In a sweeping blow to the efforts of the Chiropractic Cartel to expand the scope of chiropractic and position chiropractors as Primary care Providers, the Washington State Department of Health said no to the Washington State Chiropractic Association's request for expanding the scope of practice to include physical examinations for sports physicals and commercial drivers' licenses.
1. Physical examinations for student athletes and commercial drivers are clearly not within the existing statutory scope of practice for chiropractors in Washington.
2. The applicant’s proposal should not be enacted, even with additional training it intends to include in amendment language, because the proposal still fails to add the elements of a comprehensive physical examination to the chiropractic scope of practice.
3. The department found potential risk of patient harm if these exams are added to the chiropractic scope of practice. Specifically:
- The addition of these exams would expand the chiropractic scope of practice well outside of the current scope of diagnosing and treating conditions relating to the musculoskeletal system.
- These exams are intended to be comprehensive physical examinations, not cursory screenings.
- These exams are sometimes the only examination a person receives regularly.
- For students, this includes the opportunity to receive age appropriate vaccinations, which chiropractors can’t perform.
- Chiropractic educational programs do not include adequate focus on pharmacology, which is necessary in both types of physical examinations.
- Although chiropractic training includes basic understanding of body and organ systems, including the cardiovascular system, the department is unable to find that it prepares chiropractors to potentially be the sole evaluator of all or most medical conditions.
- The additional trainings proposed by the applicant do not appear to adequately bridge the gap in training.
The Department of Health stated:
"Examining a patient to evaluate his or her overall health should be done by a primary care provider who can use their broad spectrum of training, clinical residency, and experience to conduct the evaluations, and whose daily practice includes functions of primary care."
Chiropractic Colleges Weigh In
All chiropractic programs in the United States claim to train chiropractors as primary care physicians. In fact, this is mandated in the Council on Chiropractics' educational training Standards. National chiropractic trade organizations also claim that chiropractors are trained and function as primary care providers. Even the International Chiropractors Association claims chiropractors are primary care providers.
Dr. Joseph Brimhall, President of Western States, submitted a lengthy document outlining the primary care and broad body diagnosis and management training that chiropractic students allegedly receive. Brimhall argued:
"For example, the discovery of stage 1 or 2 hypertension, visual acuity deficits or uncontrolled diabetes would be expected of a competent chiropractic physician under any clinical situation, not just a DOT physical."
He went on to defend chiropractors' expertise in diagnosing heart problems such as cardiac bruits, inguinal hernias, metastatic bone lesions, traumatic brain injuries and concussions.
Brimhall's evidence of this training included the Council on Chiropractic Education's (CCE) Accreditation Standards and the testing of these skills on the related parts of the National Board of Chiropractic Examiners (NBCE) tests.
Dr. Gary Schultz, the Vice President of Academic Affairs and Chief Academic Officer at the University of Western States stated:
"...that the very broad education prepares chiropractors to diagnose any condition that would likely walk through an ambulatory care center’s doors."
Testimony in support of expanding the scope to include these physicals was also submitted by Palmer's Chancellor Dr. Dennis Marchiori. Stating he was the President of the largest chiropractic college, Marchiori lamented that there was a great deal of misinformation regarding this issue.
Marchiori stated:
"Chiropractors in general and Palmer graduates specifically are highly trained in providing comprehensive health evaluations."
He went on to cite the number of hours in the chiropractic program, accreditation by the CCE and related licensure as evidence of these qualifications.
Palmer, under the leadership of Marchiori recently adopted a new mission centered around chiropractors as primary care physicians for the spine. Brimhall and Marchiori's testimony is consistent with the general push within chiropractic education and regulation to position chiropractors as another provider of primary care. Several states are pursuing the expansion of the chiropractic scope of practice in order to include primary care and drugs.
The Washington State Department of Health was not impressed. They stated:
"Current chiropractic programs provide broad medical training, including supervised clinical training; however, it is minimal in comparison to the substantial training they receive in aspects of chiropractic care. In addition, chiropractic programs are not required to include training in pharmacology. Some programs offer some training in this area, but the amount varies from program to program. Chiropractic schools don’t require clinical rotations specific to areas such as family medicine, internal medicine, or pediatrics."
The Department of Health expressed further concern in regards to the evaluation of children pointing out how over a quarter of the children in the United States are on at least one medication and raised concerns regarding the inadequacy of chiropractors' training in the area of pharmacology.
It is expected that the Washington State Chiropractic Association and those who have a vested interest in expanding the role of the chiropractor as a primary care provider will regroup on this issue including attempting to change the scope of practice language in Washington State. Further efforts are expected on the part of the Council on Chiropractic Education in the area of pharmacology training. The stage for this was set recently when the CCE along with controlling members of the Chiropractic Summit and several College Presidents agreed to changing the definition of chiropractic as being "without drugs and surgery" to "without unnecessary drugs and surgery".
Other issues that could be potential problem areas for chiropractic schools include those schools who claim to train primary care providers in their marketing materials, course catalogs, and websites. Not only is there the issue that a Department of Health or other entity does not beleive that the institution is actually doing that, but what of the student who beleived those marketing materials and made the $200,000.00 decision to attend chiropractic school under the belief that they would be able to practice primary care once they graduated.
For now the Washington State Department of Health makes their position on the reality of chiropractic training very clear:
"These physical examinations are clearly outside the existing chiropractic scope of practice. Allowing performance of these physicals would be a substantial increase to the current scope. This would require the examiner to take on the role of primary care provider, examining and diagnosing systems and issues of the whole body, including assessing possible side effects and interactions of medications. Chiropractors have limited training in pharmacology and no prescriptive authority in Washington. CMV exams may necessitate the examiner to make highly subjective decisions, such as whether cardiovascular disease should disqualify an individual, or whether a diabetic whose condition is adequately controlled by medication and diet should be allowed to drive."
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