The well-documented work-force challenges facing the current American ‘health’ care system seem to paint a very dark picture for patients. According to a 2010 study by the American Association of Medical Colleges, by 2025 there will be a projected shortage of 65,800 primary care physicians. One estimate published in Chiropractic & Manual Therapies tallied that there are currently about 74,000 separately licensed DCs across the US. Seems like a good fit, doesn’t it?
There are other professions that think so, too. Nurses and Physician’s Assistants (PAs) also look at the workforce numbers and imagine a greater role for themselves in a system where allopathic physicians are in shorter supply. Many in our profession believe we should more visibly be serving in this role. Where should chiropractic be in all this?
The Academic Consortium for Complementary and Alternative Health Care (ACCAHC) issued a monograph last year called Meeting the Nation’s Primary Care Needs. Assembled with input from the chiropractic profession and others, it proposed that licensed non-medical professions review their curricula and consider modifying them to ensure that their members were better prepared for delivering primary care.
But just what constitutes primary care may be defined somewhat differently by different stakeholders. The ACCAHC used a definition that’s in wide use, excerpted from a white paper from the World Health Organization in 1978 which states: “Primary health care is essential health care based on practical, scientifically sound and socially acceptable methods and technology … It is the first level of contact of individuals, the family and community with the national health system bringing health care as close as possible to where people live and work, and constitutes the first element of a continuing health care process.” On the face of it, that sounds reasonable. But what should stand out to doctors of chiropractic is the phrase ‘…essential health care based on practical, scientifically sound and socially acceptable methods and technology.’ The question should be asked: essential from whose perspective? And with what level of evidence to support it?
In the current medical primary care model, services are constructed around some essential questions. Those questions generally cover areas of safety, nutrition, disease prevention/control, and personal behaviors. What is not always remembered is that those areas of inquiry and services come out of needs that are observed and defined within the medical paradigm. The issue of what lens you’re looking through here is pertinent. Allopaths ask about our safety, nutrition, vaccinations, etc., based on the observation that public health is diminished if those areas are not addressed. There’s good evidence that they should do so–from the allopathic paradigm (the use of drugs that depend on action in opposition to the symptoms, as opposed to homeopathy, where substances are used in concert with the symptoms). But aside from the opportunity to ask those questions and counsel patients about the right things to do, the services a MD can actually provide are pretty limited: examinations to rule out problems or abnormalities, supplemental nutrition where indicated (from an orthodox nutrition perspective), vaccinations and other drugs. Setting aside the vaccination debate for now, depending on the population and its needs, MDs may be providing essential services. But there are a number of questions that are not being asked in much of what passes for primary care–questions that don’t fit the medical paradigm. Those questions may be as or more important than much of what gets explored in medical primary care. Moreover, the questions are being asked of the medical and public health community, and not the actual consumer/patient community. That’s a critical difference.
Changing the Lens
In much the same manner as medically-observed phenomena or problems drive medicine’s public health agenda, doctors of chiropractic (and any profession that serves as point-of-entry for health care services) in the course of operating within our own paradigm can contribute a set of potentially important, even critical observations and services. The paradigm, however, is necessarily different than allopathy. In the course of our practices we ask patients and ourselves whether their bodies are as unrestricted to express their innate capacities for optimal health as is possible, and if not, what the sources of interference may be. We may conceive of and identify those sources of interference as environmental, nutritional, structural, neurological, rooted in emotional trauma, or others. Instead of offering drugs that counteract physical conditions, we seek to support the innate self-correcting capacities of the human body–which address problems in those physical conditions. The services we can provide, aside from our ability to ask those questions and counsel patients about the right thing to do and the services we offer are aimed at supporting a very different set of needs and concerns than medicine. The paradigm is very different.
Is one paradigm right, and the other wrong? It may not be an issue of right and wrong, but of the kind of questions we’re asking about public and population health.
If I conduct research, how I frame the question is all-important. If I ask, ‘does the sun rise?’ the answer will be ‘yes’ based on what I observe. If I ask ‘why does the sun appear to rise?’ I open myself up to a much more open-ended answer that may be more scientifically correct and valid. In the same manner, if I ask, ‘does this population have any diseases I need to suppress or pre-empt?’, the answers I get are going to be very different than if I ask, ‘does this population have the unrestricted ability to respond to challenges to its health?’ To measure success in the first question, the absence of disease is a nice, distinct metric. To measure success in the second one, a much more complicated, multi-variate set of factors must be identified. Both sets of metrics can be valued. Each paradigm’s metrics taken in isolation may be incomplete and misleading. And each profession is able to offer counseling, guidance and positive relationships for their populations. It’s just that the paradigms of treatment and intervention are completely different.
The chiropractic profession has sought inclusion and incorporation in aspects of the existing health care system, for many good reasons after being locked out of the system for decades. But it may be true that being included in an aspect of the system where the paradigm is inappropriate for us does not really help the profession–or the public that we wish to serve. Being included in a system where our inclusion is dependent on the degree we emulate someone else’s services does not seem wise. If chiropractic is to be part of primary care services for the needs of the American public, it is probably important that we insist on efforts to revisit just what those needs are, and to ensure that they are framed in terms consistent with our own paradigm. If we do not, it makes perfect sense that we should give injections and prescribe drugs. If we do, it makes ‘more perfect’ sense that we function as stewards for public health goals related to optimal neurologic functioning.
And what are those needs, anyway? The short answer is that we really don’t know, because we are accustomed to operating with the notion that these can be most effectively determined by providers, rather than the population itself.
The model of community-oriented primary care (COPC) is worth examining. Originally conceived in the 1940s in South Africa, COPC is essentially health care reverse-engineered to the needs of the community. Assessment of what those needs are is accomplished, and services are assembled that are designed to effectively meet those needs. In terms of supply and demand, the ‘supply’ is organized by what the ‘demand’ side is determined to need–and perhaps want. This common-sense approach stands in stark contrast to what has been normally the case in American healthcare: that the supply side has designed its own elegant version of services that it presumes the demand side needs. I say ‘presumed’ because despite the wealth of evidence supporting many community and population health goals, the determination of those goals has been made by the supply (provider and system) side, rather than the consumer/patients. There may be a critical difference.
As the ACCAHC and others look at the issues of primary care in the US, it’s important that we begin to ask ourselves whether we really can assume we know what the public needs and wants. It’s only when people are asked that we can make that analysis and comparison, then figure out what our contribution might be. It’s not an issue of which paradigm will win, but more of a conscious and intentional effort to assemble the services needed to meet the goals. Until we have a broader sense of what those goals are, we really have no idea of what primary care should be.