- Email: [email protected]
CHIROPRACTIC CLINICAL PURPOSE: PRIMARY CARE OF LIMITED SPECIALTY
CHIROPRACTIC CLINICAL PURPOSE: PRIMARY CARE OF LIMITED SPECIALTY DONALD M. CASSATA, Ph.D.
As the chiropractic profession approaches its centennial year in 1995, many questions face this growing profession. What role will chiropractic play in meeting the health care needs of the public in the twenty-first century? How does the profession become an integral, essential member of the nation's health delivery system? And will the profession be included in impending national health insurance? These and other questions must be addressed pertinent to chiropractic's role in managed health care systems, in long term care of the elderly and in hospital and nursing home care. However, the profession must first address its own internal inconsistencies on chiropractic care's clinical purpose. Is the overall clinical purpose of a Doctor of Chiropractic to be a primary care provider or a limited practitioner specializing in musculoskeletal disorders and/ or corrections of vertebral subluxations? If the purpose is primary care, the functions served by a limited practitioner can be subsumed under the primary care role . However, as will be discussed, this role requires broader clinical responsibilities and competencies than those of a limited practitioner. By definition, a limited practitioner such as a podiatrist, optometrist or particular medical specialist provides services for a particular area of the body or specialty. Clinical purpose dictates the role chiropractic will play in the health care delivery system and how chiropractic will serve the public in the twenty-first century. This distinction also defines the parameters and standards for future chiropractic education and future curriculum. The educational standards of the Council on Chiropractic Education (CCE) specify that the mission of the CCE chiropractic colleges is to develop primary care chiropractors with the appropriate clinical competencies to perform this role. How this question is answered impacts directly on third party payors and the delineation of what services will be entitled to reimbursement. In the discussion of clinical purpose, the differentiation between practice philosophy and profession philosophy is critical. Practice philosophy emphasizes the principles and practice of chiropractic, its philosophy and adjustive techniques. Communication of this
clinical purpose occurs in the practice setting with the patient. Professional philosophy addresses the role of chiropractic in the health care delivery system. It clarifies how chiropractic serves the public. This is communicated to government, regulators, mass media, other health professionals and to the public at large. The ensuing discussion on clinical purpose focuses on profession philosophy. The paper posits that the chiropractor is a primary care provider who has special expertise in caring for neuromusculoskeletal aspects of the human body. The purpose of this paper is to identify parameters of primary care and the principles of chiropractic pertinent to this discussion.
PRIMARY CARE In 1920, Dawson, Lord Dawson of Penn, first initiated the public use of the term "primary care (1)." Since this time, many interpretations have been presented ranging from first portal-of-entry or first contact provider to identifying a level of care for the whole person involving patient education, health promotion, maintenance, prevention and treatment. According to the World Health Organization (WHO), health is Ira state of complete mental, physical and social well-being and not just the absence of disease and infirmity (2)." This definition is apropos to how chiropractic views health and describes the comprehensive perspective of health - a key aspect of primary care. Primary care is usually performed in an ambulatory care setting and is the point of first contact for patients. Here, more than 80% of the presenting problems or complaints can be diagnosed and/ or managed. Secondary care is specialty care usually on referral from a primary care doctor. Tertiary care services are often university based or are large hospital services which focus on rare or major disorders (3). Secondary care and tertiary care is provided by a specialist who, by definition, is a limited practitioner. In terms of frequency of care and need, primary care doctors serve the greatest need by providing broadbased care for the most common acute and chronic problems. This is an important point for the chiropractic
profession because as primary care providers they are not specialists per se, and are not limited practitioners who care for one part of the body or identify and care for certain problems which affect the person's health. Through the focus on the relationship of the structure and function of the body, chiropractic care is concerned about the functioning of the whole person and is only limited to factors that are not responsive to neuromusculoskeletal interventions (4). This pertains to conditions needing surgery or medication therapy and specific emergency situations. Parker, a primary care medical practitioner describes four responsibilities of primary care (5): 1. Affording entry, screening and routing or referral for the health care system (first portal-of-entry). 2. Providing comprehensive services which include basic services necessary to preserve health, prevent disease and care for common illness and disabilities. 3. Providing human support for patients and their families (psychosocial and lifestyle intervention and patient education) . 4. Assuming responsibility for management and coordination of personal health care services on a continuing basis throughout the entire care process. Petersdorf, a wellknown medical authority, succinctly illustrates the role of primary care Professional philosophy physician. The physician who has addresses the role of the first contact with the chiropractic in the patient makes the initial assessment, tries to solve health care delivery system. as many of the patient's It clarifies how chiropractic problems as possible, coordinates the health serves the public. This is care team, acts as the communicated to government, patient's adviser and confidant, maintains regulators, mass media, continued contact with other health professionals the patient and his/her family, and assumes and to the public at large. responsibility for his/her care on a continuing basis
following composite definition of primary care: Primary care is care that provides for the general health needs of the patient; is a first or direct contact service; provides an assessment of health; is acceptable to the consumer of health care services; is accountable; provides education and counseling; provides coordinated, continuous, comprehensive and essential care (7). It is important to emphasize that in the provision of primary health care, no single health professional provides all health services and treatment for all patients.
ATTRIBUTES OF PRIMARY HEALTH CARE From these descriptions, five characteristics of primary care are identified and shown in Table 1. These characteristics will be utilized to assess further the role of the chiropractor as a primary care provider.
Characteristics of Primary Care
•••
Doctor-PatientRelationship (AccessibiliM Continuity of Care ComprehensiveCare Coordination Prevention
•••
TABLE 1
Doctor-Patient Relationship (Accessibility) The relationship between the doctor and patient is the essence of quality patient care. The primary care physician is a first portal-of-entry practitioner who is accessible to all patients regardless of age or gender. The doctor and patient are partners for the betterment of the patient's health. Through continuity, the doctor comes to know the patient as a person and the milieu in which the patient lives. In assessing this function, chiropractors are first portal-of-entry practitioners for patients who enjo y easy accessibility. A few published reports discount the primary care role of chiropractors; other reports indicate that chiropractors are performing this role
(6).
Thi s de scription generally characterizes a chiropractor's role. While chiropractors are handicapped by the limited access the y have within the health care delivery system (hospitals, nursing homes, managed care organizations, etc.), strong partnerships are established with their patients. This is important in assisting patients in caring for themselves. Through spinal adjustment and the restoration of proper stru ctu re and function, the chiropractor also aids the body to heal itself as well. Finally, Kranz, a chiropractor, in a presentation to the American Public Health Association, derived the
(8-12).
One study reported three of four patients went to a chiropractor first for assistance in dealing with an ailment (13). Patients utilize chiropractors as primary care providers and their community practices allow for accessibility. The chiropractors' therapeutic relationship is distinctive. It is enhanced through the "laying on of .).
the hands," and the use of touch has subsequent healing effects. An important aspect of this relationship is that chiropractors are unique in being both a doctor and a healer. Education and subsequent knowledge of the basic and clinical sciences, and skills in physical diagnosis and patient assessment enhance the doctor's role; the philosophical orientation, therapeutic relationship and processes foster the special role as healer. The combination of the scientific method and natural healer is a most powerful therapeutic approach. Continuity of Care Continuity is the provision of care over time to the patient and members of a family or living unit. Time is utilized as part of the diagnostic and therapeutic process, and, as mentioned previously, assists the primary care doctor in knowing the patient as a person. Chiropractic care of chronic ailments and management of structural or biomechanical concerns depends on continuity of care. It is also essential for maintenance care. As professional relationships between chiropractic physicians and other health care providers become stronger, continuity of care is particularly improved for referral purposes. Comprehensive Care Comprehensive care is the process of providing a wholistic approach to health and caring for a wide spectrum of health concerns not limited by age, sex or condition of the patient. In serving the patient in a comprehensive manner,
there is recognition of the impact of physical, social, nutritional, chemical, psychosocial, financial, occupational, environmental and other factors. D.O. Palmer, chiropractic's founder, espoused that chiropractic encompasses a wholistic approach to the understanding of the health of the human body. Health and disease is viewed in the total context of the body, its systems, the myriad inter-relationships within and the forces from outside, which impact on it. Determining the "cause" of the patient's ailment rather than treating the symptoms is an important principle in chiropractic. In identifying and "correcting" or "affecting" the cause, practitioners must make a comprehensive assessment. This view is counter to a "one cause - one cure" nature of the subluxation. As chiropractors strive to have patients attain optimal body functioning, a comprehensive approach is also essential. Chiropractic philosophy emphasizes the natural intelligence of the body to heal itself if no structural or chemical interference is present. Coordination Coordination is the close collaboration between the doctor and patient in the management and restoration of health. Education or consultation of the patient in regard to therapeutic options or referral is part of coordination. Essentially, the chiropractor serves as a patient advocate within the health care system. Chiropractors provide an important alternative to traditional medicine and are able to provide patient education and counseling through the strong relationships most chiropractors attain with their patients.
CHIROPRACTIC PRIMARY CARE PARAMETERS CONTEXT ..... firslportal-of-entry (nogatekeeper) ambulatory setting , communi~-based practice ,serve bo!h sexes ,serve all ages (pediatric, adults, elderly) I
I
DIAGNOSTIC PROCEDURES ..... health history and review physical examination (vertebral subluxations, musculoskeletal, neurological, organ sys!ems) ,life s~le assessment ,nutritional and die!ary assessmen! ,exercise and fitness assessmen! psychosocial ands!ress assessment chemical usage assessmen! occupational and environmental assessmenl ,X-ray and laboratory examinations other diagnostic tests consul!a!ion and referral
PATIENT INTERVENTIONS ..... spinal adjuslments/manipulation (lechniques) physiological therapeutics druglessand nonsurgical interventions ortholic supports extremities and joint manipulations rehabilitative procedures nutritionalcounselingand supplements ,exercise counseling stress managemen! ,psychosocial support &counseling ,chemical usage counseling acupuncture/meridian therapy
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
TABLE 2 -8-
CARE RENDERED ,neuromusculoskelelal ,accessible/patienl centered ,continous/ongoing ,comprehensive/wholistic ,coordinaled ,preventive
Prevention Prevention is the process of identifying health risks, maintaining health and promoting optimal body and mental functioning. Lifestyle factors play an important role in overall health. Environmental and community aspects, occupational and safety factors, stress and chemical usage, nutrition and diet, exercise and fitness are lifestyle factors which need to be evaluated as to the potential level of risks affecting the person's health. All in all, the education and philosophy of chiropractic enables the chiropractic physician to deal more effectively with preventive aspects as compared to other health professionals. Chiropractic philosophy stresses the importance of the homeostasis of the body in the attainment of optimal health. It is through the maintaining of proper body structure and preventive care that optimal physical and mental functioning can be attained. However, preventive care needs to be better organized and integrated in everyday practice to effectively deal with the health risks affecting patients. There is also a need for third-party payors to reimburse for preventive care - reinforcing the value of such services.
appropriately, a debate over the use of modalities. Chiropractic primary care necessitates physical diagnosis, but not necessarily the use of modalities beyond the use of spinal adjustment or manipulation. Primary care practitioners are not obligated to personally provide treatment for what is diagnosed or for the concerns presented by the patient. Referral to other practitioners who may be specialists in the area of needed treatment is part of the primary care of the patient. If we limit, as a profession, our scope of practice to "orthopedic" musculoA nimpending skeletal problems or to the correction/adjustthreat to the prolession ment of vertebral is that medicine will control subluxations, and if appropriate diagnostic who obtains chiropractic care procedures are not il chiropractic physicians are performed as presented in Table 2, chiropractors deemed limited practitioners. become specialists in The mission 01 chiropractic orthopedics, limited providers, and may education should continue abdicate their primary to be the development 01 care status. The limitation of primary care doctors. doctors of chiropractic is particularly evident by the federal government's Medicare rule of limiting inclusion of chiropractic services to "correction of subluxations" and specifying a limited number of patient visits. The profession is not viewed broadly in terms of primary care even though they are classified by the federal government as category 1 practitioners - primary care providers. An impending threat to the profession is that medicine will control who obtains chiropractic care if chiropractic physicians are deemed limited practitioners. Subsequently, third party payor's reimbursement will only be for spinal or orthopedic care. There are those who argue that Doctors of Chiropractic are both neuromusculoskeletal specialists and primary care providers. Indeed, chiropractors have become recognized specialists in caring for musculoskeletal problems especially for back care, strains and sprains. It is exactly this point which this paper addresses. The difficulty with this position is as specialists, the profession becomes limited and the clinical purpose is defined by the conditions treated. Defining the clinical purpose as a primary care provider emphasizes the characteristics identified in Table 2. Because of the reliance on spinal adjustment, there are also those who define clinical purpose as the correction or adjustment of vertebral subluxations. Overemphasis on specific disorders, pain manage-
ESTABLISHING THE PRIMARY CARE ROLE Doctors of chiropractic perform the five functions of a primary care provider. The education of chiropractors in the basic and clinical sciences, in physical diagnosis and examination and in diagnostic testing procedures qualify chiropractic physicians as first portal-of-entry providers who care for the whole person. There must be understanding and acceptance within the profession of the clinical purpose of chiropractic as a primary health care provider. This needs to be embellished by the majority of the profession, state licensing boards, chiropractic colleges and state associations. A description of the role of chiropractic primary care is illustrated in Table 2. It is not meant to be definitive, all-inclusive or exhaustive. Primary care providers are obligated to perform the appropriate diagnostic procedures presented. It should be noted that spinal analysis is one part of diagnosis for the chiropractic primary care doctor. However, to be considered primary care practitioners, chiropractors do not have to provide each of the patient interventions listed. This emphasizes the importance of diagnosis for the primary care provider and places less emphasis on patient interventions except for spinal adjustment or manipulation when indicated. This also illustrates that the clinical purpose of primary care can be independent of scope of practice. The long debate between "straights" and "mixers" should not include whether to diagnose; rather, more -9-
ment, or on the subluxation complex delimits the primary care role . Throughout the profession, there is very little written about the chiropractic primary care role of recognition that the profession serves this role beyond the fact that the licensing of doctors of chiropractic allows them to be first portal-of-entry providers. It must be stressed that these remarks are not meant to minimize or negate the importance of the subluxation complex or the value and healing effects of spinal adjustment on the neuromusculoskeletal functioning of the body. Defining the clinical purpose as primary care fosters the greatest growth of the profession without becoming a practitioner who is limited by the conditions and care provided or limited by the services and procedures that are reimbursed. Each chiropractor can limit their practice as they choose and specify this to the public. Limiting a practice to children/women's health, geriatrics, sports health, physical rehabilitation, orthopedics, radiology, pain management is part of the privilege of practicing chiropractic. However, the overall profession must be viewed as primary care providers who care for the whole person and their families in a comprehensive fashion . The mission of chiropractic education should continue to be the development of primary care doctors. Finally, the clinical purpose for the doctor of chiropractic should be to provide care for the whole person; the philosophical reason for being is to facilitate the natural healing processes which enhance the "tone" of the bod y (14). In conclusion, below are three recommendations for the chiropractic profession to maintain and enhance the primary care role. 1. As mentioned earlier, a broader consensus by the majority of the profession and leaders needs to be attained on the clinical purpose of chiropractic as primary health care. 2. Clinical studies need to be performed which demonstrate the accountability and outcomes of chiropractic primary care . Standards of care should be established which can be clarified to patients, other health providers and to third-party payors. 3. As primary care physicians, the utilization of chiropractic care should be expanded to hospitals, nursing homes and managed care organizations. The continuity and coordination of care will be greatly enhanced with inclusion in these health care settings. The chiropractic profession is at a pivotal point in its evolution and in the evolution of the United States health care delivery system. If, in the immediate future the profession does not address these important issues and proclaim a primary care role, outside regulators, government authorities and other health professions will be making the decisions as to the future of chiropractic.
REFERENCES 1. Dawson. Interim Report on the Future Medical and Allied Services. (London: Great Britain Ministry of Health, Consultive Council on Medical and Allied Services, Command Paper 693, His Majesty's Stationery Office, 1920) p.7. 2. World Health Organization, First Ten Years of the World Health Organization. In: Annex I, Constitution, Geneva, 1958. 3. Andreopoulos S, ed . Primary Care: Where Medicine Fails. New York: John Wiley & Sons, 1974:5. 4. Palmer DO. The Chiropractor's Adjustor. Portland: Portland Printing Press, 1910. 5. Parker AW. The Dimensions of Primary Care: Blueprints for Chance. Andreopoulos S, ed. Chapter One. Primary Care: Where Medicine Fails. New York: John Wiley & Sons, 1974. 6. Petersdorf RG. Issues in Primary Care: The Academic Perspective. In: Association of American College, ed. Proceedings of the Institute of Primary Care. Washington, D.C: Association of American Colleges, 1974:5-16. 7. Kranz KC Chiropractic in the Health Care System with Respect to Primary Care and the Components of Primary Care. Paper presented to the 113th Annual American Public Health Association Convention, Washington, D.C, November 18,1945. 8. Yeaslis CE et al. Does chiropractic utilization substitute for less available medical services? Am J Public Health 1980;70:415-17. 9. Cleary PD. Chiropractic use : a test of several hypotheses. Am J Public Health 1982;72:727-29. 10. Shapiro E. The physician visit patterns of chiropractic users: health seeking behavior of the elderly in Manitoba, Canada. Am J Public Health 1983;73:553-57. 11. Koren T. Chiropractors are primary health providers. Struggling with the definition. Today's Chiropractic 14(2):27. 12. Hildebrandt RW. Chiropractic physicians as members of the health care delivery system: the case for increased utilization. J Man ipulative Physiol Ther 1980;3:23-32. 13. Minnesota Chiropractic Association. Minnesotans Awareness of Usage Patterns and Attitudes Towards Doctors of Chiropractic. Mid-Continent Research, Inc., October, 1983. 14. Palmer DO. The Chiropractor's Adjustor. Portland: Portland Printing Pres s, 1910. For additional information contact: Donald M. Cassata, Ph.D. President Northwestern College of Chiropractic 2501 West 84th Street Bloomington, MN 55431 ·10·
As the chiropractic profession approaches its centennial year in 1995, many questions face this growing profession. What role will chiropractic play in meeting the health care needs of the public in the twenty-first century? How does the profession become an integral, essential member of the nation's health delivery system? And will the profession be included in impending national health insurance? These and other questions must be addressed pertinent to chiropractic's role in managed health care systems, in long term care of the elderly and in hospital and nursing home care. However, the profession must first address its own internal inconsistencies on chiropractic care's clinical purpose. Is the overall clinical purpose of a Doctor of Chiropractic to be a primary care provider or a limited practitioner specializing in musculoskeletal disorders and/ or corrections of vertebral subluxations? If the purpose is primary care, the functions served by a limited practitioner can be subsumed under the primary care role . However, as will be discussed, this role requires broader clinical responsibilities and competencies than those of a limited practitioner. By definition, a limited practitioner such as a podiatrist, optometrist or particular medical specialist provides services for a particular area of the body or specialty. Clinical purpose dictates the role chiropractic will play in the health care delivery system and how chiropractic will serve the public in the twenty-first century. This distinction also defines the parameters and standards for future chiropractic education and future curriculum. The educational standards of the Council on Chiropractic Education (CCE) specify that the mission of the CCE chiropractic colleges is to develop primary care chiropractors with the appropriate clinical competencies to perform this role. How this question is answered impacts directly on third party payors and the delineation of what services will be entitled to reimbursement. In the discussion of clinical purpose, the differentiation between practice philosophy and profession philosophy is critical. Practice philosophy emphasizes the principles and practice of chiropractic, its philosophy and adjustive techniques. Communication of this
clinical purpose occurs in the practice setting with the patient. Professional philosophy addresses the role of chiropractic in the health care delivery system. It clarifies how chiropractic serves the public. This is communicated to government, regulators, mass media, other health professionals and to the public at large. The ensuing discussion on clinical purpose focuses on profession philosophy. The paper posits that the chiropractor is a primary care provider who has special expertise in caring for neuromusculoskeletal aspects of the human body. The purpose of this paper is to identify parameters of primary care and the principles of chiropractic pertinent to this discussion.
PRIMARY CARE In 1920, Dawson, Lord Dawson of Penn, first initiated the public use of the term "primary care (1)." Since this time, many interpretations have been presented ranging from first portal-of-entry or first contact provider to identifying a level of care for the whole person involving patient education, health promotion, maintenance, prevention and treatment. According to the World Health Organization (WHO), health is Ira state of complete mental, physical and social well-being and not just the absence of disease and infirmity (2)." This definition is apropos to how chiropractic views health and describes the comprehensive perspective of health - a key aspect of primary care. Primary care is usually performed in an ambulatory care setting and is the point of first contact for patients. Here, more than 80% of the presenting problems or complaints can be diagnosed and/ or managed. Secondary care is specialty care usually on referral from a primary care doctor. Tertiary care services are often university based or are large hospital services which focus on rare or major disorders (3). Secondary care and tertiary care is provided by a specialist who, by definition, is a limited practitioner. In terms of frequency of care and need, primary care doctors serve the greatest need by providing broadbased care for the most common acute and chronic problems. This is an important point for the chiropractic
profession because as primary care providers they are not specialists per se, and are not limited practitioners who care for one part of the body or identify and care for certain problems which affect the person's health. Through the focus on the relationship of the structure and function of the body, chiropractic care is concerned about the functioning of the whole person and is only limited to factors that are not responsive to neuromusculoskeletal interventions (4). This pertains to conditions needing surgery or medication therapy and specific emergency situations. Parker, a primary care medical practitioner describes four responsibilities of primary care (5): 1. Affording entry, screening and routing or referral for the health care system (first portal-of-entry). 2. Providing comprehensive services which include basic services necessary to preserve health, prevent disease and care for common illness and disabilities. 3. Providing human support for patients and their families (psychosocial and lifestyle intervention and patient education) . 4. Assuming responsibility for management and coordination of personal health care services on a continuing basis throughout the entire care process. Petersdorf, a wellknown medical authority, succinctly illustrates the role of primary care Professional philosophy physician. The physician who has addresses the role of the first contact with the chiropractic in the patient makes the initial assessment, tries to solve health care delivery system. as many of the patient's It clarifies how chiropractic problems as possible, coordinates the health serves the public. This is care team, acts as the communicated to government, patient's adviser and confidant, maintains regulators, mass media, continued contact with other health professionals the patient and his/her family, and assumes and to the public at large. responsibility for his/her care on a continuing basis
following composite definition of primary care: Primary care is care that provides for the general health needs of the patient; is a first or direct contact service; provides an assessment of health; is acceptable to the consumer of health care services; is accountable; provides education and counseling; provides coordinated, continuous, comprehensive and essential care (7). It is important to emphasize that in the provision of primary health care, no single health professional provides all health services and treatment for all patients.
ATTRIBUTES OF PRIMARY HEALTH CARE From these descriptions, five characteristics of primary care are identified and shown in Table 1. These characteristics will be utilized to assess further the role of the chiropractor as a primary care provider.
Characteristics of Primary Care
•••
Doctor-PatientRelationship (AccessibiliM Continuity of Care ComprehensiveCare Coordination Prevention
•••
TABLE 1
Doctor-Patient Relationship (Accessibility) The relationship between the doctor and patient is the essence of quality patient care. The primary care physician is a first portal-of-entry practitioner who is accessible to all patients regardless of age or gender. The doctor and patient are partners for the betterment of the patient's health. Through continuity, the doctor comes to know the patient as a person and the milieu in which the patient lives. In assessing this function, chiropractors are first portal-of-entry practitioners for patients who enjo y easy accessibility. A few published reports discount the primary care role of chiropractors; other reports indicate that chiropractors are performing this role
(6).
Thi s de scription generally characterizes a chiropractor's role. While chiropractors are handicapped by the limited access the y have within the health care delivery system (hospitals, nursing homes, managed care organizations, etc.), strong partnerships are established with their patients. This is important in assisting patients in caring for themselves. Through spinal adjustment and the restoration of proper stru ctu re and function, the chiropractor also aids the body to heal itself as well. Finally, Kranz, a chiropractor, in a presentation to the American Public Health Association, derived the
(8-12).
One study reported three of four patients went to a chiropractor first for assistance in dealing with an ailment (13). Patients utilize chiropractors as primary care providers and their community practices allow for accessibility. The chiropractors' therapeutic relationship is distinctive. It is enhanced through the "laying on of .).
the hands," and the use of touch has subsequent healing effects. An important aspect of this relationship is that chiropractors are unique in being both a doctor and a healer. Education and subsequent knowledge of the basic and clinical sciences, and skills in physical diagnosis and patient assessment enhance the doctor's role; the philosophical orientation, therapeutic relationship and processes foster the special role as healer. The combination of the scientific method and natural healer is a most powerful therapeutic approach. Continuity of Care Continuity is the provision of care over time to the patient and members of a family or living unit. Time is utilized as part of the diagnostic and therapeutic process, and, as mentioned previously, assists the primary care doctor in knowing the patient as a person. Chiropractic care of chronic ailments and management of structural or biomechanical concerns depends on continuity of care. It is also essential for maintenance care. As professional relationships between chiropractic physicians and other health care providers become stronger, continuity of care is particularly improved for referral purposes. Comprehensive Care Comprehensive care is the process of providing a wholistic approach to health and caring for a wide spectrum of health concerns not limited by age, sex or condition of the patient. In serving the patient in a comprehensive manner,
there is recognition of the impact of physical, social, nutritional, chemical, psychosocial, financial, occupational, environmental and other factors. D.O. Palmer, chiropractic's founder, espoused that chiropractic encompasses a wholistic approach to the understanding of the health of the human body. Health and disease is viewed in the total context of the body, its systems, the myriad inter-relationships within and the forces from outside, which impact on it. Determining the "cause" of the patient's ailment rather than treating the symptoms is an important principle in chiropractic. In identifying and "correcting" or "affecting" the cause, practitioners must make a comprehensive assessment. This view is counter to a "one cause - one cure" nature of the subluxation. As chiropractors strive to have patients attain optimal body functioning, a comprehensive approach is also essential. Chiropractic philosophy emphasizes the natural intelligence of the body to heal itself if no structural or chemical interference is present. Coordination Coordination is the close collaboration between the doctor and patient in the management and restoration of health. Education or consultation of the patient in regard to therapeutic options or referral is part of coordination. Essentially, the chiropractor serves as a patient advocate within the health care system. Chiropractors provide an important alternative to traditional medicine and are able to provide patient education and counseling through the strong relationships most chiropractors attain with their patients.
CHIROPRACTIC PRIMARY CARE PARAMETERS CONTEXT ..... firslportal-of-entry (nogatekeeper) ambulatory setting , communi~-based practice ,serve bo!h sexes ,serve all ages (pediatric, adults, elderly) I
I
DIAGNOSTIC PROCEDURES ..... health history and review physical examination (vertebral subluxations, musculoskeletal, neurological, organ sys!ems) ,life s~le assessment ,nutritional and die!ary assessmen! ,exercise and fitness assessmen! psychosocial ands!ress assessment chemical usage assessmen! occupational and environmental assessmenl ,X-ray and laboratory examinations other diagnostic tests consul!a!ion and referral
PATIENT INTERVENTIONS ..... spinal adjuslments/manipulation (lechniques) physiological therapeutics druglessand nonsurgical interventions ortholic supports extremities and joint manipulations rehabilitative procedures nutritionalcounselingand supplements ,exercise counseling stress managemen! ,psychosocial support &counseling ,chemical usage counseling acupuncture/meridian therapy
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
TABLE 2 -8-
CARE RENDERED ,neuromusculoskelelal ,accessible/patienl centered ,continous/ongoing ,comprehensive/wholistic ,coordinaled ,preventive
Prevention Prevention is the process of identifying health risks, maintaining health and promoting optimal body and mental functioning. Lifestyle factors play an important role in overall health. Environmental and community aspects, occupational and safety factors, stress and chemical usage, nutrition and diet, exercise and fitness are lifestyle factors which need to be evaluated as to the potential level of risks affecting the person's health. All in all, the education and philosophy of chiropractic enables the chiropractic physician to deal more effectively with preventive aspects as compared to other health professionals. Chiropractic philosophy stresses the importance of the homeostasis of the body in the attainment of optimal health. It is through the maintaining of proper body structure and preventive care that optimal physical and mental functioning can be attained. However, preventive care needs to be better organized and integrated in everyday practice to effectively deal with the health risks affecting patients. There is also a need for third-party payors to reimburse for preventive care - reinforcing the value of such services.
appropriately, a debate over the use of modalities. Chiropractic primary care necessitates physical diagnosis, but not necessarily the use of modalities beyond the use of spinal adjustment or manipulation. Primary care practitioners are not obligated to personally provide treatment for what is diagnosed or for the concerns presented by the patient. Referral to other practitioners who may be specialists in the area of needed treatment is part of the primary care of the patient. If we limit, as a profession, our scope of practice to "orthopedic" musculoA nimpending skeletal problems or to the correction/adjustthreat to the prolession ment of vertebral is that medicine will control subluxations, and if appropriate diagnostic who obtains chiropractic care procedures are not il chiropractic physicians are performed as presented in Table 2, chiropractors deemed limited practitioners. become specialists in The mission 01 chiropractic orthopedics, limited providers, and may education should continue abdicate their primary to be the development 01 care status. The limitation of primary care doctors. doctors of chiropractic is particularly evident by the federal government's Medicare rule of limiting inclusion of chiropractic services to "correction of subluxations" and specifying a limited number of patient visits. The profession is not viewed broadly in terms of primary care even though they are classified by the federal government as category 1 practitioners - primary care providers. An impending threat to the profession is that medicine will control who obtains chiropractic care if chiropractic physicians are deemed limited practitioners. Subsequently, third party payor's reimbursement will only be for spinal or orthopedic care. There are those who argue that Doctors of Chiropractic are both neuromusculoskeletal specialists and primary care providers. Indeed, chiropractors have become recognized specialists in caring for musculoskeletal problems especially for back care, strains and sprains. It is exactly this point which this paper addresses. The difficulty with this position is as specialists, the profession becomes limited and the clinical purpose is defined by the conditions treated. Defining the clinical purpose as a primary care provider emphasizes the characteristics identified in Table 2. Because of the reliance on spinal adjustment, there are also those who define clinical purpose as the correction or adjustment of vertebral subluxations. Overemphasis on specific disorders, pain manage-
ESTABLISHING THE PRIMARY CARE ROLE Doctors of chiropractic perform the five functions of a primary care provider. The education of chiropractors in the basic and clinical sciences, in physical diagnosis and examination and in diagnostic testing procedures qualify chiropractic physicians as first portal-of-entry providers who care for the whole person. There must be understanding and acceptance within the profession of the clinical purpose of chiropractic as a primary health care provider. This needs to be embellished by the majority of the profession, state licensing boards, chiropractic colleges and state associations. A description of the role of chiropractic primary care is illustrated in Table 2. It is not meant to be definitive, all-inclusive or exhaustive. Primary care providers are obligated to perform the appropriate diagnostic procedures presented. It should be noted that spinal analysis is one part of diagnosis for the chiropractic primary care doctor. However, to be considered primary care practitioners, chiropractors do not have to provide each of the patient interventions listed. This emphasizes the importance of diagnosis for the primary care provider and places less emphasis on patient interventions except for spinal adjustment or manipulation when indicated. This also illustrates that the clinical purpose of primary care can be independent of scope of practice. The long debate between "straights" and "mixers" should not include whether to diagnose; rather, more -9-
ment, or on the subluxation complex delimits the primary care role . Throughout the profession, there is very little written about the chiropractic primary care role of recognition that the profession serves this role beyond the fact that the licensing of doctors of chiropractic allows them to be first portal-of-entry providers. It must be stressed that these remarks are not meant to minimize or negate the importance of the subluxation complex or the value and healing effects of spinal adjustment on the neuromusculoskeletal functioning of the body. Defining the clinical purpose as primary care fosters the greatest growth of the profession without becoming a practitioner who is limited by the conditions and care provided or limited by the services and procedures that are reimbursed. Each chiropractor can limit their practice as they choose and specify this to the public. Limiting a practice to children/women's health, geriatrics, sports health, physical rehabilitation, orthopedics, radiology, pain management is part of the privilege of practicing chiropractic. However, the overall profession must be viewed as primary care providers who care for the whole person and their families in a comprehensive fashion . The mission of chiropractic education should continue to be the development of primary care doctors. Finally, the clinical purpose for the doctor of chiropractic should be to provide care for the whole person; the philosophical reason for being is to facilitate the natural healing processes which enhance the "tone" of the bod y (14). In conclusion, below are three recommendations for the chiropractic profession to maintain and enhance the primary care role. 1. As mentioned earlier, a broader consensus by the majority of the profession and leaders needs to be attained on the clinical purpose of chiropractic as primary health care. 2. Clinical studies need to be performed which demonstrate the accountability and outcomes of chiropractic primary care . Standards of care should be established which can be clarified to patients, other health providers and to third-party payors. 3. As primary care physicians, the utilization of chiropractic care should be expanded to hospitals, nursing homes and managed care organizations. The continuity and coordination of care will be greatly enhanced with inclusion in these health care settings. The chiropractic profession is at a pivotal point in its evolution and in the evolution of the United States health care delivery system. If, in the immediate future the profession does not address these important issues and proclaim a primary care role, outside regulators, government authorities and other health professions will be making the decisions as to the future of chiropractic.
REFERENCES 1. Dawson. Interim Report on the Future Medical and Allied Services. (London: Great Britain Ministry of Health, Consultive Council on Medical and Allied Services, Command Paper 693, His Majesty's Stationery Office, 1920) p.7. 2. World Health Organization, First Ten Years of the World Health Organization. In: Annex I, Constitution, Geneva, 1958. 3. Andreopoulos S, ed . Primary Care: Where Medicine Fails. New York: John Wiley & Sons, 1974:5. 4. Palmer DO. The Chiropractor's Adjustor. Portland: Portland Printing Press, 1910. 5. Parker AW. The Dimensions of Primary Care: Blueprints for Chance. Andreopoulos S, ed. Chapter One. Primary Care: Where Medicine Fails. New York: John Wiley & Sons, 1974. 6. Petersdorf RG. Issues in Primary Care: The Academic Perspective. In: Association of American College, ed. Proceedings of the Institute of Primary Care. Washington, D.C: Association of American Colleges, 1974:5-16. 7. Kranz KC Chiropractic in the Health Care System with Respect to Primary Care and the Components of Primary Care. Paper presented to the 113th Annual American Public Health Association Convention, Washington, D.C, November 18,1945. 8. Yeaslis CE et al. Does chiropractic utilization substitute for less available medical services? Am J Public Health 1980;70:415-17. 9. Cleary PD. Chiropractic use : a test of several hypotheses. Am J Public Health 1982;72:727-29. 10. Shapiro E. The physician visit patterns of chiropractic users: health seeking behavior of the elderly in Manitoba, Canada. Am J Public Health 1983;73:553-57. 11. Koren T. Chiropractors are primary health providers. Struggling with the definition. Today's Chiropractic 14(2):27. 12. Hildebrandt RW. Chiropractic physicians as members of the health care delivery system: the case for increased utilization. J Man ipulative Physiol Ther 1980;3:23-32. 13. Minnesota Chiropractic Association. Minnesotans Awareness of Usage Patterns and Attitudes Towards Doctors of Chiropractic. Mid-Continent Research, Inc., October, 1983. 14. Palmer DO. The Chiropractor's Adjustor. Portland: Portland Printing Pres s, 1910. For additional information contact: Donald M. Cassata, Ph.D. President Northwestern College of Chiropractic 2501 West 84th Street Bloomington, MN 55431 ·10·