Chiropractic
PERSPECTIVE
The Solution for the Lack of Medical Education on Spine and Pain
Mark Studin
FASBE(C), DAAPM, DAAMLP
William J. Owens
DC, DAAMLP
THE MOST SUCCESSFUL APPROACH TO CREATING A PARADIGM SHIFT IN THE WAY A PROFESSION IS PERCEIVED IS TO LEAD WITH ACADEMICS AND POLITICS SECOND. NEITHER CAN STAND ALONE, HOWEVER WHEN YOU LEAD WITH POLITICS YOU INEVITABLY HAVE TO SHOW THE PROOF AS TO WHY THE PROFESSION DESERVES THAT LEGISLATIVE RESPECT IN THE POLITICAL REALM. THIS ARTICLE IS ABOUT THE ACADEMIC SIDE OF CHIROPRACTIC. AFTER DECADES IN DEAD-END LOCAL AND STATE CHIROPRACTIC POLITICS, WE CONCLUDE THAT TRUE CHANGE HAS TO START WITH CHIROPRACTIC GRADUATE-LEVEL EDUCATION AND NEEDS TO BE SOLIDIFIED WITH LITERATURE (RESEARCH) THAT HAS BEEN ACCEPTED BY THE SCIENTIFIC COMMUNITY. ÜR. WILLIAM OWENS RECENTLY WAS ACCEPTED INTO A GRADUATE
TRAINING PROGRAM THROUGH THE ROYAL COLLEGE OF
PHYSICIANS AT THE STATE UNIVERSITY OF BUFFALO SCHOOL OF MEDICINE AND BIOMEDICAL SCIENCES. (DR. OWENS IS THE ONLY CHIROPRACTOR EVER TO HAVE BEEN
ACCEPTED INTO THE ROYAL COLLEGE OF PHYSICIANS’ TRAINING PROGRAM.) WHAT IS BEING TAUGHT AND LEARNED IN THIS TRAINING PROGRAM IS THAT GRADUATE MEDICAL EDUCATION, BOTH RESIDENCIES AND FELLOWSHIPS, IS THE FOCUS OF MEDICINE AND THE PROGRAM’S PLAN TO IMPROVE ITS EDUCATION SYSTEM. IMPROVED ACADEMICS LEAD TO MORE POWER IN POLITICS AND ARE AT THE CORE OF 50% OF THE SOLUTION, WITH POLITICS BEING THE OTHER HALF OF THE REQUIREMENT AFTER THE REQUISITE SCIENTIFIC VERIFICATION. THIS REALIZATION, IN PART, EXPLAINS WHY CHIROPRACTIC HISTORICALLY HAS LAGGED SIGNIFICANTLY BEHIND MEDICINE IN ACCEPTANCE AND UTILIZATION.
To underscore this point, New Jersey enacted N. J.S.A. 39:6A4a on January 3, 2013, a law that provides that the commissioner of the Department of Health and Human Services and the applicable licensing boards may reject the use of protocols, standards, and practices or lists of diagnostic tests set by any organization deemed not to have standing or general recognition by the provider community or applicable licensing boards. The department added a definition of standard professional treatment protocols to guide the acceptable evidence of standing or general recognition for a specific medical procedure or test. These aie defined as evidence-based, clinical guidelines published in peer-reviewed journals. The department has become aware that the medical necessity of a procedure or test is being supported by articles, books, and practice or treatment guidelines that are published by the proponents of the treatment or test in journals that are not peer-reviewed and where the evidence supporting the treatment or test is anecdotal. These types of treatment protocols and guidelines cannot be used as evidence that a treatment or test is medically necessary.
Although this law is specifically for New Jersey, carriers in many other states aie utilizing these same criteria as a reason for denial when considering care as “investigational” and are successfully supporting their claims for nonpayment. Regardless of the politics, academics and research are in the forefront, and no matter the political clout, services aie not included.
Currently, chiropractic is more united on the academic side than we aie on the political side, and regardless of your beliefs in chiropractic, without academics and the evidence behind it, the politics will continue to succeed at a “snail’s pace” and far behind medicine toward acceptance, utilization, and reimbursement. Based upon teaching inside both medical and chiropractic academia, chiropractic’s requisite basic training is comparable with medicine, having a slight advantage with a greater population of hands-on patients through hospital inclusion. However, chiropractic has a superior education in musculoskeletal and neuromuscular education. The dichotomy in education between chiropractic and medicine comes at the graduate level; that is where medicine excels and is one of the primary causes for medical acceptance.
In order to get board certification in medicine, an MD must go through a board. That board is required to maintain academic standards, ensure the integrity of the testing process, and be certified by a national certification entity. In addition to the stringent requirements, the board must publish. Therefore, those boards that certify orthopedics, neurology, ophthalmology, physical medicine, family medicine, internal medicine, etc., must all publish indexed peer-reviewed scientific literature. Although there ai e boards in chiropractic, there ai e far too few, equating to less participation in graduate education.
With the new laws coming into play with the Affordable Care Act, these boards will become more valuable to the average DC over the next decade, and without the requisite
scientific literature, chiropractic will fall further behind in acceptance and utilization. However, because of the lack of medical training on the musculoskeletal system in medical schools, as evidenced by the literature outlined below, this opens the door for chiropractic at a time that has been unprecedented in our history.
Medicine doesn’t understand chiropractic because medicine lacks the requisite understanding of the neuromusculoskeletal system, spinal biomechanics, and the basic physiology of structure determining function. This poor foundation is the reason that the conventional thought process in medicine is to oversimplify the evaluation and treatment of spinal-related patients at the basic medical academic and primary care levels. Their fundamental educational system ignores that system unless the medical student moves on to a surgical or neurological specialty, which is focused on the anatomical causes of pain (surgery) and neurophysiological process in the body (neurology). Even then, it is simplified into regional, compartmentalized medicine based on treatment. That has been shown to be ineffective by the poor outcomes in musculoskeletal relaxant treatment, the opioid epidemic, and other poor treatment outcomes versus chiropractic, as evidenced by Cifuentes, Willets, and Wasiak (2011); Wilkey, Gregory, Byfield, and McCarthy (2008); and Whedon, Mackenzie, Phillips, and Lurie (2014).
Cifuentes et al. (2011) reported, “In work-related nonspecific [low back pain], the use of health maintenance care provided by physical therapist or physician services was associated with a higher disability recurrence than in chiropractic services or no treatment” (p. 396). They went on to report, “In general...those cases treated by chiropractors consistently tended to have a lower proportion in each of the categories for severity proxy compared to the other groups; fewer used opioids and had surgery. In addition, people who were mostly treated by chiropractor had, on average, less expensive medical services and shorter initial periods of disability than cases treated by other providers” (Cifuentes et al., 2011, p. 399).
Wilkey et al. (2008) studied randomized clinical trials comparing chiropractic care to medical care in a pain clinic. “The treatment regimens employed by the pain clinic in this study consisted of standard pharmaceutical therapy (nonsteroidal antiinflammatory drags, analgesics, and gabapentin), facet joint injection, and soft-tissue injection. Transcutaneous electrical nerve stimulation (TENS) machines were also employed. These modalities were used in isolation or in combination with any of the other treatments...Chiropractic group subjects followed an equally unrestricted and normal clinical treatment regimens for the treatment of [chr onic low back pain] were followed. All techniques that were employed are recognized within the chiropractic profession as methods used for the treatment of [low back pain]. Many of the methods used are coimnon to other manual therapy professions” (p. 466-467). After eight weeks of treatment, the 95% confidence intervals based on the raw scores showed that improvement was 1.99 for medicine and 9.03 for the chiropractic group. This research indicates that chiropractic is 457% more effective than medicine for chronic low back pain.
Mackenizie et al. (2014) reported in “Epub ahead of print” that “risk of injury to the head, neck or trunk within 7 days was 76% lower among subjects with a chiropractic office visit as compared to those who saw a primary care physician.”
A paper by Day, Yeh, Franko, Ramirez, and Krupat (2007) published in Academic Medicine stated that the purpose of the article was, “To assess medical students’ knowledge and clinical confidence in musculoskeletal medicine as well as their attitudes toward the education they receive in this specialty” (p. 452). It should be noted that this survey was done at Harvard Medical School. The article continued by stating, “In data reported over the past 15 years, musculoskeletal complaints and injuries have comprised approximately 15% to 30% of primary care visits in the United States and Canada, 20% of emergency room visits in the United States, and 20% of non-routine pediatric visits in Europe” (Day et al, 2007, p. 452). The authors reported, “The students’ concerns about the inadequacy of musculoskeletal education are consistent with both their lack of clinical confidence in examining the musculoskeletal system as well as their lack of cognitive mastery in basic musculoskeletal medicine” (Day et ah, 2007, p. 455). This demonstrates that aside from pulmonary and cardiovascular conditions, musculoskeletal conditions are the most common reason a patient will visit his or her medical doctor. The lack of training is significant, and regulatory bodies in medicine are making corrections at the most fundamental levels. However, there is precious little time to insert more training into an already cramped curriculum. This, again, is a big opportunity for chiropractic, as we are now uniquely positioned to take the lead in academic medicine, but this will go unnoticed unless we position ourselves based upon clinical and academic excellence and lead from within the medical system.
In another study by DiCaprio, Covey, and Bernstein (2003), the authors stated, “On the basis of these reports, it is reasonable to believe that medical students in the United States are not receiving the instruction in musculoskeletal medicine that they need” (p. 565). This paper was published in 2003, nearly 12 years ago. The opportunity has been there for chiropractic to fill that void as the third largest healing profession in the United States and we have only begun to make changes within medicine. An article published by Matzkin, Smith, Freccero, and Richardson (2005), prefaced a paper by stating, “A validated musculoskeletal cognitive examination was given to medical students, residents, and staff physicians in multiple disciplines of medicine to assess the adequacy of their musculoskeletal medicine training” (p. 310). The results of this paper stated, “Seventy-nine percent of the participants failed the basic musculoskeletal cognitive examination. This suggests that training in musculoskeletal medicine is inadequate in both medical school and non-orthopedic residency training programs” (Matzkin et al., 2005, p. 310). That is a significant failure rate by any academic standard and should be cause for concern.
In spite of our far superior education through the curriculum in our CCE (Council on Chiropractic Education) accredited institutions, chiropractors aie still not perceived as experts. It is now becoming clearer that we have spent much too much time leading through politics instead of academia.
Additionally, a paper published by Kelly, Bennett, BraceBrand, O’Flynn, and Fleming (2014) stated, “There is a mismatch between the burden of musculoskeletal medicine seen by non-orthopaedists clinically and the amount of time afforded it in undergraduate training” (p. e39(l)). We have set examples of scholarly published articles that span 11 years pointing to the lack of training in medical school for musculoskeletal conditions, yet the utilization of chiropractic services continues to tumble.
While educating medical students and medical primary care physicians at the doctoral and graduate levels, due to the lack of requisite understanding by these current and future medical providers, we aie forced to communicate at the most basic level. If it were pharmacy, that would be an entirely different story, but when it comes to the musculoskeletal system, primary care physicians’ understanding is very basic and teaching is at the most basic anatomical level. The education starts with basic anatomy and the difference between fracture, tumor, infection, and dislocation care versus pain as sequela to biomechanical failure. Currently, primary care lumps this in with any type of spinal problem and, because of a lack of training, reaches as a first-line referral for drags (both opiates and musculoskeletal relaxants), injections, or surgery, all of which have much poorer outcomes than chiropractic care. Furthermore, these treatments have significant side effects that are often devastating for the lifetime of the patient.
Day et al. (2007) stated, “In 2004, the National Ambulatory Medical Care Survey indicated that musculoskeletal conditions were the number-one reason across the United States for visits to physicians’ offices, with approximately 92.1 million cases reported annually” (Day et al., 2007, p. 452). Even conservatively stating that 60% of these visits have a spinal component, which leaves a tremendous amount of opportunity for the chiropractic profession if, through academics, we can prove that we have the knowledge to be at the forefront of these conditions.
The issue is not the lack of patients, but the lack of chiropractors training medical doctors on how to use chiropractors, with the proviso that the medical doctors see most of the population at some point. Chiropractic academics in the form of postgraduate training and grassroots outreach through clinical excellence and education are the keys that will bring chiropractic to the forefront as experts on primary spine care. It will not be a marketing gimmick, a fancy letter, or a website that will bring chiropractic to the masses. It is marketing thr ough academics, which is the wave of the future.
References
1. Cifuentes, M., Willets, J., & Wasiak, R. (2011). Health maintenance care in work-related low back pain and its association with disability recurrence. Journal of Occupational and Environmental Medicine, 53(4), 396-404.
2. Wilkey, A., Gregory M., Byfield, D., & McCarthy, R W. (2008). A comparison between chiropractic management and pain clinic management for chronic low-back pain in a national health service outpatient clinic. The Journal of Alternative and Complementary Medicine, 14(5), 465-473.
3. Whedon, Mackenzie, Phillips and Lurie (2014). Risk of Traumatic Injury Associated with Chiropractic Spinal Manipulation in Medicare Part B Beneficiaries Aged 66-99, Spine [Epub ahead of print]
4. Day, C. S., Yeh, A. C., Franko, O., Ramirez, M., & Krupat, E. (2007). Musculoskeletal medicine: An assessment of the attitudes and knowledge of medical students at Harvard Medical School. Academic Medicine, 82(5), 452-457.
5. DiCaprio, M. R., Covey, A., & Bernstein, J. (2003). Curricular requirements for musculoskeletal medicine in American medical schools. The Journal of Bone & Joint Surgery, 85-A(3), 565-567.
6. Matzkin, E., Smith, E. L., Freccero, D., & Richardson, A. B. (2005). Adequacy of education in musculoskeletal medicine. The Journal of Bone & Joint Surgery, 87-A(2), 310-314.
7. Kelly, M., Bennett, D., Brace-Brand, R., O’Flynn, S., & Fleming, P. (2014). One week with the experts: A short course improves musculoskeletal undergraduate medical education. The Journal of Bone & Joint Surgery, 96(5), e39(l)-e39(7).
Dr. Mark Studin is an adjunct associate professor of chiropractic at the University Of Bridgeport College Of Chiropractic and a clinical presenter for the State of New York at Buffalo, School of Medicine and Biomedical Sciences for postdoctoral 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.DoctorsPIProgram.com); teaches MRI interpretation and triaging trauma cases to doctors of all disciplines nationally; and studies trends in health care on a national scale (www.TeachDoctors.com). He can be reached at [email protected] or at 631-786-4253.
Dr. Owens 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 [email protected] or www.mdreferralprogram.com or 716-228-3847
