Chiropractic First “Chiropractic as the Primary Care Provider for Spine”
PERSPECTIVE
Mark Studin
William J Owens
HISTORICALLY, THERE WAS AN AXIOM THAT WAS REPEATED WITH RELIGIOUS FERVOR WITHIN THE CHIROPRACTIC PROFESSION, “CHIROPRACTIC FIRST, DRUGS SECOND, SURGERY LAST.” TODAY, ALTHOUGH THIS ADAGE CONTINUES WITHIN CHIROPRACTIC CIRCLES, IT IS NOT EMBRACED BY THE PUBLIC, OUR POLITICAL LEADERS OR THE HEALTHCARE SYSTEM IN GENERAL. As A RESULT OF OUR LACK OF A TRUE LEADERSHIP POSITION IN SPINE CARE, OUR UTILIZATION HAS DECREASED WHILE DRUGS AND SURGERY UTILIZATION ARE ON THE RISE. IN THE MOST RECENTLY PUBLISHED NATIONAL STATISTICS, WHEDON ET AL (2013) STATED “THE NUMBER OF MEDICARE
BENEFICIARIES WHO USED CHIROPRACTIC SPINAL MANIPULATION GREW 13% FROM 2002 TO 2004, REMAINED FLAT THROUGH 2007 AND THEN DECLINED 5% THROUGH 2008.” (PG 1449) CURRENT STATISTICS PUT NATIONAL CHIROPRACTIC UTILIZATION SLIGHTLY BELOW 5% IN SPITE OF SUCCESSFUL CHIROPRACTIC CLINICAL OUTCOME STUDIES, COST EFFECTIVENESS COMPARISONS AND PATIENT SATISFACTION SURVEYS IN THE SCIENTIFIC LITERATURE.
There aie many facets to this discussion, but let’s take a look at one portion of the issue. To underscore the tone of this article, let’s take a look at the view of leaders in one state’s workers’ compensation system. Recently, Dr. Studin was invited to present to a panel which included every workers compensation judge in one particular state. This was a large group of judges and a unique opportunity for chiropractic, he was the first chiropractor to ever present to this organization. In conversation with that group of judges, he asked why chiropractic wasn’t considered more frequently within their system? The answer, quite simply, was that injured claimants in formal healings demand more pain medication [including opiates] and the judges fear losing their appointed positions if too many complaints aie filed by claimants. As a result, care is directed toward prescriptions including opiates and a potentially successful, drugless option in chiropractic is ignored. What he realized after this meeting was, we need stronger political and academic allies to better position chiropractic to prevent the perpetuation of this problem. So far, we politically are not doing as good a job,
academically we are getting there.
When we look at prescription pain medication in the United States, opiates are considered one of the leading causes of prescription death in our country and aie certainly responsible for the surge in opioid addiction centers and Suboxone [used to treat opioid addition/dependence] prescriptions. In fact, a recent report released by the Centers for Disease Control and Prevention in 2011 states “By 2010, enough OPR were sold to medicate every American adult with a typical dose of 5 mg of hydrocodone every 4 hours for 1 month. Increased use of OPR has contributed to the overall increases in rates of overdose death and nonmedical use...” (pg 1487). . It is highly likely that many initial opioid prescriptions in the United States for pain are related to spinal care and the mismanagement of these patients from the beginning is part of the opioid epidemic. Is chiropractic the sole solution to this problem? No, but it is part
They want increased utilization and enrollment in our schools and a formal place within the healthcare system.
of the big picture and part of the global solution. The opportunity to position chiropractic in the beginning of care instead as a last resort, has a much different result in the management of spine pain. This is a tremendous opportunity to not become medical doctors but to educate medical providers in your area on chiropractic assessment of the spine which in fact, is happening already in medical schools and hospitals at the grass roots level. Unfortunately our current political landscape, which includes 2 national organizations and multiple state organizations, causes the current focus to be placed internally on the fight to control an ever-shrinking pie resulting in a tremendous waste of time and financial resources. When we look at the chiropractic provider in the field, it appears the average doctor of chiropractic, doesn’t support the political process, and feels that the philosophical beliefs, egos and financial desires of the few control the future of the chiropractic landscape. This has resulted in an “I give up” mentality and a stagnation of our academic outreach, our graduate level education and our ability to fund political battles ensuring we aie not forced backward. Our discussions with thousands of doctors of chiropractic across the country reveal the average DC wants to ensure chiropractic thrives for future generations. They want increased utilization and enrollment in our schools and a formal place within the healthcare system. We see that the political process is not going to change any time soon and in fact may be getting more disorganized and wasteful. Currently, what we see at the national level as the best hope in validating chiropractic care and therefore the future of chiropractic is a formal collaboration between academic medicine and academic chiropractic. Medical academia understands that formal training in musculoskeletal care and spine care in general, in medical school is almost non-existent. Academic medicine has also realized that there is an opiate epidemic that is spiraling out of control and as they are searching for solutions to the management of pain, chiropractic has the potential of being a serious player in spine care. Medicine considers pain as the 5th vital sign and it realizes, formally, that there is a need to find drug-
less solutions to pain management or more time will be spent managing addictions than finding cures. With the publication of an increasing number of chiropractic outcome studies, medicine has started to become interested in chiropractic and has offered opportunities to educate their medical students, Residents and Fellows on these research findings and chiropractic’s role in our healthcare system. This opportunity is fresh and chiropractic academia, not chiropractic politics will be able to determine the “message” moving forward. The role of chiropractic politics is to educate political and policy leaders on our academic achievements creating equality for practicing chiropractors through legislative channels. Without the academics we have nothing to back up our political rhetoric
Based on all our current relationships throughout the country, we aie seeing that a formal partnership between chiropractic and medical academia has the potential to opens doors to the 95% of the population that currently receives treatment from MD primary care physicians, and can positions us to be the “first line” for referrals in spine care. This is being done not by making chiropractic more “medical” but by making medicine more chiropractic. With the success of chiropractic both in our individual practices and in the scientific literature, chiropractic has the ability to positively influence a very large problem in medicine, how to manage the spine pain patient without medication including highly addictive narcotics. This holds true for both the primary care providers and the medical specialist.
Throughout our work we see that medical primary care providers have a significant challenge in managing their spine pain patients. The patients return to the primary care medical practice with persistent spine pain which creates a road block for the provider who currently has poor choices for solutions. When it comes to biomechanical spine issues, muscle relaxéis aie not effective and opiates fix nothing. Physical therapy can help, but since their focus is on the muscles they aie not positioned to correct the underlying spinal related problems. Since physical therapists work under the direction of the MD and cannot diagnose or offer prognosis we see that spine care will continue to degrade unless chiropractic is leading. Since most of the cause of pain in the spine is biomechanical [meaning non-surgical] the patients return to the primary care office over and over creating major issues in patient care flow and disability management. Chiropractic is available to help and lead, it has been proven to work.
In regaid to the medical specialist, chiropractic can also resolve problems which they are confronted with. Malpractice rates of spinal surgeons are upwards of $330,000 annually and they cannot afford to “clog” their offices and waste time screening out the non-surgical patients. In our experience in practice and in interviewing chiropractor’s nationally, many
specialists are now very happy to have the chiropractor act as the primary care provider for spine and manage those patents conservatively, referring only those that need a surgical consultation. Specialists aie reporting that the “right, well-trained chiropractor” has been a solution to their practice problems and aie helping. Our observations are confirmed by a recent study by Busse et al (2009) stated “Approximately half (51.4%) of respondents reported that they refer patients for chiropractic care.” (pg 2821). They continue by stating “American surgeons were more likely to agree that chiropractic manipulation of the neck is generally a safe therapy and that chiropractic includes ideas and methods that could benefit conventional medicine.” (pg 2821) Lastly they stated “Improved interprofessional relations maybe important to ensure optimal care of shared patients.” (pg 2824). In our opinion the continuation of this positive trend will be achieved through chiropractic academia and not chiropractic politics.
External to our profession we see that medical academia and many medical providers in both the primary care and medical specialty worlds have started to recognize all of the above benefits and with the help of the research journals in our profession, to whom we all owe a tremendous debt, they aie starting to see chiropractic as a clinically relevant option for spine care. Internally within the chiropractic profession we need to lead with academics NOT politics [although the politics aie important]. When politics leads we are splintered, when academics takes the point, we are united. Politically speaking we see those on the far right who we speak to daily on a national level and who fear that we will lose our “subluxation” identity if we accept medical referrals, we want to remind you of the following: chiropractic works and taking a referral of a patient from a medical doctor does not make you a medical doctor any more that accepting a referral from a patient who is a janitor makes you a janitor.
To those of you on the far left of the political spectrum, who believe the only way to save chiropractic is to expand and add drugs into the profession, let us remind you that the reason chiropractic is being included is that we are doing something different and our approach is unique. Medicine already has enough providers prescribing and outcomes aie getting worse. We have started earlier in this article that academic medicine is looking for more non-phannaceutical approaches and chiropractic is first in line. We ask you how coming late to a failed paradigm will advance chiropractic? Academic chiropractic’s partnership with academic medicine is the solution and we are poised to fill our offices and educational institutions with providers who can fill that void, continuing to work in the direction that has been proven to be successful.
Our profession is on the verge of major acceptance and validation for those chiropractors that are willing to be the doctor that they have always aspired to become through academics not
politics. This is happening as you read this and shortly, you will see a very large push in the profession towards chiropractic as the primary care provider for spine. There are many academic institutions and organizations both in and out of chiropractic that realize your future is tied into the success of this paradigm. You, as individual practitioners, should be prepared. The only way to do this is through formal post graduate education and CE programs. A select few of these are now in collaboration between academic chiropractic and academic medicine with each learning and supporting each outer. Embrace chiropractic academia and leam to read MRI, triage better, support and read research and share that with the medical community and your patients. This is all integral to your practice’s financial success and the success of our profession because shortly, you will be interfacing with the medical profession at a much higher level and we all simply need to be better. There are many chiropractors in your community, when the MDs are looking to refer will it be you or the chiropractor down the sheet? Choose your continuing education wisely and seek those who are expert at what you need to be better at.
Your future success will not be predicated by some consultant showing you a new “scheme.” It will be purely predicated on your clinical excellence. Currently, there aie doctors in all 50 states reporting their practices are “exploding” in both volume and income simply because they got better clinically. I welcome
you to join us and if you ai e not sure how to call or write.
References:
1. Whedon,./. M, Song, Y, & Davis, M. A. (2013). Trends in the use and cost of chiropractic spinal manipulation under Medicare Part B. The Spine Journal,13(11), 1449-1454.
2. Centers for Disease Control and Prevention (CDC. (2011). Vital signs: overdoses of prescription opioid pain relievers—United States, 1999—2008.MMWR. Morbidity and mortality weekly report, 60(43), 1487.
3. Busse, J. W, Jacobs, C., Ngo, T, Rodine, R., Torrance, !)., Jim, ./., ... & Bhandari, M. (2009). Attitudes toward chiropractic: a survey of North American orthopedic surgeons. Spine, 34(25), 2818-2825.
iDr. Mark Studin is an Adjunct Associate ■ Professor of Chiropractic, University Of ^ V, JM Bridgeport College Of Chiropractic and a clinical presenter for the State of New York at W Buffalo, School of Medicine and Biomedical
Sciences for post-doctoral education, teaching MRI spine interpretation and triaging trauma cases.
He is also the president of the Academy of Chiropractic teaching doctors of chiropractic how to interface with the legal community (www.DoctorsPlProgram.com). He can be reached at [email protected] or at 631-786-4253.
Dr. (Jw’ens is presently in private practice in Buffalo and Rochester NY and generates the majority of his new patient referrals directly from the primary care medical community. He is an Associate Adjunct Professor at the State University of New York at Buffalo School of Medicine and Biomedical Sciences as well as the University of Bridgeport, College of Chiropractic. He also works directly with doctors of chiropractic to help them build relationships with medical providers in their community. He can be reached at dr. owens@academyofchiropractic. com or www. mdreferralprogram. com or 716-228-3847
