by Meridel I. Gatterman, MA, DC, MEd,
ACA Wellness Subcommittee on Education
Two articles in the Feb. 26, 2009 issue of DC [1,2] brought to mind the ongoing paradox of chiropractors as primary care providers and spinal specialists. While the major focus of the chiropractic research agenda is the continuing promotion of the idea of chiropractors as specialists, this concept has not worked well for many in the profession and denies patients the benefits we can offer as primary care doctors.
As long as we are satisfied to limit ourselves to one area of the body (the spine) and one modality (manipulation), we can readily be dismissed as therapists rather than full-fledged physicians. And by designating chiropractors as specialists with a co-pay double that of primary care practitioners, insurers can limit the amount paid out by making the coverage equal to the co-pay.
Having debated this issue at the chiropractic centennial celebrations in both Washington, D.C., and Davenport, Iowa, on the side of chiropractors as primary care practitioners, I find the divisiveness that permeates the profession as passionate as ever. That said, I believe it is time to consider what is in the best interest of patients and empower those doctors who wish to promote health and wellness to practice as primary care practitioners.
Can You Practice Health Promotion and Not Be a Primary Care Provider?
Promotion of health and wellness requires direct access to the provider, which is a prerequisite for a primary care practitioner. The role of primary care provider as gatekeeper was seen as a means to control costs, and is an artificial designation with arcane criteria designed to enhance the profit of insurance companies. The issue has been raised as to whether a practitioner can be both a primary care doctor and a specialist. What about the gynecologist, who fits both designations? Does this exemplify the adage that lobbying works?
The misconception that primary care doctors must treat the majority of conditions seen in their offices has often been used to keep chiropractors from this designation, both by some in the profession and by others in the health care field. Gynecologists certainly don’t treat all of their patients’ disorders, nor do they always diagnose and refer conditions when appropriate. Even so, the important point in this discussion is that primary care practitioners should be prepared to recognize and refer patients whose conditions they cannot treat. More and more nurse practitioners and naturopaths are serving as primary care practitioners. Surely most chiropractors have as much or more education and training in diagnosis and pathology as these practitioners.
The prevailing model of modern medicine is primarily curative, technical, impersonal, mechanistic and expensive.  At best, this model promotes disease prevention by screening for potential problems that are then treated with drugs; health and wellness are not dependent upon finding the right synthetic drugs. By nature chiropractors are conservative, preferring to stimulate the body’s innate capacity to heal without the need for drugs and surgery.  This in itself promotes health and wellness by avoiding the side effects often associated with drugs and surgery. If the primary care doctor has this focus as a first option, rather than what drug can be prescribed or body part removed, chiropractors traditionally qualify as more cost-effective primary care practitioners.
Health Care Reform
The current focus on health care reform cries out for primary care providers who are accessible, available and affordable. The number of citizens in the U.S. without health care insurance (more than 46 million) is the highest in the developed nations.  With the shortage of primary care providers, chiropractors who desire to fill this niche need to work together to position themselves to fill the vacuum.  In addition, those chiropractors who want to integrate with the medical model as specialists should also work to promote this end as physicians, not therapists.
Surely chiropractors are not so insecure at this stage of the profession that they expect all chiropractors to practice the same. The roles of chiropractors as primary care providers and spinal specialists are not mutually exclusive. The profession is quite capable of providing education for both types of chiropractors. With a valid intern and residency program providing education and experience for each type of practitioner, a void that exists in health care today can be filled by the chiropractic profession. Those schools that are committed to turning out spinal specialists should do so, while those whose patient-centered paradigm includes health promotion and wellness can educate their students accordingly. 
It is truly a paradigm issue that needs to be recognized so the internecine battles that are fought over chiropractic identity can be a thing of the past. Health care reform must include both holistic primary care practitioners and conservative and competent spinal specialists, neither of whom is adequately provided in the current health care arena.
Strong opposition to a holistic model can be expected from the current medical drug culture.  “Big Pharma” stands to lose “big bucks” if chiropractors and other alternative practitioners promote health and wellness conservatively. Major attacks can be expected to kill the movement toward a holistic paradigm, and legislation that will regulate or criminalize vitamins, supplements, herbal tinctures, etc., will no doubt be introduced.  As DC Publisher Donald Petersen Jr. states in his article, “‘Whole Health Healing’ in 2009,” “The need for public pressure to both protect the rights of our patients and assert chiropractic’s rightful place in the health care delivery system will require that every doctor of chiropractic get involved.” 
At the urging of the American Association of Naturopathic Physicians, a resolution to promote wellness was introduced during the last session of Congress by Rep. James Langevin (D-RI).  H. Con. Res. 406 was ultimately referred to the Subcommittee on Health, but since legislation left on the books is cleared with a new administration, this resolution will have to be reintroduced. However, it is unlikely that those points raised in the resolution will be ignored by the new administration, since President Obama had a strong wellness position in his campaign health plan and has already held a summit on health care reform.
The congressional resolution resolved that health care reform incorporate sustainable wellness programs that address the underlying causal factors associated with chronic disease. Many chronic diseases can be prevented by lifestyle changes. A number of these are associated with the musculoskeletal system. The nature of chiropractic education, with its emphasis on dysfunction related to these systems, positions the profession well to influence patients’ attitudes about lifestyle changes that prevent dysfunction and associated chronic diseases. Chiropractors working with patients as partners can ensure that they understand strategies for improving their overall health through lifestyle changes, including strategies relating to diet, exercise, smoking cessation and stress reduction. (To learn more about H. Con. Res. 406, visit: www.govtrack.us/congress/bill.xpd?bill=hc110-406.)
Transforming Disease Management Into True Health Care
Chiropractors have traditionally provided patient-centered care that addresses personal health needs, using a multidimensional approach to encourage patients to improve their own wellness through lifestyle changes and scientifically based therapies that facilitate the body’s inherent ability to maintain and restore optimal health.  Chiropractors have a detailed knowledge and understanding of the body’s innate ability to heal and of the mechanisms that regulate and repair the human body (homeostasis). They promote a vital dynamic balance and emphasize the importance of a healthy immune system in the promotion of wellness. Chiropractic health promotion and wellness strategies must utilize clearly defined standards to determine when the implementation of wellness and health promotion activities will be useful for each patient based on the diet, exercise habits, individual health history, and family health history of the patient, as the wellness resolution stipulates.  Chiropractic health promotion and wellness lines of attack must be evidence based, morally sound and fiscally responsible.
Chiropractors’ place in the U.S. health care system as reform becomes a reality must be based on the utility for promotion of patients’ health and wellness. Nurse practitioners, primary care doctors and naturopaths alone cannot provide the necessary resources if health promotion and wellness are to transform the current disease management structure into a truly health care system. Chiropractors must work together if at least a segment of the profession is to serve as primary care doctors in the promotion of health and wellness in the public’s and especially the patient’s best interest.
1. Petersen D. “‘Whole Health Healing’ in 2009.” Dynamic Chiropractic, Feb. 26,2009;27(5).
2. Campos N. “Chiropractic Suited for Primary Care?” Dynamic Chiropractic, Feb. 26,2009;27(5).
3. Fulder S. The Impact of Non-Orthodox Medicine on Our Concepts of Health. In: Lafaille R and Fulder S. Towards a New Science of Health. London, Routledge, 1993:105-17.
4. Patwardhan B. Traditional Medicine: Modern Approach for Affordable Global Health. World Health Organization, Geneva. Final Report, 2005.
5. Gatterman MI. The Patient-Centered Paradigm: A Model for Chiropractic Health Promotion and Wellness. Chiropractic J Aust, 2006.
6. “A Resolution to Promote Wellness.” Dynamic Chiropractic, Nov. 18, 2008;26(24).
7. Gatterman MI. A patient-centered paradigm: a model for chiropractic education and research. J Altern Complement Med, 1995;1(4):371-86.