Evolving Professions, Expanding Scope, Ongoing Battles

There isn’t a health care profession that has been exempt from fighting political Western medicine. The unchallenged cultural authority established by allopathic medicine and its professional social ‘norms’ has permitted medical schools to demand compliance from students and practitioners.  Rites of passage for professions trying to grow and mature have included a gantlet of legislative battles against a united front, often with incredible pressure, suppression and retribution. No profession has had it harder than chiropractic, with a painful history that includes thousands of prosecutions, time in jail, and even loss of life from those experiences. Why is this still something to talk about? Because it’s still playing out, but with new and different implications.The challenge every profession has had to address is that medicine is its own standard, and by that standard nothing else measures up. As different professions have sought statutory protection to practice responsible health care, there has always been pressure to establish standards that were in the very language of medicine–and we’ve capitulated. We’ve become dependent on the term ‘medical necessity,’ even though the phrase is inappropriate for clinical paradigms and philosophies of non-medical professions. Every profession that has had to fight for scope of practice legislation has had to deal with the burden of proving they were not practicing medicine, and thus not given the freedom to independently and responsibly define what the terms of their own practices should be. Going down the rabbit-hole to the Wonderland of health care, we have had the burden of proving the inverse of our own philosophy and clinical approach as justification for what we do.

We can’t single out medicine for this; it’s an issue that cuts both ways. Chiropractic has had to deal with others who ‘manipulate’ bones and soft tissues, and has had to let itself be figuratively painted into a corner by accepting training minimums for professions like physical therapy that have ended up being able to offer a competing service. So there are understandable, even important instances where competing scope of practice specifics need to be addressed.

But what shouldn’t be forgotten is that the issues are cloaked in legitimate terms of philosophy, clinical paradigms and other high-road vocabulary, but the reality is that they are always economic at the core. Medical doctors didn’t–and often still don’t–want chiropractors offering competing services (especially more effective ones), and chiropractors don’t want PTs or others offering competing services (even inferior ones). The economic nature of these arguments has fueled both the kinds of comparative research being done (because cost-effectiveness is relatively easy to isolate) and locked us into the ‘cheaper is better’ argument, because when you’re comparing apples and oranges the only thing you’re going to find in common to discuss and debate is price. Well, cheaper isn’t always better, and we have only to look at what we’re paid for our services to get a painful reality check.

The latest chapter in this fractious history is playing out between medicine and naturopathic medicine in California. Chiropractors should be watching and taking notes.

Naturopathy got its start about the same time as chiropractic; the term to describe the collective ‘natural’ clinical practices of professionals was coined about 1892, and the first class of the American School of Naturopathy graduated in 1902. The profession grew to over 10,000 practitioners in the 1920s, and waned until its resurgence in the late 1970s with accreditation of US schools. Differentiating itself from naturopaths who could get mail-order education, the terms ‘naturopathic medicine’ and ‘naturopathic physicians’ have grown to be preferred by those who are graduates of four-year courses at accredited schools.

Licensed in California in 2003 with the ability to have limited prescription rights and to deliver babies under medical supervision, NDs have a bill moving through the California legislature that would remove the requirement for supervision, freeing them to write prescriptions and to perform minor surgical procedures without MDs being involved. The same arguments are being trotted out that get used every time against any profession that tries to expand its scope: potential for public harm, lack of training/residencies, etc. The same counterarguments also have been dusted off: continuity of care, convenience, medicine’s own record of unsafe practices, patient convenience, and cost.

Cost is the trump card for most arguments in today’s health care world. Spiraling costs and increasing consumer exposure to first-dollar, out of pocket responsibilities through high-deductible plans mean that, presuming safety concerns are addressed, those who can deliver lower-cost services will ultimately prevail. But incorporating those services changes the profession, and no one should have any illusions about the seduction compensated services have against those that aren’t compensated or compensated as well. When a provider’s time with a patient isn’t paid for but a prescription is, what do we think is going to happen over time? When outcomes are measured in terms of symptom reduction, which practices are going to be reinforced?

That future isn’t hard to envision, but what’s harder to know at this point is what’s going to happen in consumers’ minds and wallets as a result of all this. With some chiropractors pushing for prescription rights, the same arguments for expanding scope are likely to win at some point. They’ll join the broadening scopes of nurse practitioners and physicians assistants. The likely result? It’s not hard to imagine a scenario where a patient can get prescriptions from five different providers. Some will argue this is ‘integration.’ I will argue that it’s mush. As health care comes to operate more and more along retail marketplace dynamics, differentiation becomes more important than similarities. For those in our profession who seek to fit in, we should be careful about what we assume consumer/patients want when they see a provider in a white lab coat. If fitting in means we homogenize our services, we give others no specific reason to seek us out. It will become all about the person, not about the profession.

And if we do preserve our distinctions but fail to figure out how to successfully describe those differences, their value and defend that with data of our own design and stewardship, we are just going to increase our competition and fade in the public’s eye.

Until we can control for unintended consequences, we should be very, very careful what we think we’re asking for.

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