Society for Science-Based Medicine

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Tennessee bills allow chiropractic "physicians" expanded scope; provide "direct primary care" to patients

The American Chiropractic Association is pushing to refashion chiropractors as primary care physicians. Four bills pending in Tennessee help the ACA toward its goal.

A couple of years ago, the ACA announced "Six Key Elements of a Chiropractic Practice Act," a template for amending state laws governing chiropractic practice that would give chiropractors

"Full Management, Referral and Prescription Authority commensurate with contemporary chiropractic education for Patient Examination, Diagnosis, Differential Diagnosis and Health Assessment."

The Council on Chiropractic Education is in on the deal, having declared that all chiropractic schools must teach their students to

"practice primary health care as a portal-of-entry provider for patients of all ages and genders focusing on the inherent ability of the body to heal and enhance function without unnecessary drugs or surgery."

Of course, this isn't real primary care, it's cargo cult primary care. Real primary care physicians, like family practice doctors, pediatricians and internists, complete four years of medical school and then three years of residency. Chiropractors go to small schools that are not a part of the mainstream American university system and go straight into practice after less than four full years of school. Their only clinical experience is in school clinics, where they see patients with musculoskeletal issues. The woeful inadequacy of their education and training for primary care was nicely covered over on Science-Based Medicine by Harriet Hall, MD, a retired family practice doctor. The whole idea of a DC as a PCP has been thoroughly vetted on SBM as well. 

But via the magic of Legislative Alchemy, the process by which state legislatures turn pseudoscience and fake medicine into licensed health care practices, chiropractors are moving through the states seeking practice expansion to meet the ACA's "key elements." Last year, Ohio passed a bill achieving a sort of naturopathic primary care status for chiropractors: no prescription drugs, but the authority to diagnose and treat any disease or condition. A practice expansion bill is pending in Indiana this year as well.

Chiropractic practice is currently defined under Tennessee law as

"the art of locating and removing interference with nerve transmission and nerve function . . . directed toward restoring and maintaining the normal neuromuscular and musculoskeletal function and health of the patient."

In other words, traditional subluxation-based chiropractic. Tennessee Senate Bill 313 and House Bill 387 would vastly expand chiropractic practice to include

"Differential diagnosis of human aliments through examination and evaluation of patients . . . through the ordering and performance of appropriate diagnostic procedures necessary to clinically correlate a physical examination to a diagnostic impression."

To achieve this differential diagnosis, the chiropractic "physician" could order x-rays, advanced diagnostic imaging "and other diagnostic procedures" and the "collection of bodily fluids and specimens for analysis." The chiropractor could actually perform "other diagnostic procedures" if he has "received training" in them.

Under these bills, a chiropractor could treat not only neuromuscular and musculoskeletal conditions, but also what is referred to cryptically as "other conditions." Treatment methods include, in addition to physical methods (such as "chiropractic adjustment and manipulation"), "other therapeutic care" and "chemical, electrical and thermal methods." They can also provide "supportive care with due regard for nutrition . . . and rehabilitation."

Given the vagueness of these terms, I would wager that the chiropractor could legally advise patients to take, and perhaps sell to them, non-prescription substances like OTC drugs, dietary supplements and homeopathic remedies. They are also specifically allowed to use acupuncture if they have additional training.

Chiropractors aren't permitted to "practice medicine or surgery or osteopathy," but that leaves little guidance as to just what it is they can and cannot do if one of these bills becomes law. The practice of medicine is defined under Tennessee law as "diagnose, treat, operates on or prescribes for any physical injury or deformity." Even if chiropractors are prevented from operating and prescribing, how is "differential diagnosis of human ailments," any different from "diagnose [and] treat . . . any physical aliment or any physical injury to or deformity?"

Lest you think I'm reading too much into the intent of SB 313 and HB 387, two other bills pending in the Tennessee legislature should remove all doubt. Senate Bill 224 and House Bill 334 aim to amend a state law allowing physicians to enter into direct primary care agreements with patients. Under current state law, a direct primary care agreement allows a physician to provide primary care to a patient for a set fee over a specified period of time (a year, for example) rather than, say, billing the patient's insurer or accepting fee-for-service for a particular visit. 

"Primary care" is defined in the law permitting these agreements as

"the screening, assessment, diagnosis, and treatment for the purpose of promotion of health or the detection and management of disease or injury within the competency and training of the direct primary care physician."

SB 224 and HB 334 would amend this law to permit chiropractic "physicians" to enter into direct primary care agreements with patients.

While other states have expanded chiropractic practice to include some of the functions of a primary care provider, and some define chiropractic as a form of primary care, none has put the chiropractic "physician" and the medical physician on the same playing field in as stark as manner as these bills before the Tennessee legislature.

Points of Interest 02/12/2017
Points of Interest 02/11/2017