Some day soon, more than 20 million veterans and their dependents will have a new choice in health care. For the first time in history, doctors of chiropractic will be a part of the mammoth Veterans Administration healthcare system, where they will be checking for subluxations and providing care to former service men and women on a par with medical doctors.
At least that’s the idea behind legislation signed by President George W. Bush last January calling on the VA to make chiropractic care available to all vets. Before the first adjusting table is installed, however, a somewhat reluctant bureaucracy must figure out what this upstart profession is all about and how it can best be used in hospitals and outpatient clinics.
While the idea seems simple in theory, there are studies to be completed and questions to be debated before chiropractors can be hired. When it comes to introducing a new idea into the federal government, nothing is simple.
While the final say on details rests with the Secretary of Veterans Affairs, Anthony Principi, much controversy has swirled around his appointment of a Chiropractic Advisory Committee. The 11-member body—made up of six chiropractors, two MDs, a physical therapist, and a doctor of osteopathy—is charged with issuing recommendations. They must come to grips with sticky issues such as scope of practice, whether chiropractors should be contracted or hired, and whether patients have to get a medical doctor’s permission prior to seeing a D.C.
This is new territory for everyone involved, and the committee members are determined to tread carefully.
“We need to make sure we don’t jump into this just to get chiropractic’s foot in the door,” says committee member Dr. Leona Fischer, an Elmhurst, Ill., D.C. and Navy veteran who serves on the World Chiropractic Alliance’s International Board of Governors. “If it’s done in a haphazard manner it’s not going to reflect positively on chiropractic. So the object of the game is to make sure we have looked at what’s going to work best to get direct access and deliver quality care.”
The committee came together for the first time in September and that meeting was largely consumed with getting acquainted and “housekeeping details,” says member Brian Murphy, a PT and clinical manager of rehabilitation at the VA’s Salt Lake City facility.
The real work will take place in the coming year as the committee members come to grips with the details of the new program.
It is in those meetings that early congeniality is likely to be sorely tested. The non-D.C.s on the committee frankly admit that their own knowledge of chiropractic is limited.
“That’s a concern for me, because I’m not sure how you can advise on something that you have not experienced,” observers Fischer.
To help remedy that problem, Committee Chairman Dr. Reed Phillips directed that the first order of business at the December meeting be a mini-seminar on chiropractic. Each D.C. is charged with delivering a presentation on the ins and outs of chiropractic education, practice, and politics for the benefit of their non-D.C. colleagues..
In addition, the committee plans to visit a site where the Defense Department is providing chiropractic services to military personnel.
“Certainly to see how (chiropractic) has been implemented in the military is one part of it, but also I understand we will be able to witness patients being treated,” says committee member Dr. Cynthia S. Vaughn, president of the Texas Board of Chiropractic Examiners. “They’ll be able to see patients receiving treatments in the room.”
The fact that chiropractic has gotten this far represents a considerable victory. The VA Healthcare System—dominated by medical doctors—has long resisted any inclusion of chiropractic. Many within the medical community are continuing to voice concern over the prospect of D.C.s acting as primary care providers.
The American Medical Association—powered by a $7.3 million lobbying budget—has fought to keep chiropractors from winning the right to be primary care physicians.
The chiropractors themselves must also come to grips with their own widely divergent philosophies. The major associations held together a shaky alliance long enough to shepherd the VA legislation through Congress. No sooner did it pass, however, than the infighting that has long characterized the struggle between straights and mixers flared up.
The ACA argued that members of the advisory committee that participated in the Defense Department’s chiropractic project should be reconstituted for service on the veterans’ panel. When this proposal was rejected in Congress, each organization submitted their own nominees.
Three members of the Defense committee were named to the new advisory body, but there were also representatives from medicine, osteopathy and physical therapy. To the horror of many D.C.s, even Dr. Charles DuVall, Jr. president of the National Association for Chiropractic Medicine, and a longtime ally of anti-chiropractic QuackWatch founder Dr. Stephen Barrett, was also given a seat.
Dr. Daryl Wills, ACA president, believes that “it is very alarming to me that the (VA) Secretary would also choose to include someone like Dr. DuVall on the committee. He is a divisive force, and, in my judgment, does not want the chiropractic profession to gain additional acceptance, nor does he wish us to make progress in any way. I fear that his appointment is a warning sign that the well-entrenched, anti-chiropractic bureaucracy at the DVA is alive and well, and will be working hard to sabotage or severely limit the scope of the new benefit.”
The accusations weren’t directed just at the VA bureaucracy. The ACA was also quick to blame the ICA and WCA for this turn of events.
Writing in Dynamic Chiropractic, Garrett Cuneo, ACA executive vice president, charged, “Once President Bush signed the legislation, the agreement was broken by the ICA and the WCA. . . How much of this disunity encouraged the VA to appoint a committee, which appears to have a majority bias against chiropractic, is difficult to document.”
Committee members are optimistic that the committee will be able to put aside their differences and make the legislation work.
“I know historically the ICA, ACA and WCA have all had contentious issues, but this meeting was wonderful,” contends Fischer. “Everybody was committed to working together for the greater good of chiropractic.”
Long-held divisions between the camps are obvious in the struggle over the VA advisory committee.
The ACA wanted to ensure that chiropractors be able to act as primary care providers, diagnosing illnesses and providing services beyond adjustments.
The more conservative groups such as ICA and WCA pushed for a more limited approach that emphasized adjusting the spine and correcting subluxations.
While the results didn’t seem to satisfy anyone, in the end it seems that just about every viewpoint is represented.
“If we are indeed going to work in a multi-disciplinary facility, I think it probably is wise for us to have input on how our role will be structured by other professions who will be impacted by this,” says committee member Dr. Michael McLean, a Virginia Beach, Va., chiropractor.
McLean believes that differences between chiropractic and the medical approach can be addressed and worked out before the program is launched.
Just how much consensus the committee can reach remains to be seen, but observers say total agreement isn’t necessary or even desirable.
“Federal advisory committees are not required to come to consensus,” says Sara McVicker, the VA official who serves as manager for the committee. “It’s nice if they do, but on the other hand, if you can get all these people with all these views in one room and they all agree, why do you need an advisory committee?”
She predicts that over the next two years, before it expires in 2004, the committee is likely to issue a series of recommendations—some of which may be unanimous, while others come in the form of majority and minority reports championing different points of view.
While the VA is not the first government agency to include chiropractic—D.C.s are already working under contract at various defense department locations—the sheer size and reach of its health care facilities offers tremendous opportunities for exposure. Presently, VA patients have to get a referral from their MD or other provider to see an outside chiropractor under the agency’s “fee basis” system.
“If VA doesn’t provide a service, we send the vet out to someone who is a private provider—in this case a provider of the patient’s choice,” says McVicker.
During fiscal year 2001, just 945 patients received chiropractic care during a total of 10,938 visits.
“That really didn’t surprise me much given the age of our patient population,” explains Murphy. “In my medical center (Salt Lake City) the average age of our patients is 73. Half of the people we treat are over 65.”
Murphy—like many in the medical community—believe patients suffering from osteoarthritis and other musculo-skeletal problems common to the elderly are not good candidates for chiropractic care.
While the details of chiropractic care remain cloudy, one thing that is clear is that a growing number of D.C.s will soon be working in the VA system side-by-side with other health professionals. For many of them it will be a new experience that may very well require the development of new skills.
Some observers predict that the long-term effect on the profession could be profound, as chiropractic becomes more closely integrated with the Allied Health Professions.
“It’s important to realize that virtually all of the work that will be done in the VA facilities will be done in a hospital context,” says McLean.
He believes this experience will have a profound effect on the profession. D.C.s will need to become much more familiar with not only the methods practiced by medical doctors and hospital staffs, but with the nature of patient illness as well.
“There are definitely protocols if you’re working in a multi-disciplinary setting,” he explains. “Many of the patients will have a variety of problems and may be under a variety of different care providers while they’re in the hospital, and we will be one of those. We will have responsibility for receiving referrals, but if a person should have some life-threatening condition, certainly we will have responsibility for making referrals.”
It will present a very different environment for most chiropractors, who are more familiar with a solo office practice. This change is also likely to force chiropractic colleges to begin training students in the skills needed to function within a hospital setting.
“I’m certain it will make a big change in the preparation of chiropractors,” he predicts. “I’m not saying it will change our scope, but we have to be more aware of what other practitioners do, and we have to be more open for professional interaction.”
That professional interaction may also change the way the medical community views chiropractic as well. With more than half of all medical physicians receiving their training in VA hospitals, D.C.s have an unprecedented opportunity to build relationships that can be carried outside the VA.
“For these providers to receive training in a facility where there are chiropractors working will literally change their view of the chiropractic profession,” says McLean.
Clearly, the opportunities for chiropractic are great, and perhaps that explains the passion that surrounds the push to inclusion in the VA. Much still remains in doubt, but to a greater extent then ever before, the profession has been extended the promise of greater acceptance. What D.C.s are able to do with that promise is now up to them.
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