, while at the same time skipping the education and training the latter must go through.
Colorado chiropractors attempt an end run . . .
One of the main obstacles in their way is the lack of authority to prescribe drugs. Colorado chiropractors recently attempted an end run around the time-consuming and expensive process of lobbying the state legislature and getting their practice act amended to include prescription privileges. Perhaps they were aware of certain snafus (which we’ll get to soon) bedeviling New Mexico chiropractors in their quest for practice expansion. The Colorado Board of Chiropractic Examiners’ solution was to bypass the legislature altogether by simply passing a rule giving chiropractors the authority to administer and prescribe certain drugs. Never mind the fact that this was totally beyond the authority the Colorado Legislature gave the Board.
Here’s what the Colorado chiropractic practice act says, in part, chiropractors can do, in Section 12-33-102(1.7), Colorado Statutes (emphasis added):
“Chiropractic” means that branch of the healing arts that is based on the premise that disease is attributable to the abnormal functioning of the human nervous system. It includes the diagnosing and analyzing of human ailments and seeks the elimination of the abnormal functioning of the human nervous system by the adjustment or manipulation, by hand or instrument, of the articulations and adjacent tissue of the human body, particularly the spinal column, and the use as indicated of procedures that facilitate the adjustment or manipulation . . .
Up to this point, we are in familiar straight chiropractic territory. The statute goes on, reflecting the more recent addition of “nutritional measures:”
. . . and the use of sanitary, hygienic, nutritional, and physical remedial measures for the promotion, maintenance, and restoration of health, the prevention of disease, and the treatment of human ailments . . .
Colorado law specifically prohibits chiropractors from prescribing, compounding or administering drugs. Yet, in the phrase “nutritional remedial measures,” the Colorado Board of Chiropractic Examiners found an opening for the inclusion of real drugs in the chiropractic scope of practice. Or so it thought.
In November, 2012, the Board enacted Rule 7(C), which would have gone into effect on January 14, 2013:
Nutritional Remedial Measures as referenced in Section 12-33-102(1), C.R.S., means that a doctor of chiropractic may administer, prescribe, recommend, compound, sell and distribute homeopathic and botanical medicines, vitamins, minerals, phytonutrients, antioxidants, enzymes, glandular extracts, non-prescription drugs, durable and non-durable medical goods and devices.
Administer includes Oral, Topical, Inhalation, and Injection.
However, not just any chiropractor could administer these substances by injection. To do that, the chiropractor must have a “Certification in Injectables,” which can be obtained by, according to the new rule,
Successfully complet[ing] a minimum of a combined total of 24 hours of theoretical study and supervised clinical instruction . . . [and] passing a nationally recognized Injectable certification examination recognized by a CCE [Council on Chiropractic Education] accredited chiropractic college.
No, that is not a typo. It takes only 24 hours of combined instruction to use injectables, including intravenous administration of the listed substances, which are prescription drugs under federal law. (Per federal law, a substance that may be an over-the-counter dietary supplement if taken orally is a prescription drug when injected.) You do have to pass a test, but what does it say about the rigor of this examination if there is a reasonable opportunity to pass it after a 24-hour course?
. . . and get creamed
Rule 7(C) displeased just about everyone. The straight wing of chiropractic saw this move as simply another step on the road to chiropractic ruin, as detailed in a series of articles in The Chronicle of Chiropractic, an on-line publication the Foundation for Vertebral Subluxation. (You’ll need to hold your nose to avoid the smell of the National Vaccine Information Council plug on their website.) On December 5, the Colorado Attorney General issued an opinion that the rule exceeded the scope of authority granted the Board by the legislature.
Under the Colorado Administrative Procedure Act, new rules such as this one are reviewed by the Office of Legislative Legal Services (OLLS) to make sure they are within the Board’s rule making authority. OLLS quickly determined that Rule 7(C) most certainly was not within the Board’s authority and voted 8-0 to ask the legislature to repeal the rule. And on January 8, the Colorado General Assembly’s Committee on Legal Services did just that. It is unclear to me whether this repeals the rule for good, or whether the entire legislature must vote. What is not unclear is that the rule is, for all practical purposes, dead.
The Executive and Legislative branches having weighed in on the subject, the third branch of state government, the Judiciary, was also drawn into the controversy. The Colorado Medical Society and 12 more state and local medical groups sued the Board of Chiropractic Examiners. They sought an injunction against implementation of the rule, also citing the Board’s lack of authority. In addition, according to the complaint, Rule 7(C) is an intrusion into the practice of medicine as defined by statute, which gives M.D.s the authority to prescribe drugs. (Apparently, the medical society is suddenly upset about other groups practicing medicine even though they sat on their hands when naturopaths tried to do the same thing.) The suit remains pending, although I suppose it will be dismissed as moot.
How the Board of Chiropractic Examiners ever thought it could get away with this is beyond me. No doubt chiropractors will try the legislative route next time.
Before we leave Colorado for its neighbor to the south, one more of the Board’s new rules bears mentioning, as it appears to be an effort at furthering the notion that chiropractors are somehow qualified to be PCPs. Rule 7(B)(3), which is unchallenged, states that “Electrocardiography (EKG/ECG)” is included in the chiropractic scope of practice, if the chiropractor has
One hundred and twenty (120) hours of initial and related clinical with didactic training and demonstrated competency in cardiac medicine.
“A demonstrated competency in cardiac medicine?” The very thought induces angina. No specifics are given for how said “competency” is achieved or what “initial and related clinical with didactic training” consists of. Typical of other chiropractic “specialties,” I suppose this competency is accomplished in weekend courses. Perhaps competency can be achieved by becoming a “Diplomate” of the American Board of Chiropractic Internists (DABCI), although it appears this course would actually over qualify its participants by a large margin. Here’s what an ABCI functionary says about the course, courtesy of the American Chiropractic Association website:
This specialty, says its council president, Cindy Howard, DC, DABCI, FIAMA [Fellow, International Academy of Medical Acupuncture], is essentially the chiropractic version of primary care. “We look at primary care a little bit differently,” she says. “A lot of people look at it in terms of being the first doctor someone comes to. We look at it from the perspective that we want to handle everything: work up the problem, diagnose you, and treat you. Instead of referring you to the ‘proper person,’ we want to be that person.”
Dr. Howard acknowledges that not all cases can be treated by a chiropractic physician, but thanks to the extensive training provided by the DABCI . . . certification, there are many that can. The 26 sessions of 12-hour weekends take three years to complete, followed by a three-part board exam—two written segments and one clinical competency examination.
“We do laboratory workups, blood chemistries, adrenal and hormone testing, GI function studies, EKGs,” says Dr. Howard. “We treat everything from allergies to thyroid problems to fatigue. It makes us more of a family doctor—not in the sense that we always take care of the whole family, but we can take care of all that ails them. I have people come into my office not for neck and back pain, people who don’t get adjusted, because we have other capabilities to treat naturally. If I’m adjusting somebody and not getting them better, [my training] gives me a broader range of things to look at as to what it might be.”
What family practice doctor or internist wouldn’t love to complete his training with “26 sessions of 12 hour weekends” instead of three grueling years of hospital-based residency working 80 hours a week. Let’s see, at 80 hours per week, you could do your whole residency in less than four weeks and avoid all the messiness involved in taking care of people who are really sick. Brilliant!
New Mexico: An update
Meanwhile, in New Mexico, the battle over chiropractic prescribing continues. As reported in a previous post, the legislature amended the chiropractic practice act to create a new iteration of chiropractor, an “advanced practice” version, which takes all of 90 hours of additional training plus passing a test.
The New Mexico Chiropractic Association describes part of this training on its website [capitalization and punctuation as in original]:
Routes of administration [for ‘naturally derived’ substances], of course, are oral, topical and rectal, which we may already do but new to us here are intravenous (IV) and intramuscular (IM) administration. Doctors completing the certification will be prepared to do: IM injections (B12, homeopathic, magnesium, trigger point, etc.), neural therapy injections Intravenous procedures (meyer’s [sic] cocktails, H2O2, chelation, ascorbates, amino acids, minerals, etc.), emergency procedures Laboratory testing and diagnosis.
In other words, a veritable pantry full of quack remedies, now conveniently available via an IV.
Not satisfied with the formulary it had stipulated to with the state’s medical and pharmacy boards, the Board of Chiropractic Examiners, like its compatriots in Colorado, tried an end run around its statutory authority by enacting a new formulary without the required approval of the other boards. This landed the chiropractic board in court, with the medical and pharmacy boards, as well as the International Chiropractors Association, all seeking an injunction against implementation of the formulary. The New Mexico Court of Appeals agreed with the plaintiffs and upheld a stay of the formulary. That proceeding remains pending.
Here’s an update: On September 13, 2012, the aforementioned American Chiropractic Association (ACA), filed an amicus curiae (friend of the court) brief. All the brief really says is that chiropractors, working through their state legislators and regulatory agencies, are best suited to determine their scope of practice. This is an ambiguous statement – if they mean that chiropractors should be the ones to determine what their scope of practice is, that is certainly not true. That is solely up to the legislature, which (at least ideally) takes into account all points of view, not just chiropractors. In any event, it is totally irrelevant to the issue before the court: whether the chiropractic board exceeded its authority, which it most certainly did. Even its own lawyer told the board that.
But the brief does make some interesting, if irrelevant, statements further demonstrating the ACA’s dedication to reinventing D.C.s as PCPs. The ACA actually says that chiropractors’
. . . academic and clinical training is both extensive and exhaustive and is very comparable to the level of the education and training received by medical doctors.
They go on to provide a handy chart which supposedly compares the hours required for a D.C. degree at Western States University with the hours required for a medical degree at Oregon Health Sciences University, along with the names of courses and number of hours. It purports to show that chiropractic students actually spend a few more hours in combined classroom and clinical training (4,896 v. 4,877). Of course, the Council on Chiropractic Education recently got into hot water with the U.S. Department of Education over just how accurate the system of credit hour determinations were among chiropractic colleges. Even without getting into that issue, I don’t know where this chart got its figures as the OHSU medical school curriculum doesn’t look anything like the chart. But you be the judge: Western States D.C. degree (click on “Program Curriculum” pdf) v. Oregon Health Sciences M.D. degree (see links under “Curriculum” in left column). Do you think they are “very comparable?”
The ACA brief totally fails to mention the fact that graduating from medical school is only the beginning for M.D.s. It skips the subject of residency entirely. The brief also describes several “post-graduate” training programs in a variety of “clinical disciplines and specialties,” including Chiropractic Pediatrics, Chiropractic Clinical Neurology (post-graduate training can be had at the “Carrick Institute for Graduate Studies”), and training provided by the American Board of Chiropractic Internists, whose Cindy Howard, D. C., is quoted above.
Before we leave New Mexico, let’s see what one advanced practice chiropractor, Stephen Perlstein, D.C., who was instrumental in getting the advanced practice legislation passed, is offering patients under the formulary currently allowed by law.
a technique that bioregulates the body’s immune system, meaning that it heals the injury by enabling and enhancing the mechanisms that control inflammation, pain, and tissue regeneration. Biopuncture traditionally uses small needles to inject substances subcutaneously (just under the skin). On occasion, a deeper injection is required. In a single session, single or multiple injections may be necessary to cover the injured area. . . . Substances typically used in Biopuncture are homeopathic medicines, lidocaine or procaine (analgesics), sarapin (a natural pain reliever), and dextrose (an immune stimulant).
Now, you may be thinking this sounds awfully modest for a CAM treatment. Where’s the ubiquitous “one true remedy” claim. It’s right here:
Biopuncture is not only effective for sprain and strain injuries, both new and old, or pain at various joints or parts of the body of indeterminate origin, but is also remarkably effective for the following conditions:
Carpal Tunnel Syndrome
Homeopathic Flu Vaccines
After making misleadingly simplistic statements about the mutation of flu viruses and its effect on flu vaccine effectiveness, Perlstein goes on to make this absurd claim about the homeopathic “flu vaccine:”
These [homeopathic] vaccines also stimulate an immune response to a flu virus, but, unlike the conventional ones which rely on the actual virus itself which has changed, these homeopathic preparations stimulate an immune response designed to strengthen resistance to all flu viral elements, whether last year’s or any other years, making the mutating quality of flu virus irrelevant and not a factor in the effectiveness that conventional flu vaccines demonstrate.
Apparently this guy knows something that “130 national influenza centers in 101 countries [which] conduct year-round surveillance for influenza and study influenza disease trends” as well as five World Health Organization (WHO) Collaborating Centers for Reference and Research on Influenza located in the USA, the UK, Australia, Japan and China, don’t know.
Here we go again
The Arizona Association of Chiropractic has filed an application with the state legislature for an expansion of chiropractic scope of practice to include
the use of natural substances, homeopathic medication and orthomolecular therapy as an opportunity to enhance care for their patients.
According to the petition, these “services” are currently available to chiropractic patients in Oklahoma, Utah, Alaska, Oregon and Idaho, as well as New Mexico and Colorado. Ten other states are in the process of considering legislation.
We’ll return to these unfortunate developments in a future post.