Know Your Scope: Variation in Chiropractic Scope of Practice
At New York Chiropractic College, there is an unofficial pre-final exam tradition of taking pictures clad in the blue coat and stethoscope of a chiropractic intern. For students, it signifies a significant step in their education. Learning the skills and tools of patient assessment is a step towards the full competencies of a doctor of chiropractic. “Frame it, give it to your mom, make her cry,” the doctor teaching the class instructs.
Yet travel to practice in the booming college town of Ann Arbor, or provide services in the struggling city of Detroit, and the same picture could be used as legal evidence. In Michigan, examination with a stethoscope is outside of the scope of practice for a doctor of chiropractic.
Chiropractic scope demonstrates wide regional variation. According to a recent article in the Journal of Manipulative and Physiological Therapeutics, the most restrictive state was New Hampshire, with 49 surveyed services not allowed for doctors of chiropractic. However, most of the diagnostics, treatments, and adjunct therapies taught in the New York Chiropractic College curriculum were still permitted here, with the notable exception of sphygmomanometry (for measuring blood pressure). Other states reported fewer restrictions, but in more conspicuous services. Hawaii, for example, does not allow chiropractors to adjust joints of the limbs, while Wisconsin does not allow nutritional supplementation without additional certification. At the other end of the spectrum, the least restrictive state was Missouri, which allowed all surveyed services except for drug prescription and minor surgery. While New York appeared to fall at the less restrictive side of the survey, all therapies are required to relate to matters of the spine, and in Virginia diagnosis and treatment is limited to “the 24 movable vertebrae,” restricting doctors here much more than initially apparent. Such specifications create more poorly defined scopes, leaving more to the interpretation of licensing boards and courts. Vermont acknowledged this gray area explicitly: “presumably a person properly trained may be able to do this procedure, but… there is nothing in the statute that expressly permits or prohibits this procedure.” Clearly, knowing the individual region of practice is important for traveling doctors or new graduates. To further complicate matters, the study notes that many scopes have proposed modifications in the works as a result of retooling of current legal and healthcare environments in the US.1
Scope of practice laws have evolved significantly throughout American history. “In the early days of chiropractic, the Palmer graduates were alternative practitioners to the common medical practice,” said Dr. Roderic Lacy of the First Chiropractic Physician Association of America in an interview with trade publication Dynamic Chiropractic. “As the profession progressed and pressure mounted from other health care professions, chiropractic was pushed into a corner and ultimately retreated to becoming ‘back specialists,’” he explains.2 During the critical early years of chiropractic licensure, this pressure contributed to the scope of practice embraced- or not- today.
Conflicts of opinion abound regarding the services characteristic to chiropractic practice. Dr. Lacy and the FCPAA organization specifically look to integrate doctors of chiropractic into the wider landscape of healthcare with full prescriptive rights. They seek a scope where chiropractors may practice as full primary care physicians. The International Chiropractic Association, meanwhile, states that one of their primary objectives is to “Maintain and promote chiropractic’s unique identity as a non-therapeutic, drugless and surgical-free health science, based on its fundamental principles and philosophy.”3 Identity is their core motivation in this objective, ensuring that chiropractic remains explicitly distinct from other health professions, and that its doctors remain at all times the most conservative healthcare option.
Meanwhile, non-chiropractic organizations have taken their own opportunities to weigh in on chiropractic practice. In 2013 the Texas Medical Association sued to challenge the right of doctors of chiropractic to diagnose any non-musculoskeletal conditions. This step of diagnosis is part of an appropriate referral process for patients requiring other doctors’ care.4 While a court eventually struck down the challenge, it indicates one more influence on the evolving legal scope of chiropractic.
Other healthcare professions join chiropractic in debating their proper scopes. While doctors of medicine and doctors of osteopathy are licensed to attend to any ailment in any manner they deem fit,5 mid-level providers like nurse practitioners and physician assistants currently dominate medical headlines as they seek additional rights within their scope. Says Californian practice consultant Keith Borglum, in an interview with Medical Economics, “Some doctors are anti-NPs, politically they want to protect their turf. But the forecast for available medical professionals in the future is so bleak.”6 Citing a more personal connection to patients and practical experience, and presenting themselves as a solution to a care shortage facing most areas of the United States, the nurses seek to provide care without the supervision of a doctor. The nurses are currently allowed to perform extensive evaluation and implement many forms of care, but it all must be under the orders of a doctor.7 The doctors, for their part, point out extensive schooling in diagnosis and treatment beyond the typical training of their nurse counterparts. A complex interplay emerges, with each organization appearing to see its own members as the primary solution to an array of healthcare problems.
Most American healthcare professions struggle with scope of practice inconsistencies over time and between states. For chiropractors, it can mean a very different experience for patients based on the state of practice, and even the state where the doctor was educated. Doctors must be sure to learn the intricacies of their own locale to choose a region that suits their clinical interests, and to deliver the highest quality patient care possible. And in an evolving healthcare system, both doctors and patients need to become self-advocates when disparities arise between patient needs and legally allowed levels of care. Ultimately, when every patient receives the care they need, then we can call our scope of practice laws successful.
- Chang, M. The chiropractic scope of practice in the United States: a cross-sectional survey. J Manipulative and Physiological Therapeutics. 2014;37(6):363-76. Access via: http://www.ncbi.nlm.nih.gov/pubmed/25015008. Accessed September 17, 2014.
- FCPAA: Fighting for Full Scope Chiropractic. Dynamic Chiropractic. 2014; 30(22). Available at: http://www.dynamicchiropractic.com/mpacms/dc/article.php?id=56184. Accessed August 6, 2014.
- International Chiropractic Association. About ICA. Available at: http://www.chiropractic.org/about. Accessed September 17, 2014.
- Edwards, J. Texas Medical Association Denied. Dynamic Chiropractic. 2014; 33(13). Available at: http://www.dynamicchiropractic.com/mpacms/dc/article.php?id=56584. Accessed September 17, 2014.
- Doctor of medicine profession. MedlinePlus. April 3, 2013. Available at: http://www.nlm.nih.gov/medlineplus/ency/article/001936.htm. Accessed September 17, 2014.
- Marbury, D. There are no easy solutions to the scope of practice debate. Medical Economics. September 10, 2013. Available at: http://medicaleconomics.modernmedicine.com/medical-economics/news/scope-practice-debate. Accessed September 17, 2014.
- Oregon State Board Of Nursing. Standards and scope of practice for the licensed practical nurse and registered nurse. Or. Rev. Stat. § 851-045. Available at: http://arcweb.sos.state.or.us/pages/rules/oars_800/oar_851/851_045.html. Accessed September 17, 2014.