New legislative sessions have begun in all but a couple of states. Unfortunately, this means more legislative alchemy (the process by which state legislatures turn pseudoscience and quackery into licensed health care practices) is brewing across the U.S.
The American Chiropractic Association (ACA) and the Council on Chiropractic Education (CCE), the accrediting agency for chiropractic schools, are pushing the idea that chiropractors are primary care physicians, a topic we’ve covered extensively here on SBM. To carry out their scheme, the ACA, CCE and like-minded chiropractors need to amend the state chiropractic practice acts to broaden their scope of practice so that they are no longer limited to “detecting” and “correcting” the non-existent vertebral subluxation. Today, we look at several bills aiming do just that.
In 2015, the ACA announced “Six Key Elements of a Modern Chiropractic Practice Act,” its ideal version of what chiropractors should be allowed to do under state law. They included:
- “Chiropractic Physician” and “Chiropractic Medicine” as the Regulatory Terms of Licensure.
- Scope of Practice Determined by Doctoral and Post-Doctoral Education, Training and Experience Obtained Through Appropriately Accredited Institutions.
- Full Management, Referral and Prescription Authority commensurate with contemporary chiropractic education for Patient Examination, Diagnosis, Differential Diagnosis and Health Assessment.
- Full Management, Referral and Prescription Authority commensurate with contemporary chiropractic education for the Care and Treatment of Neuromusculoskeletal and Other Health Conditions or Issues.
- Full Authority for the Delivery of Information, Advice, Recommendations and Counseling Regarding General Health Matters, Wellness and Health Optimization.
Indiana defines the practice of chiropractic as the diagnosis and analysis of “any interference with normal nerve transmission and expression” and “the correction thereof by an adjustment . . . of the vertebral column.” In other words, traditional subluxation-based chiropractic.
It is unlikely the average Indiana legislator reading Senate Bill 437 would be aware of the huge expansion in practice scope it portends or its implications for patient care. (I cannot find evidence that the Indiana State Medical Association has taken any position on this legislation.) But if you’ve followed the chiropractic industry for over a decade, as I have, you learn how to read between the lines. Here’s how SB 437 aligns itself with the ACA’s “Six Key Elements.”
“Chiropractic Physician” and “Chiropractic Medicine” as the Regulatory Terms of Licensure.
The bill allows chiropractors to call themselves “chiropractic physicians.”
Scope of Practice Determined by Doctoral and Post-Doctoral Education, Training and Experience Obtained Through Appropriately Accredited Institutions.
SB 437 authorizes a huge expansion of chiropractic practice, including sophisticated diagnostic testing and diagnosis and treatment of virtually any disease or condition. (We’ll return to the particulars in a moment.) The only limitation is that the chiropractor learned, in the language of the bill, “a therapy” he uses:
in a chiropractic college or chiropractic program in a university that has been accredited by the Council on Chiropractic Education [CCE] . . . or approved by rules of the [state chiropractic] board . . .
With this provision, the state will essentially default to the state chiropractic board and CCE-accredited chiropractic schools to determine chiropractic scope of practice. The board, by simply enacting a rule, could decide what therapies a chiropractor could use.
For its part, the CCE has already declared that all chiropractic schools are required to teach students to “practice primary health care as a portal-of-entry provider for patients of all ages and genders.” The CCE-accredited National University of Health Sciences, which has programs in chiropractic, naturopathy and acupuncture, among others, says that its “Students are well prepared to become first-contact, primary care physicians, ready to diagnose, treat and manage a wide range of patients and conditions.” (Of course, this isn’t actually true, but it reveals the depth of their delusion that their education and training prepares them to become primary care practitioners or PCPs.)
In addition, the ACA has set up so-called “post-doctoral” programs to train, for example, “chiropractic internists” and “chiropractic pediatricians.” These 300-or-so-hour courses are taught on weekends, often in hotel conference rooms. Via affiliation with a CCE-accredited school, or by virtue of recognition of a “specialty” by the state chiropractic board, practices learned in these courses would automatically become part of the legal scope of chiropractic practice.
Full Management, Referral and Prescription Authority commensurate with contemporary chiropractic education for Patient Examination, Diagnosis, Differential Diagnosis and Health Assessment [and] . . . for the Care and Treatment of Neuromusculoskeletal and Other Health Conditions or Issues. (Emphasis added.)
SB 437 does not give chiropractors prescription authority, but they come close to getting everything else the ACA wants in this regard. The bill prohibits chiropractors from treating (but not diagnosing) infectious diseases, endocrine disorders, or atypical or abnormal histology, but otherwise allows them to diagnose and treat an unlimited array of diseases and conditions. They would be able to:
. . . evaluate and examine individuals to determine the presence of, or absence of, and diagnosis of physical or physiologic injuries, conditions, or disorders of the body.
What is striking is how hard the bill tries to avoid coming out and saying the word “disease” while at the same time clearly meaning exactly that.
They will also be able to “treat injuries, conditions, and disorders” with “the administration or dispensing of supportive therapies” and “any other therapeutic procedure or service (emphasis added).” It’s hard to get any more inclusive than “any other.” (Remember, the only limitation being that they learned this “therapy” in a chiropractic school or the chiropractic board approves it.)
Given these broad parameters, while never saying the words “dietary supplements” (which includes vitamins, minerals, herbs, enzymes, and glandulars) or “homeopathic remedies,” clearly chiropractors will be able to recommend and “dispense” (translation: sell) these and other “supportive” remedies to their patients. This is reinforced in a provision allowing chiropractors to give “nutrition” advice. The bill also allows chiropractors to “use filiform needles for the treatment of muscle pain,” or dry needling.
If you’re thinking it’s a stretch to interpret SB 437 as an attempt to vastly expand chiropractic practice, the bill’s provisions on diagnostic testing will erase your doubts. As long as the magic wand of board rule or instruction in a CCE-accredited institution is waved over it, chiropractors would be able to:
. . . order, perform, and interpret laboratory, radiological, electrodiagnostic, or any other diagnostic studies . . . including the ordering of advanced imaging of all parts of the human body. (Emphasis added.)
In sum, they will be able to order and perform any diagnostic test an MD can order: MRIs, PET scans, mammograms, EKGs, barium enemas, colonoscopies, hearing studies, pap smears, genetic testing, thallium stress tests, coronary artery cath studies, obstetric pelvimetry, pneumoencephalograms, xenon 127 pulmonary ventilation scan . . . you name it.
And that’s the legit tests. For the more quackery-minded chiropractor, there’s ALCAT and IgG food “sensitivity” testing, breast thermography for cancer screening, “functional” lab testing, salivary testing for hormones, MTHFR genetic testing (the quack version), and lab tests for heavy metals and “toxins.”
To mimic the language, if not the actual skill, of real primary care, SB 437 authorizes chiropractors to:
. . . manage, coordinate, or delegate patient care functions including initiating referrals, to specialists for concurrent, additional, or alternative services or care the chiropractic [sic] believes is most suited for the individual’s chiropractic condition.
I am not sure what limitation, if any, the term “chiropractic condition” puts on the chiropractor’s authority to manage a patient’s care. Given the extremely broad scope of practice this bill allows, I am chalking it up to poor drafting, not an intent to curb a chiropractor’s authority to diagnose and treat virtually any disease or condition.
Chiropractic practice is currently defined under Tennessee law as:
. . . the art of locating and removing interference with nerve transmission and nerve function . . . directed toward restoring and maintaining the normal neuromuscular and musculoskeletal function and health of the patient.
Again, traditional subluxation-based chiropractic. Tennessee Senate Bill 313 and House Bill 387 would expand chiropractic practice to include:
. . . differential diagnosis of human aliments through examination and evaluation of patients . . . through the ordering and performance of appropriate diagnostic procedures necessary to clinically correlate a physical examination to a diagnostic impression.
To achieve this differential diagnosis, the chiropractic “physician” could order x-rays, advanced diagnostic imaging “and other diagnostic procedures” and the “collection of bodily fluids and specimens for analysis.” The chiropractor could actually perform “other diagnostic procedures” if he has “received training” in them.
Under these bills, a chiropractor could treat not only neuromuscular and musculoskeletal conditions, but also what is referred to cryptically as “other conditions.” Treatment methods include, in addition to physical methods (such as “chiropractic adjustment and manipulation”), “other therapeutic care” and “chemical, electrical and thermal methods.” They can also provide “supportive care with due regard for nutrition . . . and rehabilitation.”
Given the vagueness of these terms, I would wager that the chiropractor could legally advise patients to take, and perhaps sell to them, non-prescription substances like OTC drugs, dietary supplements and homeopathic remedies. They are also specifically allowed to use acupuncture if they have additional training.
Chiropractors aren’t allowed to “practice medicine or surgery or osteopathy,” but that leaves little guidance as to just what it is a chiropractor can and cannot do if one of these bills becomes law. The practice of medicine is defined under Tennessee law as “diagnose, treat, operates on or prescribes for any physical injury or deformity.” Even if chiropractors are prevented from operating and prescribing, how is “differential diagnosis of human ailments,” any different from “diagnose [and] treat . . . any physical aliment or any physical injury to or deformity?”
Lest you think I’m reading too much into the intent of SB 313 and HB 387, two other bills pending in the Tennessee legislature should remove all doubt. Senate Bill 224 and House Bill 334 amend a state law allowing physicians to enter into direct primary care agreements with patients. Pursuant to a direct primary care agreement, a physician provides primary care to a patient for a flat fee over a set time period (a year, for example) rather than, say, billing the patient’s insurer or accepting fee for service.
Primary care is defined in the law permitting such agreements as:
. . . the screening, assessment, diagnosis, and treatment for the purpose of promotion of health or the detection and management of disease or injury within the competency and training of the direct primary care physician.
SB 224 and HB 334 would amend this law to permit chiropractic “physicians” to enter into direct primary care agreements with patients, leaving little doubt as to the intent of the chiropractic industry in lobbying for expanded scope of practice. Inexplicably, HB 334 is sponsored by Rep. Sabi Kumar, a general/vascular surgeon. I could not find evidence that the Tennessee Medical Association has taken a position on any of these bills.
For the third session in a row, the indefatigable chiropractic promoter Rep. Cisco McSorley has introduced a bill (Senate Bill 150) expanding chiropractic scope of practice beyond his previous accomplishments in that regard, which were substantial. Like other pending bills, scope of practice would extend beyond detecting and correcting subluxations, to include:
. . . diagnosis and treatment of a condition for which the chiropractic physician has been educated and trained.
Chiropractic practice is renamed “chiropractic medicine” and chiropractors become “chiropractic physicians.” The bill does away with the current law’s definition of scope of practice, leaving it up to the state chiropractic board to determine what chiropractic “physicians” can and cannot do.
New Mexico is unique in giving “advanced practice” chiropractors limited prescription privileges. Their formulary contains quack favorites like dessicated animal thyroid and homeopathic remedies, including “homeopathic flu shots,” which, according to one New Mexico chiropractor, have this amazing advantage over the real flu vaccine:
[They] 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.
Someone call the CDC!
However, they cannot prescribe or administer dangerous drugs, controlled substances, any drugs for injection or substances not listed in their practice act without approval by the medical and pharmacy boards. Rep. McSorley’s bill does away with the requirement that the medical and pharmacy boards’ approve drugs for injection and expands the drugs they can use. “Collaboration” with (not approval by) the medical and pharmacy boards is required only if they want to expand the formulary even further. This means they would be allowed to inject patients with bioidentical hormones, vitamin cocktails and “live cell products,” among other substances. (I could not find that “live cell products” is an established regulatory term. Perhaps they mean stem cells?)
But wait, that’s not all: SB 150 would create a new category called the “Level Two advanced practice chiropractor,” who could, after an additional 650 hours of education and training beyond Level One (the current iteration of “advanced practice”):
. . . prescribe, administer, inject and dispense dangerous drugs that are used in a standard primary care practice,
with the exception of Schedule I and II controlled substances.
This 650 hours, presumably taught at a chiropractic or perhaps naturopathic school, would have to include “primary care case management” and “patient safety and standards of primary care.”
In past years, attempts to expand chiropractic prescribing privileges in New Mexico by statute or board rule has resulted in heated debate and litigation, pitting the medical and pharmacy professions, with an assist from the International Chiropractic Association (ICA), against the “DC as PCP” faction of chiropractors. This year, however, the bill isn’t even mentioned on the websites of the New Mexico Medical Society, the New Mexico Chiropractic Association or the ICA, which currently appears to be totally consumed in fighting (in cahoots with the National Vaccine [Mis]Information Center), California’s new law eliminating personal belief exemptions from vaccination and other pro-vaccination legislative initiatives. (Yes, many chiropractors are anti-vaccination, making the prospect of their practicing as PCPs particularly horrifying.)
Connecticut, Oregon, Colorado and Florida
More modest attempts to expand chiropractic scope of practice are pending in other states.
In Connecticut (Senate Bill 323; House Bill 6249) and Oregon (Senate Bill 217; House Bill 2390), bills are pending to allow chiropractors (and, in Oregon, naturopaths) to return students to play after a concussion. Connecticut House Bill 6029 would go even further by allowing chiropractors to diagnose a concussion. Mark Crislip, MD, has discussed in depth why their lack of education and training, plus their use of pseudoscience in the treatment of concussions, makes chiropractors wholly inadequate to the task of diagnosing and treating this form of brain trauma.
Finally, Colorado law permits the inhumane practice of “animal chiropractic,” defined as “diagnosing and treating animal vertebral subluxation,” including the use of x-rays for diagnosis. This is a neat trick to convince pet owners of the need for treatment by “showing” Fluffy’s “subluxation” on x-ray film. The law requires chiropractors to get clearance from a veterinary physician before “detecting” and “correcting” subluxations in animals. Colorado Senate Bill 135 removes the clearance requirement for chiropractors who are registered in animal chiropractic with the state.
Update: I just learned that bills are pending in my own state, Florida, which would allow chiropractors to enter into direct primary care agreements with patients. (Senate Bill 240; House Bill 161) As in other states, chiropractic is defined under Florida law as the detection and correction of vertebral subluxations. “Primary care service” is defined in these bills as
the screening, assessment, diagnosis, and treatment of a patient for the purpose of promoting health or detecting and managing disease or injury within the competency and training of the primary care provider.
Again, chiropractors are incompetent to provide this level of care and it is misleading to the public to imply that they are by allowing chiropractors to enter into direct primary care agreements with patients. It is important to remember that these agreements are not bound by the usual limitations imposed by health insurers based on the lack of evidence of safety or effectiveness. (See, for example, Aetna’s discussion of coverage of chiropractic services.) While patients are always free to pay out of their own pockets for services not covered by insurance, questions concerning the evidence base for a particular diagnosis or treatment will not be raised in the minds of consumers as they are when an insurer denies coverage.
We are following this and other Legislative Alchemy over on the Society for Science-Based Medicine website, where Mark Crislip has installed a nifty new map of the U.S. You can click on your state to see what’s brewing. For a depressingly comprehensive look at the entire country, there’s also a list of all pending legislation. The map and list are updated weekly, so check back often. To find out how to contact your state representative and voice your opinion on these bills, check out usa.gov.