Chiropractic—primary care, neuromusculoskeletal care, or musculoskeletal care? Results of a survey of chiropractic college presidents, chiropractic organization leaders, and Connecticut-licensed doctors of chiropractic

REVIEW

OF

LITERATURE

CHIROPRACTIC—PRIMARY CARE, NEUROMUSCULOSKELETAL CARE, OR MUSCULOSKELETAL CARE? RESULTS OF A SURVEY OF CHIROPRACTIC COLLEGE PRESIDENTS, CHIROPRACTIC ORGANIZATION LEADERS, AND CONNECTICUT-LICENSED DOCTORS OF CHIROPRACTIC Richard Duenas, DC,a Gina M. Carucci, DC,b Matthew F. Funk, DC,c and Michael W. Gurney, DCd

ABSTRACT Background: The Connecticut Chiropractic Association authorized an ad hoc committee to study Connecticut chiropractic scope of practice in January 1999. This committee was chaired by Richard Duenas, DC, and included 4 other Connecticut-licensed doctors of chiropractic who responded to an appeal to participate. Objective: Committee members investigated the terms primary care, primary care provider (PCP) (clinician, physician), neuromusculoskeletal care, neuromusculoskeletal care provider (clinician, physician), musculoskeletal care, and musculoskeletal care provider (clinician, physician) to determine which, if any, apply to the practice of chiropractic. Data Sources: A literature review was performed with in-depth analysis of the definitions of these terms and an interpretation of Connecticut Statutes for chiropractic, comparing the legal description of chiropractic practice to the term definitions. The literature review produced several detailed definitions of primary care and/or primary care provider (clinician, physician); however, no accurate description of neuromusculoskeletal (NMS) care or musculoskeletal care was found. Results: Two opinion surveys were conducted: 1 survey included presidents of accredited chiropractic colleges, as well as leaders of chiropractic organizations throughout the world. The other survey was sent to doctors of chiropractic (DC) licensed in the State of Connecticut. Survey topics addressed definitions of primary care and PCP, the formulation of these terms, neuromusculoskeletal care and neuromusculoskeletal care provider, individual rights in selecting a PCP, and the types of practitioners considered PCPs. The consensus among chiropractic college presidents, organization leaders, and Connecticut-licensed doctors of chiropractic was that the doctor of chiropractic is qualified to provide primary care. Most considered any definition of primary care invalid if the chiropractic profession was not involved in its formulation. The overwhelming majority felt the patient should retain the ultimate choice in determining who should be their PCP. Mission statements of accredited chiropractic colleges were reviewed, paying particular attention to educational goals and professional qualifications of graduates. The committee found these institutions strive to train students in all aspects of primary care. Conclusions: Upon review of the literature and term definitions, interpretation of the statutes pertaining to chiropractic practice, results of both surveys, and review of the chiropractic college mission statements, the committee concluded that the Connecticut-licensed DC, by education, licensure, definition, and intraprofessional consensus, qualifies as a PCP. (J Manipulative Physiol Ther 2003;26:510-23) Key Indexing Terms: Chiropractic; Musculoskeletal Care; Primary Care

a

Private practice of chiropractic, West Hartford, Conn. Private practice of chiropractic, Wethersfield, Conn. c Chiropractic clinic consultant, Triad Healthcare, Inc., Plainville, Conn. d Private practice of chiropractic, Wethersfield, Conn. Submit requests for reprints to: Richard Duenas, DC, DABCN, b

510

557 Prospect Avenue, West Hartford, CT 06105. Paper submitted December 11, 2001; in revised form January 4, 2002. Copyright © 2003 by National University of Health Sciences. 0161-4754/2003/$30.00 ⫹ 0 doi:10.1067/S0161-4754(03)00108-8

Journal of Manipulative and Physiological Therapeutics Volume 26, Number 8

Duenas et al Chiropractic Primary or Specialty Care

INTRODUCTION n recent years, it has largely been the impression of government, private industry policymakers, many health care professions, the general public, and some within the chiropractic profession itself that chiropractic practice is not primary care and should be utilized for the treatment of neuromusculoskeletal or musculoskeletal conditions only.1,2 Consequently, this impression, especially within the third-party payment system, may deter the health care consumer from choosing chiropractic as a naturally based discipline of primary care. Others, however, do consider the training and clinical practice of the doctor of chiropractic (DC) to constitute primary care.3-6 A review of mission statements of chiropractic colleges accredited by the Council on Chiropractic Education (CCE), European Council on Chiropractic Education, Council on Chiropractic Education-Canada, and Australian Council for Chiropractic and Osteopathy reveals, additionally, that these institutions are preparing students to render primary care (Table 1).7-26 This is consistent with the CCE’s stated purpose27 and established standards of chiropractic education and practice.28 According to the Bylaws of the Connecticut Chiropractic Association (CCA), its objectives include: ● To maintain the science of chiropractic as a separate and distinct healing arts profession. ● To protect in every way not contrary to the law, the philosophy, science and art of chiropractic, and the professional welfare of its members. ● To serve as an official spokesman for and representative of the chiropractic profession in the state of Connecticut.29 A plan for the future of chiropractic in the state of Connecticut, established by the CCA in 1998, includes 4 primary strategies of development. One strategy, “To increase access to the patient population”, includes the objective, “...achieving direct access to patients, equitable payment for services provided and protection of the scope of practice in Connecticut.”30 To this end and on inquiry regarding the CCA position on the issues of the DC as a primary care or neuromusculoskeletal care provider, an Ad Hoc Committee on Chiropractic Scope of Practice was formed in January 1999. The committee’s objectives were to: ● Study the terms primary care, primary care provider (clinician, physician) (PCP), neuromusculoskeletal care, neuromusculoskeletal care provider (clinician, physician), musculoskeletal care, and musculoskeletal care provider (clinician, physician). ● Analyze the chiropractic scope of practice in Connecticut according to state statutes. ● Determine how the clinical practice of chiropractic relates to the legal scope of practice and these terms.

I

●

Formulate a CCA position statement on the role of chiropractic practice in Connecticut as primary care and/or neuromusculoskeletal care and/or musculoskeletal care. The committee felt an established CCA position statement on these issues would be essential for the CCA to fulfill its mission, objectives, and strategic plan, and to further the chiropractic profession in the eyes of government, private industry, and the public.

METHODS A Medline, Chiropractic MANTIS Database, and Congressional Information Services Code of Federal Regulations search were performed for the terms primary care, primary care provider (clinician, physician), neuromusculoskeletal care, neuromusculoskeletal care provider (clinician, physician), musculoskeletal care, and musculoskeletal care provider (clinician, physician). The literature obtained was distributed by the chairman for review by committee members. Articles were chosen which would offer insight into the establishment and use of these terms. Seven definitions of primary care and/or primary care provider (clinician, physician) were reviewed in depth.31-38 These definitions were selected for their varied sources of origin (ie, American Medical Association [AMA], World Health Organization [WHO], a medical researcher, US Government, a chiropractic researcher, Institute Of Medicine [IOM], and the insurance industry) and to follow the development of the definitions over the past 33 years. Chapter 372 of the Connecticut General Statutes39 was interpreted for applicability of primary care, neuromusculoskeletal care, and musculoskeletal care to the practice of chiropractic in Connecticut. The committee conducted 2 surveys as follows: Presidents of CCE-accredited chiropractic colleges in the United States and other accredited chiropractic colleges throughout the world, as well as leaders of chiropractic organizations throughout the world were queried in February 1999 for their opinions about the qualifications of the DC in providing primary care, the validity of the term without the participation of the chiropractic profession, groups that should be involved in the process of establishing primary care policy, and individual rights in selecting a PCP (Appendix 1 - online only). The organization leaders were chosen for their not-for-profit status and obtained through the American Chiropractic Association (ACA) 1999 Directory of Members,40 the International Chiropractors Association (ICA) Council Membership Directory 1996-1997,41 and an internet search. All college presidents and organization leaders were called on at least 1 occasion by committee members to remind them to complete and return the survey. Connecticut-licensed DCs were surveyed in March 1999, asking their level of agreement that the DC meets the criteria for each of the 7 definitions of primary care and

511

512

Duenas et al Chiropractic Primary or Specialty Care

Journal of Manipulative and Physiological Therapeutics October 2003

Table 1. Descriptive terminology of chiropractic practice by chiropractic colleges Institution 1 2 3 4

Los Angeles College of Chiropractic Life University Life Chiropractic College West

10

Cleveland Chiropractic College Los Angeles Cleveland Chiropractic College Kansas City New York Chiropractic College The National College of Chiropractic Palmer College of Chiropractic Palmer College of Chiropractic West Parker College of Chiropractic

11

Texas Chiropractic College

12

Western States Chiropractic College Northwestern College of Chiropractic University of Bridgeport College of Chiropractic Logan College of Chiropractic Sherman College of Straight Chiropractic Anglo-European College of Chiropractic* Canadian Memorial Chiropractic College† Institut Francais De Chiropractic Macquarie University, Center for Chiropractic Studies Royal Melbourne Institute of Technology, Chiropractic Unit University of Quebec at Trois Rivieres Council on Chiropractic Education

5 6 7 8 9

13 14 15 16 17 18 19 20 21 22

PHCPr

PHCPh

X

PCPr

PCCl

PCFCP

POE HCPr

SNMSC

PCHCP

G

Other term

X

X X

X

POE, chiropractic health care provider

X X X X

Primary care

X

X X

X X

X

X X

Holistic health model (not allopathic) Chiropractic health care providers

X X X

Primary care

X X X X

X First contact therapists Unknown Not received First contact health care professional

X

X

PHCPr, Primary health care provider; PHCPh, primary health care physician; PCPr, primary care provider; PCCl, primary care clinician; PCFCP, primary care first contact physician; POEHCPr, portal of entry healthcare provider; SNMSC, specialist treatment neuromusculoskeletal conditions; PCHCP, primary contact healthcare provider; G, gatekeeper; CCE, Council on Chiropractic Education; POE, portal of entry. *AECC does not have a “Mission Statement.” Leadership position in health maintenance and prevention for patients of all age groups and walks of life. Describes Chiropractic as a “rapidly expanding primary healthcare profession.” † CMCC recognizes the CCE Educational Standards for Chiropractic Colleges and cites the objective, “the preparation of the Chiropractic doctor as a primary health care provider,” in its Statement of Purpose.

PCP. A second survey in April 1999 sought their opinion of the qualifications of the DC in providing primary care, if the DC is a neuromusculoskeletal provider only, the amount of time they devote to providing primary care, neuromusculoskeletal care and other care in their office, from what health care discipline(s) a PCP should be chosen, and their opinion on individual rights in selecting a PCP. The doctors were given 2 weeks to complete each survey. There were no reminder contacts.

Mission statements of CCE-accredited chiropractic colleges in the United States and other accredited chiropractic colleges throughout the world (N ⫽ 20) were obtained via mail, reviewed for educational goals and descriptive terminology, and tabulated (Table 1). On review of the literature, term definitions, statutes pertaining to chiropractic practice, results of both surveys, and chiropractic college mission statements, the committee

Journal of Manipulative and Physiological Therapeutics Volume 26, Number 8

composed a position statement to be recommended for adoption by the CCA Board of Directors.

RESULTS Literature Review The American health care system is presently undergoing a dramatic transformation. Whether the current trend in utilization of naturally based treatment alternatives is due to disenchantment with allopathic medicine or renewed interest in vitalistic health care,42-45 increased accountability of all health care disciplines will inevitably ensue. Moreover, in the midst of the confusion, a current issue in chiropractic’s own evolution involves taking itself to task to establish a unified identity.46 Enduring scientific scrutiny and the criticism of safety and effectiveness may pale by comparison. One ongoing debate addresses the issue of whether the practice of chiropractic may be considered primary or specialty care. The literature is replete with work by individuals who present convincing evidence that chiropractic education and licensure qualify as primary care and the profession should embrace this fact and publicly advocate it.4-6,47-49 Opponents voice compelling dissent asserting that, in a practical sense, the public perceives the DC as treating neuromusculoskeletal conditions only and utilizes chiropractic care for just that. Thus, the DC rarely practices primary care. This self-fulfilling prophecy extends to chiropractic college clinics, limiting students’ exposure to primary care issues.2,50,51 There are also those who feel the primary care/specialty care debate is largely one of semantics. The patient-centered practitioner who provides efficient, coordinated treatment should simply be conscious of professional limitations and focus on the well-being of patients.52

Definitions Primary care and primary care provider (clinician, physician). Several definitions of primary care and primary care provider were obtained from the literature. The definition is first cited and a discussion follows. “The delivery of first contact medicine, the assumption of longitudinal responsibility for the patient regardless of the presence or absence of disease and the integration of physical, psychological, and social aspects of health to the limits of capability of the health personnel.”31,32

Recognizing that the state of graduate medical education and subsequently the practice of medicine had become a process of specialization and fragmented in the delivery of health care, the AMA sought external examination from the Citizens Commission on Graduate Medical Education to study and recommend improvements for the organization of graduate medical education. It was the second time this century the AMA had commissioned an external review of the medical profession. The first study was the Flexner Report, which resulted in the standardization of “American

Duenas et al Chiropractic Primary or Specialty Care

medical education and, therefore,...medical care of our citizens.”32 The purpose of the latter study was to address the needs of the public for “. . .physicians who are interested in them as human beings instead of their organs or diseases; who appear to be willing to make available comprehensive, continuing medical service, . . . .”32 Three general objectives for the study were listed as follows: 1. “A determination of the various kinds of professional medical careers necessary to provide...society with medical services of a quality limited only by available medical knowledge. To the extent it is feasible, this should include an estimation of the quantitative distribution of the differing medical talents within the medical profession as a whole.” 2. “Definition of the general and specific characteristics of educational programs beyond medical school which will most effectively provide medical school graduates with the competencies necessary for these professional careers. This should present the ideal design of graduate educational programs in medicine.” 3. “A proposal for modifying or otherwise altering existing programs so that they may approach or attain ‘ideal’ as quickly as possible.”32 The 1 component of this definition which may disqualify the DC from providing primary care is the term medicine. However, the term as defined at present is not specific to allopathic medicine and may be said to include all health care disciplines. “Primary Health Care is essential health care made universally accessible to individuals and families in the community by means acceptable to them, through their full participation and at a cost that the community and country can afford. It forms an integral part both of the country’s health system of which it is the nucleus and of the overall social and economic development of the community.”33

This study concentrates on the determination of Primary Health Care and does not necessarily seek to define PCP. Conducted by the WHO, it was meant to address the pressing need to establish a foundation for primary health care throughout the world as “. . .part of social development and in the spirit of social justice.”33 It was recognized that there was a widening gap between affluent countries and developing nations, as well as within individual countries themselves, regarding the availability and delivery of health care. The trends toward increased sophistication, specialization, concentration of health care in urban areas, access to comprehensive health care by only the affluent of any population, high cost of care with low health benefit, as well as the loss of contact between those providing and those receiving care led to the conclusion that a more practical approach had to be developed. The WHO and the United Nations Children’s Fund conducted the joint report on primary health care in September

513

514

Duenas et al Chiropractic Primary or Specialty Care

Journal of Manipulative and Physiological Therapeutics October 2003

1978. The purpose and objectives were to exchange information on the development of primary health care and to promote the primary health care concept in member states. It addressed the following topics: review the importance of primary health care as integral to the development of society, establish criteria and a worldwide policy for primary health care, and formulate a strategy for the availability and delivery of primary health care to all people within a country. Most of the report was written from the perspective of public health, however the individual’s cultural qualities are respected and accounted for in describing the system of primary health care. The interest in basic health care integrated with sound community health in the areas of agriculture, sanitation, hygiene, water supply, public works and communication, proper nutrition, and self-responsibility are consistent with the principles of chiropractic practice. “First-contact care, coordination, comprehensiveness.”34

longitudinality,

and

This was written to identify the essential functional components of primary care as opposed to providing an arbitrary definition. The main objectives of the report are review of current definitions, obtain and review data of conditions seen by various specialists, and establish criteria and qualitative measures for primary care. A definitive determination of primary care would be beneficial to society, to the establishment of health care policy, and to examine and compare the attainment of primary care. It is argued that the empirical approach is inappropriate in defining the term. Starfield34 demonstrates that the conditions common in primary care practices are also seen in other specialties. She contends the type of diagnosis or variety of diagnoses does not distinguish primary care from nonprimary care specialties. Additionally, the assumption that primary care offices provide a larger percentage of preventive health care measures is not supported by the data nor is the common belief that more patients continue treatment in the primary care practice only. “Thus, primary care and specialty care cannot be differentiated using descriptions of their characteristics in data currently available.”34 Over the past 20 years, much has been gained in characterizing primary care in accordance with Starfield’s contributions. To the chiropractic profession, this method of analysis would be useful in measuring the degree to which a practitioner provides primary care. The 4 attributes of primary care mentioned here (first-contact care, coordination, longitudinality, and comprehensiveness) are recognized as traits of chiropractic practice.28,53 The 1 attribute which has been identified as a possible disqualifying term for chiropractic primary care is comprehensiveness.2 However, Starfield34 stated the term does not require the full provision of a broad range of services but rather recognition of a problem, arrangement for appropriate care, and explicit notification of the services provided within the facility.

“Primary care is distinguished by being ‘front-line’ or ‘first contact’ care, person centered (rather than disease or organ system-centered), and comprehensive in scope, rather than being limited to illness episodes or by the organ system or disease process involved. Primary care is distinguished from other levels of care by the scope, character, and integration of the services provided. Primary care practitioners deal with ambulatory patients at the initial interface of the individual with the health care system. Patients present with a variety of illnesses, ailments and concerns that represent early stages of disease that are not easily classified by organ system or diagnostic label. Often, patients have multiple problems, and a rational approach to one problem may make another worse. Primary care thus provides an integrating function, balancing the multiple requirements of the patient’s problem(s), using information developed from many sources, and developing a strategy to help each individual achieve the highest level of function possible.”35

The United States Department of Health and Human Services (DHHS), Public Health Service (PHS), and the Agency for Health Care Policy and Research (AHCPR) held plenary sessions January 13-15, 1991, addressing primary care research in the areas of functional and health status, minority health, medical effectiveness, managed care, rural health, prevention and prevention implementation, and classification and case mix. The conference director, Heddy Hibbard, RN, MPH, and the Director for the Division of Primary Care, Paul A. Nutting, MD, MSPH, identified the need to reform the health care system with a greater emphasis on primary care. The reductionism approach to health care had led to a trend toward specialty and subspecialty care at the expense of improving our research base in the study of common diseases and conditions such as headache, low back pain, insomnia, fatigue, and depression, as well as in the identification and care of undifferentiated disease processes. The introduction to the conference asked the same basic question chiropractic asks, “Why, for example, does one person respond to stress with chronic headaches while another responds with peptic ulcer disease?”35 Health care policy financing was conveyed with a strong emphasis on funding for primary care research and development. Key purposes of this article included: “First, we need additional research to expand the knowledge base that supports the practice of primary care. Second, additional research is needed on the biobehavioral environment of primary care. The importance and therapeutic value of the practitioner-patient relationship has long been recognized by primary care practitioners but only recently has it been the subject of serious study. Third, health services research on the organization and financing of primary care is needed to support whatever health care system structure results from the upcoming reform.”35 Primary care is defined by the authors in the first article of the conference, Research in Primary Care: A National Priority, with a very good understanding of the contributions provided by different disciplines. The definition is comprehensive, considered lengthy by some, but largely

Journal of Manipulative and Physiological Therapeutics Volume 26, Number 8

addresses the issues which characterize the practice of primary care. It provides for the application of chiropractic principles of practice within the health care system, is patient-centered, and recognizes the importance of the doctor to respond to all aspects of patient health and illness. Multiple perspectives are emphasized in arriving at the definition to assure a diverse nature of primary care and stimulate interest in conservative and innovative research. Chiropractic care would be well suited for this definition, as the emphasis is on patient-centered value, the patientdoctor relationship, and the integration of many sources of care. The phrase “comprehensive in scope” may pose some difficulty with the profession. However, it is taken to mean “...rather than being limited to illness episodes or by the organ system or disease process involved.”35 Applying this primary care definition to chiropractic would lead to improved application of care to patients and lend much to the diversity of practice and the research that the authors call for in their paper. “First contact care, accessible to those who need it, available and attainable, acceptable to the consumer of health, affordable, accountable, continuous, longitudinal, coordinated, provides for the general health needs of the patient, provides comprehensive care and services for the widest possible range of common conditions, provides essential care and basic services, provides an assessment of health, provides education and counseling, and involves the community in which it is located.”36

This description of primary care, developed from a literature review, recognizes the term may be defined from 3 perspectives—society, provider, and patient. Typically, the literature is from the perspective of the provider (medical profession) and society (public health) with little or no participation from the individual. This observation is important, because the American principles of individual freedom, liberty, choice, and self-determination may be compromised. Kranz36 makes note of this issue and points out that authors of primary care research often assume, “...the lay patient/consumer perspective closely parallels the physician/provider orientation.” This is risky, as evidenced by patients turning their backs on conventional medical care for naturally based health care despite the lack of insurance coverage.42 Two particular definitions from the IOM and Starfield, along with other sources, are integrated into this definition to attain the attributes of primary care. They are well reviewed and provide an excellent understanding of the character of primary care. Those listed include direct contact, accessibility (availability, attainability, acceptability, accommodation, and affordability), accountability, continuity of care, comprehensive care, essential or basic health care, assessment, education, counseling, community involvement, and other components. Of these, comprehensive care and essential care or basic services would appear to disqualify the DC from providing primary care.

Duenas et al Chiropractic Primary or Specialty Care

Kranz36 did not comment on the chiropractic profession’s ability to meet his definition for primary care but did make some important observations in his concluding remarks: 1. Defining primary care is “...somewhat of a conundrum - it can only be defined by consensus in words that themselves are inadequately defined.” 2. Groups typically address primary care from their own parochial or biased point of view. 3. Invariably the predominant allopathic perspective on health care will influence the process. 4. The debate fails to recognize the more important participant in health care - the patient. “Primary care is the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community.”37

Formulated by the IOM as the second review of the topic, this report encompasses the creation of the Committee on the Future of Primary Care. This committee, consisting of 19 esteemed individuals from academia, private practice, the insurance industry, medical organizations, and government, conducted literature reviews of primary care, interviews, surveys, and workshops. Invited guests were from academic allopathic medicine, medical organizations, insurance associations, philanthropic groups, and government agencies. The chiropractic profession did not participate in any of these functions. This study is considered the most up-to-date and comprehensive report on primary care. Considered an official document recognized by the US National Institutes of Health (NIH), it is written from the perspective of allopathic medicine with absolutely no participation from the chiropractic profession or any other naturally based health care discipline. Nevertheless, the final definition may be applied quite well to chiropractic care. Primary care, in this study, is defined in a functional sense. It offers a comprehensive definition for which the practice of chiropractic may qualify. It makes 30 recommendations for government and private policymakers who would have a profound effect on the manner in which health care funding is spent, the application of research funding, and how the delivery of health care is established. A question that may be posed to the IOM is its tolerance to having 2 independent models of health care coexist in the primary care field. To have 2 models would require a respectful recognition and willingness of each discipline to work interdependently for the good of the individual, family, and community. “Primary care providers may include general or family practice physicians, geriatricians, internal medicine physicians, pediatricians, physician assistants and nurse practitioners. Primary care providers are defined as health care practitioners whom members are able to select as their first point of entry into the system and who are defined by the plan as primary care providers for

515

516

Duenas et al Chiropractic Primary or Specialty Care

that purpose. Obstetricians and gynecologists whom the health plan considered to be primary care providers are also included in this measure.”38

The National Committee for Quality Assurance (NCQA), in developing its Health Plan Employer Data and Information Set (HEDIS), has established a policy on the term primary care provider. In addressing the number and percent of PCPs who accept new members with no restrictions in health care planning, the NCQA arbitrarily sites specific types of PCPs. With the exception of the phrase, “...whom members are able to select as their first point of entry into the system...,”38 there is no measure of identifying the character of primary care. Thus, the opportunity for a patient to utilize the DC as their PCP is not supported in this description. Neuromusculoskeletal care, neuromusculoskeletal care provider (clinician, physician), musculoskeletal care and musculoskeletal care provider (clinician, physician). The terms neuromusculoskeletal care, neuromusculoskeletal care provider, musculoskeletal care, and musculoskeletal care provider were searched and are discussed. Neuromusculoskeletal, according to Taber’s Cyclopedic Medical Dictionary, concerns “...both nerves and muscle.. . .”54 Neither the Lexicon of the Joint Commission on Accreditation of Healthcare Organizations nor the Federal or State of Connecticut governments offer a formal definition for this term.55-58 The Medical Subject Headings (MESH) of the National Library of Medicine does not include the term in its word search list. The ACA publishes the Journal of the Neuromusculoskeletal System. According to Editor-in-Chief, Scott Haldeman, DC, MD, PhD, the journal acknowledges the concept that the nervous, muscular, and skeletal systems are integrated. A disorder of 1 system will impact the function of the other (S. Haldeman, DC, MD, PhD, personal conversation, August 20, 1999). A private alternative medicine managed care group, however, describes neuromusculoskeletal as, “...conditions which display symptoms of and/or signs related to the nervous, muscular and/or skeletal body systems.”1 Failure to find even a satisfactory definition of neuromusculoskeletal care made it impossible to find a definition of neuromusculoskeletal care provider (clinician, physician). Taber’s Cyclopedic Medical Dictionary does not adequately address the type of treatment that may be expected from a practitioner of neuromusculoskeletal care.54 The provider may be of an allopathic discipline where care would be primarily pharmaceutical or of a chiropractic discipline where care would include manual, nutritional, and/or other physical treatment. Conditions treated may range from simple strains to muscular dystrophy, nerve compression to multiple sclerosis. Thus, the use of these terms appears unclear. Taber’s Cyclopedic Medical Dictionary defines the term musculoskeletal as, “ . . . pertaining to the muscles and skeleton. . . . ”54 The Joint Commission on Accreditation of Health Care Organizations does not define musculoskeletal,

Journal of Manipulative and Physiological Therapeutics October 2003

musculoskeletal care, or musculoskeletal care provider (clinician, physician). It does, however, recognize the North American Academy of Musculoskeletal Medicine, “ . . . an organization composed of 350 physicians interested in promoting and conducting scientific studies in manipulative and manual medicine.”55 The federal government recognizes the term as it pertains to the National Institute of Arthritis and Musculoskeletal and Skin Diseases.56,57 The state of Connecticut had no formal definitions for musculoskeletal, musculoskeletal care or musculoskeletal care provider (clinician, physician).58 With this paucity of established definitions for musculoskeletal, it would be reasonable to consider the term inadequate when describing the chiropractic profession.

Connecticut General Statutes Title 20, Chapter 372 of the Connecticut General Statutes39 reads, in part, “Sec. 20-24. Definitions. As used in this chapter: (1) The practice of chiropractic means the practice of that branch of the healing arts consisting of the science of adjustment, manipulation and treatment of the human body in which vertebral subluxations and other malpositioned articulations and structures that may interfere with the normal generation, transmission and expression of nerve impulse between the brain, organs and tissue cells of the body, which may be a cause of disease, are adjusted, manipulated or treated. (2) The term ‘chiropractic,’ ‘doctor of chiropractic,’ ‘chiropractor,’ and ‘chiropractic physician’ are synonymous, and mean a practitioner of chiropractic as defined in subdivision1 of this section. (3) The term ‘accredited chiropractic college or colleges’ means only those institutions which are at the time of the applicant’s graduation, either (A) accredited by the Council on Chiropractic Education or other specialized accrediting agency recognized by the United States Department of Education or (B) if located outside the United States, deemed by said council to meet its educational standards.”39

“Sec. 20-28. Examination. Scope of practice.” includes, “(b) Any chiropractor who has complied with the provisions of this chapter may: (1) Practice chiropractic as defined in Section 20-24, but shall not prescribe for or administer to any person any medication or drug included in materia medica, except vitamins, or perform any surgery or practice obstetrics or osteopathy, (2) Examine, analyze and diagnose the human living body and its diseases, and use for diagnostic purposes the x-ray or any other general method of examination for diagnosis and analysis taught in any school or college of chiropractic which has been recognized and approved by the State Board of Chiropractic Examiners, (3) Treat the human body by manual, mechanical, electrical or natural methods, including acupuncture, or by use of physical means, including light, heat, water or exercise in preparation for chiropractic adjustment or manipulation, and by the oral administration of foods, food concentrates, food extracts or vitamins, (4) Administer first aid and, incidental to the care of the sick, advise and instruct patients in all manners pertaining to hygiene and sanitary measures as taught and approved by recognized chiropractic schools and colleges.”39

Of note in the interpretation of these statutes is the phrase in Section 20-24(1), “ . . . which may be a cause of disease,

Journal of Manipulative and Physiological Therapeutics Volume 26, Number 8

Duenas et al Chiropractic Primary or Specialty Care

Fig 1. Percent of college president and organization leader respondents who agreed the DC qualifies as a PCP under each definition. . . . . ”39 This reference is made to the type of disease that may be caused by, “ . . . vertebral subluxations and other malpositioned articulations and structures that may interfere with the normal generation, transmission and expression of nerve impulse between the brain, organs and tissue cells of the body, . . . ”39 Since interference with nerve impulses may adversely affect virtually any human physiological function, it could be argued that, in accordance with this description, chiropractic practice may address any disease of the human body. In Section 20-28(b),2 the phrase, “Examine, analyze and diagnose the human living body and its diseases . . . ”39 also holds particular significance. There are no distinct restrictions placed on the type of diagnoses and diseases investigated by the DC. The methods of treatment, however, are delineated and specifically exclude several allopathic procedures. In view of these limitations, though it is not specifically stated in the statute, professional ethics would dictate that if the DC considers his or her particular expertise insufficient or contraindicated for the safe and effective treatment of a particular diagnosis or disease, a referral is indicated with appropriate follow-up and/or coordination of care. It is evident that the general parameters of chiropractic practice described by this statute would easily fit any of the current definitions of primary care.

Survey 1 Surveys were returned by 13 (59%) of 22 accredited chiropractic college presidents and 14 (38%) of 37 chiropractic organization leaders. Question 1A. Respondents were asked to indicate whether or not they agreed that the DC qualifies as a PCP under each

definition of primary care and/or PCP. Figure 1 lists the author(s) and year of each definition and the percentage of respondents who agreed the DC qualifies as a PCP. Questions 1B and 1C. Respondents were asked to select the words or statements in each definition that would disqualify the DC from PCP status and to offer comment. Table 2 lists comments on each definition. Question 2. The college presidents (N ⫽ 13) and organization leaders (N ⫽ 14) were asked whether a definition of primary care would be valid if the chiropractic profession was not involved in the formulation process. One (8%) of 13 college presidents and 1 (7%) of 14 organization leaders considered the definition of primary care valid under these circumstances. Question 3. This asked which group(s) should determine the type of discipline an individual should use as their PCP. All college presidents responding and 13 (93%) of 14 organization leaders felt the patient should make this determination. Question 4. This asked who should decide on the specific provider to be an individual’s PCP. Again, all college presidents responding and 13 (93%) of 14 organization leaders felt the patient should decide. Question 5. The college presidents and organization leaders were asked if more than 1 healing art discipline should be available as a PCP. Twelve (92%) of 13 college presidents and 11 (79%) of 14 organization leaders answered yes. Question 6. This asked which type(s) of providers should be available to individuals as PCPs in any health care system developed. Of the various choices presented, all college presidents responded that a medical doctor (MD)/Doctor of Osteopathy (DO) and DC/Doctor of Naturopathy (ND)

517

518

Duenas et al Chiropractic Primary or Specialty Care

Journal of Manipulative and Physiological Therapeutics October 2003

Table 2. College president and organization leader comments offered for primary care and primary care provider (clinician, physician) definitions Definition 1. Millis32

2. WHO33

3. Starfield34

4. Hibbard and Nutting35

5. Krantz36

6. Donaldson et al37

7. NCQA38

Comments More comprehensive than DC laws and capabilities The DC would be required to treat infections, for example, as well as diagnose Chiropractic objectives are not the same as medicine’s; therefore, the DC would not deliver first contact medicine If medicine is changed to health care, then this is a good definition Medicine implies pharmaceuticals and surgery Clearly Chiropractic scope Essential may be debatable; needs a definition “Of which it is the nucleus” would disqualify the DC Chiropractic is an integral part of the community health team Comprehensiveness has a certain meaning within the medical community and general community; would likely need to include ability to handle acute trauma Infers the DC would need to be responsible for secondary and tertiary care by other providers Does not have enough intrinsic meaning to be useful as a definition DC not available for 24-hour care DC does not treat cancer or heart disease Health care policymakers would not consider chiropractic care comprehensive in scope Very good definition since it includes person-centered rather than disease-centered Comprehensive and widest possible range are problem terms, since the DC scope of practice may not include all conditions Good definition since DCs educate and counsel in the areas of prevention, nutrition, stress, and exercise No single practitioner can treat all things DCs do provide comprehensive care and services for the widest possible range of a community’s conditions DC disqualified under this definition, since (s)he cannot handle a large majority of health care needs DCs can do this with some limitations Definition is broad enough to fit many types of providers DCs do these things regularly No disqualifying terms, we could strive to follow this definition and stay within our scope Definition is for insurance purposes Cites specific medical specialties only Good definition if patient can choose a competent DC as point-of-entry DC graduates are easily capable of meeting the standards set for physician assistants and nurse practitioners who have limitations on use of medications and surgery as part of their licenses

DC, doctor of Chiropractic; NCQA, National Committee for Quality Assurance.

should be available. Nine (64%) of 14 organization leaders responded in kind.

Survey 2 In part 1 of this survey, 674 surveys were mailed to Connecticut-licensed DCs, and 20% were returned. Respondents (N ⫽ 138) were asked to rate their appropriate level of agreement that the DC qualifies as a PCP under the aforementioned definitions of primary care. Figure 2 lists the survey results. In part 2, 200 (30%) of 674 DCs responded to questions 1-3 regarding DC-PCP qualifications (Table 3). With respect to descriptions of “other” services rendered in question 3, the following statements were provided: ● Family practice ● Nutritional assessment/treatment ● Occupational health, ergonomics, and preemployment screening ● Sports medicine ● Exercise and rehabilitation

●

Environmental medicine Stress management and counseling ● Acupuncture/acupressure ● Teaching the chiropractic principles ● Treatment of organic illnesses or somatovisceral disorders ● Subluxation correction ● Turn the power on Several respondents stated that it was impossible to separate PCP activity from neuromusculoskeletal activity because, while treating a NMS problem, they may be asked about a systemic problem or vice versa. Some respondents commented they could not define their practices in medical or allopathic terms, such as PCP or NMS, since they practice chiropractic 100% of the time. One respondent urged that chiropractic should be uniquely defined so that “...every American should have the ability and knowledge base to use chiropractic for their own benefit. Public choice has created chiropractic and it will move legislative and economic trends. Educate the public.” ●

Journal of Manipulative and Physiological Therapeutics Volume 26, Number 8

Duenas et al Chiropractic Primary or Specialty Care

Fig 2. Number and percent of Connecticut-licensed DC respondents who agreed (agree, strongly agree responses) and who were neutral in their response to whether the DC qualifies as a PCP under each definition. Table 3. Response to doctor of Chiropractic-primary care

Table 4. Response to type of discipline qualified to provide

provider qualifications

primary care

1. The Doctor of Chiropractic is qualified as a Primary Care Provider. Yes: 168 (84%) No: 23 (12%) Yes/No: 2 (1%) Abstain: 7 (4%) 2. The Doctor of Chiropractic is a Neuromusculoskeletal Provider only. Yes: 23 (12%) No: 166 (83%) Yes/No: 1 (⬍1%) Abstain: 10 (5%) 3. In your practice, indicate the percentage of time (total must equal 100%): A. You practice as a Primary Care Provider 1. 10 (5% of respondents) practiced primary care 100% of the time. 2. 28 (14% of respondents) practiced primary care 50-99% of the time. 3. 138 (69% of respondents) practiced primary care 1-49% of the time. 4. 17 (9% of respondents) practiced primary care 0% of the time. 5. 7 (4% of respondents) mis-answered. B. You practice as a Neuromusculoskeletal Provider 1. 13 (7% of respondents) practiced NMS care 100% of the time. 2. 148 (74% of respondents) practiced NMS care 50-99% of the time. 3. 19 (10% of respondents) practiced NMS care 1-49% of the time. 4. 12 (6% of respondents) practiced NMS care 0% of the time. 5. 8 (4% of respondents) mis-answered. C. Other 1. 5 (3% of respondents) practiced other care 100% of the time. 2. 2 (1% of respondents) practiced other care 50-99% of the time. 3. 31 (16% of respondents) practiced other care 1-49% of the time. 4. 162 (81% of respondents) practiced other care 0% of the time.

Question 4. A Primary Care Provider should be (there can only be up to ONE yes answer to this question) (Table 4 shows response).

Primary care provider option

Yes

Percent

No

Percent

MD or DO ONLY DC or ND ONLY MD or DO OR DC or ND MD or DO AND DC or ND

14 4 44 143

7% 2% 22% 72%

186 196 156 57

93% 98% 78% 29%

MD, medical doctor; DO, Doctor of Osteopathy; DC, Doctor of Chiropractic, ND, Doctor of Naturopathy.

Table 5. Response to type of discipline available as PCP in any American health care system Primary care provider option

Yes

Percent

No

Percent

MD or DO ONLY DC or ND ONLY MD or DO OR DC or ND MD or DO AND DC or ND

13 6 43 151

7% 3% 22% 76%

187 194 157 49

94% 97% 79% 25%

MD, medical doctor; DO, Doctor of Osteopathy; DC, Doctor of Chiropractic; ND, Doctor of Naturopathy.

Question 5. Should every American have the right in any health care system that is created (there can only be up to ONE yes answer to this question) to select a Primary Care Provider (Table 5 shows response).

Chiropractic College Mission Statements The majority of accredited chiropractic colleges in the United States (15 of 16; 94%) and, indeed, the majority of chiropractic colleges worldwide (16 of 22; 73%) utilize the term primary care provider or a synonymous term when describing the educational preparation of their students. Figure 3 lists the various terms used by CCE-accredited chiropractic colleges in their mission statements.

DISCUSSION Based on this study, including primary care definitions, the definition of chiropractic, education, licensure, intrapro-

519

520

Duenas et al Chiropractic Primary or Specialty Care

Journal of Manipulative and Physiological Therapeutics October 2003

Fig 3. Terms used by accredited chiropractic colleges to describe preparation of the chiropractic student.

fessional consensus, and clinical practice, the CCA Ad Hoc Committee concluded the Connecticut-licensed DC is qualified to provide primary care.

Definition of Primary Care While the committee’s analysis of 7 primary care definitions revealed some terms which may bring into question the primary care qualifications of the DC, a review of those terms and the context in which they are used was not considered to preclude the DC from practicing primary care. 1. Medicine. “ . . . the science and art of diagnosing, treating, curing, and preventing disease, relieving pain, and improving and preserving health. . . . ”59 While some DCs argue that chiropractic does not seek to diagnose, treat, cure, and prevent disease, or is even interested in addressing disease, the mission statements and curricula of CCE-accredited colleges are clear in establishing that the DC is trained to address the diagnosis, treatment, cure, and prevention of diseases or conditions affecting the human being. The term is not specific to the allopathic discipline and arguably may include all disciplines of the healing arts. The most contemporary and comprehensive definition from the IOM does not make the distinction of practicing medicine.37 2. Comprehensiveness. This term is addressed in the Starfield definition.34 She points out that the provider need not render a broad range of services but rather recognize problems presented by the patient, give explicit notification of the services provided in the facility, and arrange for appropriate patient care. Furthermore, as Bowers and Mootz52 observe, “no physician, chiropractic or medical, is truly comprehensive in delivery of primary care.” 3. Widest possible range of common conditions. According to the IOM, this phrase connotes the provider act as a patient advocate.37 A full range of patient concerns are addressed and managed in the primary care practice, the scope of which includes acute care, chronic

care, early detection and prevention, and coordination of referrals. To “manage” the patient throughout the scope implies the clinician “. . .direct[s] or control[s] the use of. . .”60 health care services. The definitions of primary care and primary care provider have undergone periodic refinement over the last 30 plus years as a result of ongoing study by government agencies, academic and allopathic groups, insurance associations, philanthropic interests, private industry, and individuals. Little contribution has been made by health care consumers. Furthermore, the chiropractic profession has not participated in any group studies involving formulation of a definition. Thus, without significant input from the health care consumer and active involvement of the chiropractic profession, a definition would be limited to the predominant allopathic model of health care. The inclusion of consumer opinion for determining the type of primary care discipline and specific provider is a highly regarded concept revealed in studies of this kind.

Definition of Chiropractic Established by the CCE and largely adopted by all CCEaccredited colleges, the definition of chiropractic adds support to the position that the DC qualifies as a PCP. “The application of science in chiropractic concerns itself with the relationship between structure, primarily the spine, and function, primarily coordinated by the nervous system of the human body as that relationship may affect the restoration and preservation of health. Further, this application of science in chiropractic focuses on the inherent ability of the body to heal without the use of drugs or surgery. The purpose of chiropractic professional education is to provide the doctoral candidate with a core of knowledge in the basic and clinical sciences and related health subjects sufficient for the doctor of chiropractic to perform the professional obligations of a primary care clinician. As a gatekeeper for direct access to the health delivery system, the doctor of chiropractic’s responsibilities as a primary care clinician include wellness promotion, health assessment, diagnosis,

Journal of Manipulative and Physiological Therapeutics Volume 26, Number 8

and the chiropractic management of the patient’s health care needs. When indicated, the doctor of chiropractic consults with, comanages, or refers to other health care providers. . . . The accreditation criteria indicate the minimum education expected to be received in the accredited programs and institutions that train students as primary health care providers.”28 Describing chiropractic as a neuromusculoskeletal or musculoskeletal profession is counter to the character of chiropractic in caring for the human being as a whole rather than the illness or a particular physiological system. This reduces the profession and fractionates health care, which is precisely what the first study on primary care sought to avoid.32 The terms neuromusculoskeleta and musculoskeletal are vague with little to no descriptive support in the literature. Some DCs may choose to limit their practice to neuromusculoskeletal conditions, yet this does not fully describe the chiropractic discipline. This description limits the opportunity for patients in the health care system to fully benefit from chiropractic care. In general, it limits consumer choice for a naturally based approach to their primary health care needs and would run counter to the IOM’s goal to assure a patient-centered health care system that is “respectful of and responsive to individual patient preferences, needs, and values.”37 The CCE clearly structures chiropractic education to establish competencies in the “primary care role of the doctor of chiropractic.”28,61 With this mission to prepare the student in primary care, the CCE assures the Doctor of Chiropractic Degree Program accreditation encompasses an adequate number of instructional hours, a curriculum consistent with whole body health care study, competent clinical skills, and quality care with instruction provided by instructors with credentials in their respective fields of study. Accordingly, achievement of these goals helps assure the DC is prepared to answer the call to primary care. Postgraduate education to improve primary care qualifications may be pursued in pediatrics, family practice, behavioral health, neurology, and nutrition.

Connecticut General Statutes The Connecticut General Statutes clearly recognize the CCE as the accrediting body for establishing standards of chiropractic education. In fact, these statutes dictate that candidates for licensure must have graduated from a CCEaccredited (or equivalent) chiropractic college. Review of those chiropractic college mission statements reveals that their training includes the application of current scientific knowledge of health and disease in preparing the DC to render primary care. Thus, Connecticut credentials the DC consistent with his or her professional training, that is, as a PCP.

Duenas et al Chiropractic Primary or Specialty Care

Intraprofessional Consensus Based on the results of the second survey, the majority of Connecticut-licensed DCs consider themselves qualified to practice primary care. Additionally, only 12% consider the DC to be a neuromusculoskeletal provider only. In clinical practice, the majority of these respondents report that up to half of their time is spent providing primary care service. The majority of chiropractic college presidents, association leaders, and Connecticut-licensed DCs who responded to the surveys felt chiropractic practice closely fits most of the given definitions of primary care. There was also general agreement that the profession should be involved in the formulation of any definition of primary care, and the patient should have the right to choose an MD or DO, as well as a DC or ND, as their PCP. This illustrates a need for our health care system to be more responsive to and inclusive of other healing arts practitioners and health care consumers. Historically, the chiropractic profession, by virtue of its distinct naturally based paradigm of health care, evolved independent of allopathic medicine. As such, it has made every effort to establish itself as a first-contact health care discipline capable of addressing the total health care needs of the patient, recognizing that providers from all disciplines serve important positions on the health care team. This practice is evident in the varied and generalist health care services provided by DCs throughout the twentieth century. These services included obstetrics, pediatrics, minor surgery, general health care, and care for the handicapped in the outpatient and inpatient setting.62-64 This chiropractic primary care role is carried forward into the managed care system with the establishment and successful utilization of the chiropractic primary care network, Alternative Medicine, Inc.65 With a formal recognition of chiropractic primary care, the profession may further its scientific development with research directed at the effect of chiropractic care on the whole individual rather than musculoskeletal conditions only. It provides the profession with the impetus to develop its natural and holistic approach to health care with the opportunity to develop specialties within the profession. It is illogical to develop primary care from a specialty base. A naturally based healing art provides choice and opportunity for the nation to reduce its reliance on pharmaceutical and surgical intervention, often shown to be detrimental to the individual and environment. Furthermore, the chiropractic profession, as a primary care discipline, may ably contribute to the full spectrum of dialog for much needed improvements in the United States health care system. This choice of primary care is consistent with society’s values of self-responsibility, self-determination, and selfempowerment and supports the IOM’s goal in 1996 to assure a patient-centered health care system that is “respectful of and responsive to individual patient preferences, needs, and values.”37 This goal is important enough to be

521

522

Duenas et al Chiropractic Primary or Specialty Care

reaffirmed by the IOM in its 2001 report calling for a patient-centered health care system that is “respectful of and responsive to individual patient preferences, needs, and values and ensuring patient values guide all clinical decisions.”66

CONCLUSION The committee set out to apply the terms primary care, neuromusculoskeletal care, or musculoskeletal care to the practice of chiropractic, particularly in Connecticut. The evidence supports chiropractic as a primary care profession and the Connecticut-licensed DC as qualified to provide primary care. The study also revealed the DC’s interest in providing neuromusculoskeletal or musculoskeletal specialty care. It was very clear that health care consumer/ patient choice is very important, if not essential, when the type of primary care discipline and the specific provider is to be determined by the individual. We propose that all primary care healing arts professions, including chiropractic, should be included in the formal study and practice of primary care at the governmental, industrial, interprofessional, and consumer levels. A partisan authoritarian system fails under its own weight and self-indulgence. Our health care system may improve only when all healing arts professions are respected and able to contribute to the formulation of health care policy for the present and future. This respects the citizen’s liberty to choose a primary health care approach consistent with their way of life. Further study should be conducted to determine the economic effects of chiropractic primary care throughout all types of communities within the health care system. For instance, chiropractic treatment effects on pharmaceutical and hospital utilization and cost per diagnostic episode should be investigated. Investigation of allopathic primary care from the chiropractic perspective and chiropractic primary care from the allopathic perspective are suggested. Finally, investigating patient or health care consumer perspectives of chiropractic and allopathic primary care and the reasoning of such perspectives should be undertaken.

ACKNOWLEDGMENTS We extend our gratitude to the 1998-1999 CCA Board of Directors for recognizing the necessity of this study and authorizing the formation of the Ad Hoc Committee. Malcolm Doyle and Marge LaCroix were instrumental in helping this project run smoothly; we appreciate their assistance. We thank Sheryl Horowitz, PhD, for her guidance in preparing and reviewing the surveys.

REFERENCES 1. An overview of credentialing guidelines. Sacramento (CA): Landmark Chiropractic Independent Practice Associations; 1997.

Journal of Manipulative and Physiological Therapeutics October 2003

2. Nelson CF. Chiropractic scope of practice. J Manipulative Physiol Ther 1993;16:488-97. 3. Brick LL. The future of chiropractic medicine: a primary role. Colorado Chiropr J 1999;4:11-8. 4. Ciancuilli A. Chiropractic: a primary care gatekeeper. Des Moines: Foundation for Chiropractic Education and Research; 1992. p. 1-14. 5. Gonyea MA. The role of the doctor of chiropractic in the health care system in comparison with doctors of allopathic medicine and doctors of osteopathic medicine. Des Moines: Foundation for Chiropractic Education and Research; 1993. p. 7. 6. Sokoloff TH. Chiropractic scope of practice: another perspective. J Manipulative Physiol Ther 1994;17:194-7. 7. Los Angeles College of Chiropractic academic catalog 19971999. Whittier (CA): Los Angeles College of Chiropractic; 1997-1999. p. 13, 20. 8. Life University bulletin 1997-1999. Marietta (GA): Life University; 1998. p. 64. 9. Life Chiropractic College West catalog 1998-2000. San Lorenzo (CA): Life Chiropractic College West; 1998-2000. p. 3. 10. Educating leaders in chiropractic health care catalog 19971998. Los Angeles: Cleveland Chiropractic College of Los Angeles; 1997-1998. p. 10. 11. Educating leaders in chiropractic health care catalog 1998. Kansas City (MO): Cleveland Chiropractic College Kansas City Campus; 1998. p. 8. 12. Changes in NYCC’s mission statement reflect specialized role of chiropractic. Seneca Falls (NY): New York Chiropractic College Transitions; 1998. p. 4-6. 13. The National College of Chiropractic 1996-1997 bulletin. Lombard (IL): The National College of Chiropractic; 1996. p. 9. 14. Palmer College of Chiropractic catalog 1997-1998. Davenport (IA): Palmer College of Chiropractic; 1997. p. 16. 15. Palmer West College of Chiropractic catalog 1997-1999. Vol. XIII. San Jose (CA): Palmer West College of Chiropractic; 1997, p. 12. 16. Parker College of Chiropractic catalog 1997-98. Dallas: Parker College of Chiropractic; 1997. p. 11. 17. Texas Chiropractic College the future in health care 19982000 catalog. Vol. 76. Pasadena (CA): Texas Chiropractic College; 1998. p. 3. 18. Western States Chiropractic College catalog 1998-1999. Portland (OR): Western States Chiropractic College; 1998. p. 9. 19. Northwestern College of Chiropractic 1998-2000 general catalog. Minneapolis: Northwestern College of Chiropractic; 1998. p. 17. 20. University of Bridgeport College of Chiropractic catalog 1997/1998. Bridgeport (CT): University of Bridgeport College of Chiropractic; 1997. p. 1. 21. Logan College of Chiropractic catalog 1997-1999. Chesterfield (MO): Logan College of Chiropractic; 1997. p. 8. 22. The philosophy, science, and art of straight chiropractic bulletin 1998-1999 Sherman College of Straight Chiropractic. Spartanburg (SC): Sherman College of Straight Chiropractic; 1998. p. 11. 23. Prospectus Anglo European College of Chiropractic. Bournemouth, England: Anglo European College of Chiropractic; 1997. p. 6, 10. 24. Canadian Memorial Chiropractic College. 1998/1999 course calendar on the web. Available at: http://www.cmcc.ca/ calendar/trad.htm. Accessed June 5, 1999.

Journal of Manipulative and Physiological Therapeutics Volume 26, Number 8

25. Institut Franco-European De Chiropratique. Ivry-Sur-Seine (France): Institut Franco-European De Chiropratique; 1996. p. 5. 26. Universite’ du Quebec a Trois-Rivieres 1993-1994 Chiropratique. Trois-Rivieres (Quebec, Canada): Universite´ du Que´ bec a` Trois Rivie`res, le service des relations publique; 1993. p. 1. 27. Standards for chiropractic programs and institutions. Scottsdale (AZ): Council on Chiropractic Education Commission on Accreditation; 1999. p. 5. 28. Standards for chiropractic programs and institutions. Scottsdale (AZ): Council on Chiropractic Education Commission on Accreditation; 1999. p. 1-103. 29. Bylaws of the Connecticut chiropractic association. Rocky Hill (CT): Connecticut Chiropractic Association; May 5, 1994. 30. Minutes of strategic planning meeting. Rocky Hill (CT): Connecticut Chiropractic Association; November 5, 1998. 31. Simpson L, Lee PR. Primary care: an idea in search of a paradigm? Am Fam Physician 1993;47:323-6. 32. Millis JS. The graduate education of physicians. Report of the citizens commission on graduate medical education. Chicago: American Medical Association; 1966. 33. Primary health care: a joint report by the director-general of the World Health Organization and the executive director of the United Nations Children’s Fund. International conference on Primary Health Care; 6-12 September 1978; Alma Ata, Union of Soviet Socialist Republics. Geneva, New York: WHO, UNICEF; 1978. p. 2. 34. Starfield B. Measuring the attainment of primary care. J Med Educ 1979;54:361-9. 35. Hibbard RN, Nutting PA. Research in primary care: a national priority. In: Grady ML, Hibbard RN, Nutting PA, editors. Conference proceedings primary care research: theory and methods. Rockville (MD): US Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research, AHCPR Publication No. 91-0011; 1991. p. 1-4. 36. Kranz KC. An overview of primary care concepts. Topics Clin Chiropr 1995;2:55-65. 37. Donaldson MS, Yordy KD, Lohr KN, Vanselow A. Primary care—America’s health in a new era. Washington (DC): Institute of Medicine; National Academy Press; 1996. p. 27-51. 38. NCQA. Book 111, HEDIS 3.0/1998. Measurement specifications. Washington (DC): National Committee for Quality Assurance; 1998. p. 87. 39. The general statutes of Connecticut, revision of 1958, revised to January 1, 1999. Vol. 7. State of Connecticut; 1999. p. 34-40. 40. American Chiropractic Association 1999 directory of members. Arlington (VA): American Chiropractic Association; 1999. p. 11-22. 41. International Chiropractors Association council membership referral directory 1996-1997. Arlington (VA): International Chiropractors Association; 1996. p. 3, 5, 63, 97. 42. Eisenberg DM, Kessler RC, Foster C, Norlock FE, Calkins DR, Delbanco TL. Unconventional medicine in the United States: prevalence, costs and patterns of use. N Engl J Med 1993;328:246-52. 43. Clinical practice guidelines in complementary and alternative medicine. An analysis of opportunities and obstacles. Practice and Policy Guidelines Panel, National Institutes of Health Office of Alternative Medicine. Arch Fam Med 1997;6:14954. 44. Eisenberg DM, Kessler RC, Van Rompay MI, Kaptchuk TJ, Wilkey SA, Appel S, et al. Perceptions about complimentary therapies relative to conventional therapies among adults who

Duenas et al Chiropractic Primary or Specialty Care

45. 46. 47. 48. 49. 50. 51. 52. 53. 54. 55.

56. 57. 58. 59. 60. 61.

62. 63. 64. 65. 66.

67.

use both: results from a national survey. Ann Intern Med 2001;135:344-51. Kaptchuk TJ, Eisenberg DM. Varieties of healing: medical pluralism in the United States. Ann Intern Med 2001;135:18995. Issues in chiropractic—the ACC chiropractic paradigm. Position paper #2. Bethesda (MD): Association of Chiropractic Colleges; 1996. Council on Diagnosis and Internal Disorders. What does the future hold for chiropractic? Internist 1995;2:24-6. Jamison J. Chiropractic education: reflecting the paradigm dilemma of chiropractic practice. J Manipulative Physiol Ther 1994;17:186-93. Seater S. Chiropractic, primary care, and the emerging natural health care market. J Chiropr Humanit 1995;7:42-5. Gentile M. Chiropractic scope of practice [letter]. J Manipulative Physiol Ther 1994;17:200-1. Murphy DR. Chiropractic scope of practice [letter]. J Manipulative Physiol Ther 1994;17:198-9. Bowers L, Mootz R. The nature of primary care: the chiropractors role. Topics Clin Chiropr 1995;2:66-84. Vear HJ. Objectives and standards for practice in chiropractic: standards of practice and quality care. Gaithersburg (MD): Aspen Publishers, Inc.; 1992. p. 69-83. Thomas CL. Taber’s cyclopedic medical dictionary. 18th ed. Philadelphia: F. A. Davis; 1997. p. 1251. O’Leary MR. Joint commission lexicon, dictionary of health care terms, organizations and acronyms for the era of reform. Oakbrooke Terrace (IL): Joint Commission on Accreditation of Healthcare Organizations; 1994. p. 543. Congressional Information Service. Congressional universe— document list. Available at: http://web.lexis-nexis.com. Accessed June 22, 1999. Fisanich F. Federal yellow book, who’s who in federal departments and agencies. Washington (DC): Leadership Directories, Inc; 1999. p. xiii. Index to the general statutes of Connecticut, revision of 1958, revised to January 1, 1999. Vol. 15. State of Connecticut; 1999. Guralnik DB. Webster’s new world dictionary of the American language. 2nd college ed. New York: World Publishing Co; 1970. p. 882. Costello RB. American heritage college dictionary. 3rd ed. Boston: Houghton Mifflin Co; 1993. p. 822. Council on Chiropractic Education Commission on Accreditation. Standards for chiropractic programs and institutions. Available at: http://www.cce-usa.org/. Accessed February 2001. Bakkum BW, Green B. Chiropractic hospitals in America: a case study of the Bakkum hospital (1936-1950). J Manipulative Physiol Ther 2001;24:34-43. Peterson D, Wiese G. Chiropractic: an illustrated history. St. Louis: Mosby Year Book; 1995. p. 459. Wardwell WI. Chiropractic: history and evolution of a new profession. St. Louis: Mosby Year Book; 1992. p. 116. Peterson D. DCs as primary care providers, interview with CEO James Zechman, part II. Dyn Chiropr 2001;19(5):1. Richards WC, Berwick DM, Bisgard JC, Bristow FR, Buck CR, Cassel CK, et al. Crossing the quality chasm, a new health system for the 21st century. Washington (DC): Institute of Medicine, National Academy Press; 2001. p. 6. Estes EH, Banta DH, Fenderson DA, Fisher AA, Ford LC, et al. Report of a study—a manpower policy for primary health care. Washington (DC): Printing and Publishing Office, National Academy of Sciences; 1978. p. 23.

523

APPENDIX I. Survey of Primary Care and PCP Definition for Chiropractic College Presidents and Chiropractic Organization Leaders

1E

2E

Journal of Manipulative and Physiological Therapeutics

Journal of Manipulative and Physiological Therapeutics Volume , Number

3E