A profession’s maturity is defined by the knowledge and behavior of its members. True professionalism in health care requires that interest in economics be subordinated to the best interest of the patient, that guidelines based on objective information be developed and respected, that members of the profession be knowledgeable of the scientific literature relating to their practice, that research be encouraged so that the new knowledge it reveals can accrue to the benefit of present and future patients, and that those who aspire to professional stature interact with each other in a professional rather than political manner. By these measures, the chiropractic profession is now far more mature than it was a generation ago, but it still falls well short of its potential.
Chiropractic has made tremendous strides in the last quarter century with regard to educational standards and the development of a solid scientific research base. As a result, government agencies, private insurers, and the health care community as a whole have increasingly recognized chiropractic as a valid form of health care. Full integration into the mainstream health care system, however, still appears to be a generation or two away.
Why? After-effects of the decades-long antichiropractic boycott by organized medicine (for which the United States Supreme Court in 1990 affirmed liable the American Medical Association) still cast a pall over chiropractors’ relations with other health professions and the general public. However, blaming others is too easy. Chiropractors must also look within.
Substantial improvement is required in two critical areas: (1) respect for reasonable, objectively based practice guidelines and (2) development of a profession-wide ethic of financial fairness.
PRACTICE GUIDELINES: WHAT THEY ARE AND WHY THEY ARE NEEDED
Political Imperative
By the early 1990s, chiropractic leaders understood that a significantly more fact-based era had begun in which political muscle and agility could not be relied upon to take the place of objectively agreed-on measures of clinical efficacy. The profession faced an urgent need to design and develop its own practice guidelines. Failure to do so would have allowed the resultant vacuum to be filled by default, with guidelines prepared by medical directors, nurses, people with a master’s degree in business administration, attorneys, managed care organizations, insurers, and third-party payers.
Guidelines for Chiropractic Quality Assurance and Practice Parameters, 1 which grew out of the 1992 Mercy Center Consensus Conference, placed the chiropractic profession at the cutting edge of the guidelines movement. In contrast to professions that attempted to delay the inevitable, or, similar to the orthopedic surgeons, to allow their guidelines to be prepared by a single individual, chiropractors convened a consensus conference representing an appropriate balance of opinions in the profession and then debated the issues until consensus was reached. Minority opinions were included in the published report, which is specifically intended to be a living document, open to ongoing revision as new information emerges.
Because chiropractic proactively moved forward with this project, the specter of chiropractic guidelines prepared by outsiders was averted. The consensus conference, by bringing together so diverse a profession, set a positive tone for chiropractic’s future.
Need for Objectivity
Science seeks to counter the well-known inclination of the human mind to fool itself. That a particular patient, or group of patients, recovers from back pain or any other ailment after receiving chiropractic adjustments does not necessarily indicate a cause-and-effect relationship between the adjustments and the recovery. The placebo effect and the natural course of the illness must be factored into the equation.
To clarify these crucial issues, practice guidelines identify and organize available hard data in the peer-reviewed literature. When such data are lacking or inconclusive, a consensus process is used to determine which procedures are safe and appropriate. One of the great virtues of the guidelines development process is that identifying areas in which insufficient objective information exists encourages outcome studies and other research.
Most of chiropractic history has been marked by a freewheeling empiricism in which individual practitioners developed new techniques, applied them immediately in patient care, and then taught them to as many colleagues as possible. This process, in some ways, has served the profession well—many current chiropractic techniques originated in this manner. However, anecdotal evidence, no matter how powerful, does not qualify as proof. All chiropractic methods, and those of other health care disciplines, must eventually be subjected to rigorous scientific investigation, facing what Thomas Huxley called “the great tragedy of science: the slaying of a beautiful hypothesis by an ugly fact.”2 Such scrutiny can cause intense uncertainty as the process unfolds. Possibly some widely used chiropractic methods may fail to pass muster. In the current era, however, no acceptable alternative to this system exists. If chiropractors wish to become full participants in the health care mainstream, they must abide by the emerging rules of the level playing field.
Because the Mercy conferees required that all claims either be documented in the scientific literature or acquire a measurable and significant level of consensus, the report they produced has stood up well when presented to agencies that require high standards of documentation, such as the Agency for Health Care Policy and Research (AHCPR) panel on acute low back problems in adults. Professions that appeared before the AHCPR panel lacking such documentation were markedly less successful than chiropractic. In the long run, such documentation spells the difference between integration and isolation. No responsible professional wishes to permanently relegate his or her profession to the fringe.
Key Areas in the Mercy Guidelines
The Mercy Guidelines address all key areas of chiropractic practice in a manner consistent with AHCPR procedures for guideline development. These guidelines cover a wide range of diagnostic and therapeutic procedures employed by contemporary chiropractors, determining in each case whether such procedures are supported by scientific data, evaluating and rating the quality of that data, and in the absence of conclusive data, seeking a consensus of clinical opinion.
Areas covered in Mercy Guidelines include the following:
2. Diagnostic imaging
3. Instrumentation
4. Clinical laboratory
5. Record keeping and patient consents
6. Clinical impression
7. Modes of care
8. Frequency and duration of care
9. Reassessment
10. Outcome assessment
11. Collaborative care
12. Contraindications and complications
13. Preventive maintenance and public health
14. Professional development
Addressing all of these topics in detail is beyond the scope of this chapter. However, practicing chiropractors and chiropractic students have a responsibility to read the Guidelines and to consider the appropriateness of bringing their practices into accord with the consensus recommendations.
Critiques of the Mercy Guidelines
Probably the most common criticism of the Guidelines is that the document is difficult to read. Unfortunately, documents that committees prepare are seldom hailed for their high literary quality. Most other critiques of the Guidelines identify certain perceived failings, which on deeper analysis turn out to be failures of the profession, not the Guidelines. These failings include concerns about inadequate research, inadequate objective thinking, and inadequate organization of results and outcomes. All of these areas need improvement, but guidelines can only reflect the current state of professional development. Furthermore, although imperfections are certainly present, Guidelines for Chiropractic Quality Assurance and Practice Parameters compares quite favorably with guidelines prepared by other professions and specialties.
Other criticisms of the Mercy Guidelines relate to recommendations on duration of care, the appropriate number of visits for various conditions, and the suggestion that cases not demonstrating clear improvement within a 1-month period be referred out. In particular, strong concerns have been raised about insurance companies using the Guidelines as a basis for cutting off reimbursement for chiropractic care sooner than is warranted.
Instances undoubtedly exist in which the Guidelines have been misused, whether from malice or ignorance. The flaw, however, lies not in the Guidelines themselves, but in their misuse. The Mercy document specifically states that the purpose of such recommendations is “to assist the clinician in decision making based on the expectation of outcome for the uncomplicated case [emphasis in original]. They are NOT designed as a prescriptive or cookbook procedure for determining the absolute frequency and duration of treatment/care for any specific case.”1 Furthermore, guidelines should not be confused with standards. Guidelines are voluntary; standards are mandatory.
DURATION OF CARE
Duration of care is a major unresolved issue in chiropractic. Depending on which chiropractor a patient sees, the recommended course of care for the same condition may vary drastically, from several visits with one doctor to several dozen—sometimes hundreds—with another. Such variations appear in all regions, among graduates of all chiropractic colleges, and in urban, suburban, and rural settings. 3,4 Reducing these variations is crucial to the further advancement of the chiropractic profession.
Abuses of the System
The question of why a patient needs to return to a chiropractor for a series of visits is legitimate and controversial. Like it or not, chiropractors have a reputation for lengthy courses of care. In the absence of a rational, patient-centered explanation for this reputation, the unfortunate corollary assumption is that such extended care is primarily for the financial benefit of the chiropractor. Sadly, in some instances, this scenario is indeed the case. Such abuses of the system will be confronted first, and then how duration of care can be addressed within a patient-centered framework will be explored.
In the early 1990s, the author of this text participated in a retrospective review of a year’s already-paid chiropractic claims, in which page after page of outrageous overtreatment by chiropractors was discovered. In one case, 278 visits for a diagnosis of mitral valve disorder occurred; in another, 155 visits for a uterine infection was recorded. Such doctors are a danger to society. In another case, a chiropractor had taken 70 x-ray films of a 12-year-old girl. The opinion of this author is that this person should be behind bars.
Honest chiropractors pay a high price for the fraudmerchants in the profession. One particularly disturbing example of overuse and its consequences involves the highly respected John Deere health maintenance organization (HMO), which initially included chiropractic benefits in its health plan. During the first year of Deere’s HMO operation, two doctors of chiropractic who were involved in the highly dubious practice of “forgiving” deductibles and co-payments so that their patients had no out-of-pocket expenses, billed the HMO $1 million each! Almost immediately, chiropractic benefits were removed from the plan. The damage caused by unscrupulous practitioners such as these is incalculable. Many thousands of people with a genuine need for chiropractic care will not receive it as a result of these practitioners’ unmitigated greed.
Unethical practices such as these have created a situation in which all chiropractors are tarred with the same brush. The title “doctor of chiropractic” is too often associated with “scam artist” or “trumped up” fraudulent insurance claims. In addition, when these cases of abuse are subjected to the glare of media attention, chiropractic care becomes associated with the 1½- to 3-minute office visits common in such assembly line operations. It is a sad state of affairs. Chiropractors cannot reform the entire health care system, but the profession can certainly clean up its own backyard. Unless honest chiropractors speak out against this behavior, the entire profession will continue to be judged guilty by association.
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