Point–Counter Point


I recently received an email containing a Letter to the Editor in the October 2008 Palmer College Beacon. The letter was written by two members of the Diagnosis Department at the college in response to a previous Pivot article of mine that had been reprinted in the Beacon. The author of the letter felt that “another opinion that is reasonable and prudent” concerning the subject of diagnosis should be presented. I think the major problem is that we just see chiropractic differently. If chiropractic is just another “physician-level health profession(al),” then diagnosis is reasonable and prudent and my approach is dangerous. If chiropractic is something different as the Founder and Developer of their school maintained, as the profession has maintained, as the state governments understood in licensing our profession, and as we continue to maintain by continuing to exist as a separate and distinct approach from medicine, then on that basis their approach is unreasonable and unwise.

They argue that competence in diagnosis is necessary to obtain a chiropractic degree and also to “obtain a chiropractic state license.” However, so is a knowledge of obstetrics and gynecology. Many subjects were once taught for informational purposes and not as part of the practice of chiropractic. Somehow our profession began to embrace diagnosis. Thankfully, we have not ventured into the fields of obstetrics and gynecology, at least not yet. Microbiology, bacteriology and pathology were also taught. Like the others, including diagnosis, no one thought they were of practical value. They were for informational purposes and to “obtain a degree and license.” The respondents spend two paragraphs presenting the argument that we teach it, you need to know it to pass our courses, and therefore you need to use it in practice. Palmer also teaches about a dozen adjusting techniques, which a student must show competency in, but are they expected/required to use them all in practice? No doctor of any kind is expected/required to utilize everything he/she was taught in school.

To choose diagnosis is a specious argument. There are certain minimal standards that are expected of a “physician-level health professional.” The problem is that the chiropractic profession is not a physician-level health profession in the mind of anyone except a few people in our profession. If you want to be on a level with a physician then go to medical school and become a physician. What some of us have done is call ourselves physicians implying that our training is on a par with a medical doctor and then we have gone about attempting to elevate our educational program to reach the level of expertise we have laid claim to. That is like assuming the role of an NFL quarterback before you have even touched a football. The difference is no NFL team will hire you. Unfortunately, in our profession we have state boards in charge of determining your qualifications who do not know what medical diagnosis involves. If I do not know what it takes to be an NFL quarterback, I could maintain that you are qualified even though neither one of us has ever played the game. I recall being at Palmer a few years ago when one of the diagnosis faculty was boasting that the top students in diagnosis were allowed to go on rounds at a local hospital. My response was that they should send the worst students to do rounds, not the best. The greater point though is that if they send anybody to a hospital to do rounds, they are admitting that their chiropractic education in diagnosis is inadequate.

I am perfectly content to respect the medical diagnosis approach to the practice of chiropractic if the diagnosis doctors are willing to respect my approach. If they want to practice medical diagnosis and go through the training that a medical doctor does, be examined as a medical doctor is, I am willing to allow them. I still feel it is a dangerous approach because even the medical doctors really are not that good at it. We need to agree that we have two vastly different visions and objectives for chiropractic. In my objective, medical diagnosis is not only not necessary, it is counterproductive. It teaches people that treating disease is important and is part of the role of a chiropractor, thus undermining the uniqueness of the chiropractic objective. In their approach it is absolutely necessary. If we could just allow each group to pursue their professional mission and allow the consumer to determine which product they want. Of course, to be fair to the consumer we must distinguish the two approaches. Unfortunately, the pro-diagnosis chiropractors, cannot allow us to continue because to the public our position is reasonable, rational and, in comparison to theirs, far more acceptable. Consequently, they must denigrate, refuse to teach, and ultimately try to pass laws against our approach. They can not or will not be satisfied with an approach based on mutual respect and tolerance. They must attack our approach as dangerous and not in the best interest of the consumer. It is even worse when it is done by chiropractic school faculty who usually have little if any experience in practice. I believe that the unnecessary fear that they are instilling in students and the “defensive” approach to practice that they advocate is actually more dangerous and, in my estimation, is partly responsible for chiropractors failing in practice. If you practice their approach, you probably confine your care to minor back sprains and you really cannot build much of a practice that way.

Consider the safety factor or as the respondents put it, we “should be focused on one question: ‘What is best for my patient?’” I agree that “we should put the needs of the patient before our own philosophical wishes,” which is why I think patients should be diagnosed by a professional who is properly and extensively trained and experienced in diagnosis. No chiropractor ever has or ever will be trained in diagnosis as a medical doctor is. It is delusional to think as a chiropractor that you are. To tell your practice members that you do not diagnose and if they want or need a diagnosis they should see a physician is what is best for the patient. However, they also need a spine that is free of vertebral subluxations and that is what we have to offer as chiropractors.

The bottom line is, there is only a conflict between the needs of the practice member and one’s “philosophical wishes” when one wishes to practice medicine (the diagnosis and treatment of diseases) without a license to do so i.e., this is not a conflict for medical doctors. That has historically been the conflict with medicine and chiropractic and as long as we have chiropractors and instructors who have a therapeutic philosophy, we will never be respected in the eyes of the medical world or accepted by the public.

The respondents to my article claim that the better diagnostician you become, the “more likely you will be able to keep them under your care and management.” That goes to the crux of the problem with some in our profession. They want to be an alternative to the practice of medicine. To be that alternative, you must do everything medicine does only better or at the least as well, but more affordable. Chiropractic never has and never will succeed at that, and while we keep trying we do not have the education or the resources to compete with medicine in either the diagnosis or treatment of disease. To think that we will get as good as medicine in diagnosis when we are being taught by people who only have a chiropractic degree and no medical training, is simply “ludicrous and dangerous.”

The other argument that people promoting diagnosis in chiropractic often make is of a personal or practical nature. It concerns itself more with the chiropractor than with the patient or practice member. As what usually happens with the diagnosis argument, it becomes personal and presented on a so-called practical basis. I am not sure that I ever said that you could never be sued for mis-diagnosis if you do not diagnose. The fact is that you can be sued for anything these days. The issue is whether you are more likely to be sued for mis-diagnosis when you demonstrate that you do not diagnose or when you claim to have the same expertise as a physician. If, as the respondents suggests, “Missing a diagnosis is one of the top reasons for successful malpractice claims against chiropractors,” I would rather take my chances in explaining to a practice member why I do not and will not make a diagnosis and documenting that fact than using my limited expertise to try and make one. Chiropractors, in claiming a level of expertise of a physician, have placed upon themselves the responsibility of doing not what a “reasonable and prudent chiropractor (would) have rendered…” but what a medical doctor would have. Wait until the trial lawyers come to that realization. There will be thousands of medical doctors lining up to be expert witnesses against chiropractors. Right now, the chiropractors, like the respondents to my Pivot article, want us to be held to a chiropractic standard but they maintain they are teaching a standard equivalent to medicine. You cannot have it both ways and frankly, I do not think that the majority of the profession wants to be held to a medical standard.

I do not know whether the respondents even practice chiropractic (most faculty do not), but I will put my experience and philosophy of 41 plus years and over 70,000 different practice members up against their experience. Being “extremely lucky” is only an issue if you are going to be a diagnostician and try to guess what disease your practice members have without the tools, the expertise, the education or the training. I would suggest you need to be “extremely lucky.” The other choice is to be competent at explaining what you do, making the practice member aware of the difference between chiropractic and medical objectives, and not being afraid to tell the practice member who wants a medical diagnosis to go to a medical doctor. That does not involve luck but an understanding of what you do and the knowledge to convey that to the public. That is the mark of a professional and there is no luck involved. V24n2

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