C hiropractic utilization in the United States remained static at 12.1 million from 2003 until 2006. as reported by Davis. Brenda. and Williams in 2010. This represents 4.12% of the population in 2003. as reported by the Encyclopedia of the Nations (2013). Davis. Sirovich. and Weeks also reported that in the early 1990s, chiropractic utilization was 7.7% of the adults in the United States, realizing a net loss of utilization of 3.58% in just a decade. If we take a careful look at our identity of being a chiropractor versus a doctor versus a doctor of chiropractic, perhaps we can better understand and help to reverse the trend. Chiropractors are considered to be primary care doctors, a portal of entry into the healthcare system. According to Wickcs (2002). "The Council on Chiropractic Education (CCE). the US Department of Education's specialized accrediting agency for chiropractic education, has established standards for education of chiropractic physicians that includes specific reference to primary care. In the Forward to the Standards, the following statement appears: a doctor of chiropractic is a primary care physician whose purpose, as a practitioner of the healing arts, is to help meet the health needs of individual patients and the public, giving particular attention to structural neurological aspects of the body...As a gatekeeper for direct access to the health delivery system, the doctor of chiropractic's responsibilities as a primary care physician include wcllness promotion, health assessment, diagnosis, and the chiropractic management of the patient healthcare needs" (p. 175). According to the International Chiropractic Association, "The doctor of chiropractic is a portal of entry, primary health care provider, and. as such, is well-educated in the basic, clinical and chiropractic sciences and other health-related areas" (http://www.chiropractic.org/ica/policy.htm). The University of the State of New York - New York State Education Department (2009) holds chiropractors as primary care providers and offers the following explanation: "The chiropractor will conduct a physical examination and record a comprehensive case history related to the chiropractic sen ices. Like other primary care health professionals, chiropractors consider many different causes for your symptoms. If some other type of care is needed in addition to or instead of chiropractic care, you may be referred to another health care provider. Chiropractors often consult with other health professionals, such as medical doctors" (http://www.op.nyscd.gov/prof/chiro/chirobroch.htm). Most other states" regulatory boards have similar definitions of the practice of chiropractic. Because of our "primary care status." a public trust lias been rendered on chiropractic that has been acknowledged in our education, scope of practice, and our national and state organizations to ensure the health and well-being of the public. As chiropractors, we are "laser locked" into the ncuromuscu-loskclctal system for the detection and correction of vertebral subluxations. structural misalignments, postural imbalances, causes of pain. etc. As doctors, we need to be a lot more. It is for this reason that a cliiropractor has a doctoral level of education that separates him or her from a physical therapist and every other secondary healthcare provider. To illustrate this issue, consider that all chiropractors are trained to know how to take a patient"s blood pressure, pulse, height, and weight. These basic vital statistics are universal and performed in every primary care medical doctor's office and in the offices of most specialists because they provide general insight into the overall health of the patient. If your patient presents with a blood pressure of 230/180 and a resting pulse of 160. do you ignore that and "hope" your adjustment will fix the underlying problem? Or do you inimediateh' refer the patient to an emergency room, primary care physician, or cardiologist? However, if you do not take your patient's blood pressure and pulse, and arc ignorant to his or her vital statistics, arc you breaking that "public trust" if you send that patient on his or her way to a potentially much shorter life by delaying possible lifesaving intervention? You may even break some laws by ignoring such critical signs or symptoms. The above scenario is part of the "doctor" component of being a doctor of chiropractic. According to this author, the Council on Chiropractic Education, even- chiropractic educational entity in the United States, every state liccnsurc board, and every national and state organization, the words "doctor" and "chiropractor" are mutualh' inclusive and a prime reason for universal liccnsurc. All too mam medical specialists, courts, carriers, and legislative bodies have reviewed too main chiropractic records that lack even the most basic of vital statistics. It has raised many unnecessary questions that do not bode well for the present and future of chiropractic. Conversely, the word chiropractic must not be ignored because we are doctors. In too many "chiropractic circles." some feel that giving a "chiropractic lay lecture" or "report of findings" to a patient borders on being unethical or misleading to the public. This statement is just as upsetting as the doctor of chiropractic who does not take vital statistics. A close family member recently undenyent successful cancer treatment and the oncologist spent over an hour explaining the diagnostic findings, treatment options, potential side effects, and the prognosis. In short, he gave an "oncological lay lecture" or "oncology report of findings." What's the difference? The answer is none, and not giving tliat level of explanation is unfair to the patient who is entitled a full explanation of his or her care. Part of the utilization problems in the United States is clearly that, as primary care providers, we must do a more complete job in triaging our patients, which includes complete documentation. However, if utilization is to increase, there must be a more thorough education of patients and the public about what chiropractic is. what chiropractors treat, and the results chiropractors render. Regarding chiropractic results, do we go back to 1895 or adhere strictly to an evidence-based practice? Regarding a strict evidence-based dogma, the literature suggests that this argument is one from lobbyists, and not healthcare organizations. Decades ago. lobbyists realized that this was an area under the banner of cither ovcrutilization or fraud, and had plausibility in spite of the overwhelming positive results of best practice, also known as "experience." in conjunction with evidence-based practice that the healthcare industry has employed for decades, if not centuries. Sackett. Rosenberg. Gray. Haynes. and Richardson (1996) state. "Criticism has ranged from cvidcncc-based medicine being old hat to it being a dangerous innovation, perpetrated by the arrogant to serve cost cutters and suppress clinical freedom" (p. 71). They go on to comment. "Good doctors use both individual clinical expertise and the best available external evidence, and neither alone is enough. Without clinical expertise, practice risks becoming tyrannized by evidence, for even excellent external evidence maybe inapplicable to or inappropriate for an individual patient. Without current best evidence, practice risks becoming rapidly out of date, to the detriment of patients" (Sackett et al, 1996. p. 72). The point is that the provider plays a huge role and ultimately is the check and balance of this process. Without the provider, the payer becomes the determining factor in the delivery of health care by "tying the doctor's hands" with the limitation of evidence. Thcv state further. "External clinical evidence can inform, but can never replace, individual clinical expertise, and it is this expertise that decides whether the external evidence applies to the individual patient at all and. if so. how it should be integrated into a clinical decision" (Sackctt ct al. 1996. p. 72). Lastly, they state. "Evidence based medicine is not restricted to randomized trials and mcta-analyscs. It involves tracking down the best external evidence with which to answer our clinical questions" (Sackctt et al. 1996. p. 72). This process often takes years, preventing the final papers from being published in a timely enough fashion to meet the ever-changing advancement of medicine and the technologies supporting the current needs of the patients. Solutions to chiropractic utilization involve being a "doctor of chiropractic" coupled with employing all of the latest research while not ignoring the results rendered in chiropractic offices around the globe where research has not yet caught up to the "why" some of those results have been obtained. We must become better at what we do through clinical excellence while simultaneously being relentless in educating the public, starting with, but not limited to. our patients. References: 1. Davis. M.. Siren ich. B.. & Weeks. W. (2010).UliIization and expenditures on chiropractic care in the United Slates from 1997 to 2006. Health Research and Education Trust. 45(3). 748-761. Advamcg. Inc. (2013). United Slates population. Encyclopedia of the Nations. Retrieved August 20. 2013 from http://www.nationscn- cyclopcdia.com/Amcricas/U nitcd-Slatcs-POPULATION.html Wickcs. D. (2002). Educating primary care chiropractic physicians. Journal of Chiropractic Physicians. (4)1. 175-179. The International Chiropractic Association, (n.d.). The practice of chiropractic. ICA Policy Statements. Retrieved August 20.2013 from http://www.chi ropractic.org/ica/policy.htm University of the State of New York - New York State Education Department. (2009). Office of the Consumer information. Office of the Professions. Retrieved August 20. 2013 from http://ww w.op.m sed. gov/prof/chiro/chirobroch.htm Sacked. D. L.. Rosenberg. W. M.. Gray. J. A.. Hayncs. R. B.. & Richardson. W. S. (1996). Evidence based medicine: What it is and what it isn't. British Medical Journal. 312(7023). 71-72. Dr. \ larkStuclin is an adjunct assistant professor in clinical sciences altliel'i liversity ofBridgeport C Allege qfC liiropractic and a clinical presenter for the State of New York at Buffalo, School ofMedicineaiulBiomedical Sciences for post-doctoral education, leaching.\flil,spine interpretation andtriaging trauma cases. lie is also the president of the Academy o/C liiropractic leadiing doctors ofdiiro-practichow to interface with the legal community (www.lMwyersPIProgram. com) and leaclies .\ IRI interpretation and triaging trauma cases to doctors of all disciplines nationally (www. 'IeachlJoclors.com/. He can be readied at DrMarkfdiTeadiDoctors.com or at 631-786-4253.
