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• W2101050592 abstract "I find it reassuring to see that the interest in chiropractic primary care continues to develop. Gaumer et al1Gaumer G. Koren A. Gemmen E. Barriers to expanding primary care roles for chiropractors the role of chiropractic as primary care gatekeeper.J Manipulative Physiol Ther. 2002; 25: 427-449Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar address the issue pertaining to barriers of chiropractic primary care. They find perceptions from the profession, consumer, and third party organizations, as well as scope of practice laws, as obstacles for the practical provision of chiropractic primary care. Initially, they introduce 2 concepts related to the topic that I would like to address.They recognize the differentiation of primary care into primary health care and primary medical care. Primary health care according to Bowers and Mootz2Bowers L.J. Mootz R.D. The nature of primary care the chiropractor's role.Top Clin Chiropr. 1995; 2: 66-84Google Scholar is “community-oriented health care focusing on a public health perspective with services provided by a health care team rather than a physician.” Primary medical care is described as care “focused on the individual in an encounter-based system that uses the bio-medical paradigm, with services provided by a physician or other health care professional.”2Bowers L.J. Mootz R.D. The nature of primary care the chiropractor's role.Top Clin Chiropr. 1995; 2: 66-84Google Scholar They choose to address the chiropractic primary care issue from the perspective of primary health care with the chiropractor functioning “as part of an interdisciplinary health-care team providing coordinated, community-oriented primary care, rather than the individual, encounter-based model of primary medical care.”1Gaumer G. Koren A. Gemmen E. Barriers to expanding primary care roles for chiropractors the role of chiropractic as primary care gatekeeper.J Manipulative Physiol Ther. 2002; 25: 427-449Abstract Full Text Full Text PDF PubMed Scopus (14) Google ScholarI do not believe that primary care should be differentiated in this or any other manner. Primary care, by its very nature, includes aspects that address the individual and community. This is noted in Gaumer's citation of 7 primary care definitions, including definitions from the Institute of Medicine and the American Academy of Family Physicians. Primary care incorporates the individual's care within the concept of their home, work, and community environment. As the physician provides care to the individual, so too must he/she be aware of the community or public health issues that are influenced by their patient's condition. Furthermore, during the course of primary care practice, the primary care physician (PCP) will naturally establish a broad list or team of providers to which their patients are referred. Thus, the team is in place for the PCP to direct or help direct patient care. To recognize the Doctor of Chiropractic (DC) as a PCP only when the DC is on an established health care team implies an inability of the doctor to carry the full PCP responsibility. It implies the doctor must be in the same facility as the health care team addressing predominantly public health matters as opposed to “addressing a large majority of personal health care need.”3Donaldson M.S. Yordy K.D. Lohr K.N. Vanselow A. Primary care—America's health in a new era, institute of medicine. National Academy Press, Washington (DC)1996Google ScholarI believe it is inappropriate to group the chiropractic profession into the primary health care faction. Chiropractic doctors have traditionally cared for individuals in an encounter-based manner that uses the naturally based biomedical or chiropractic paradigm of care. Historically, the chiropractic profession has provided primary care as evidenced by training,4Council on Chiropractic Education Commission on Accreditation. Standards for chiropractic programs and institutions. Available at: http://www.cce.org. Accessed February 2001Google Scholar conditions treated,5Bakkum B.W. Green B.N. Chiropractic hospitals in America—a case study of the Bakkum hospital (1936-1950).J Manipulative Physiol Ther. 2001; 24: 34-43Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar, 6Chapman-Smith D. The chiropractic profession. NCMIC Group Inc, West Des Moines (IA)2000Google Scholar, 7Fallon J.M. The role of the chiropractic adjustment in the care and treatment of 332 children with otitis media.J Clin Chiropr Pediatr. 1997; 2: 167-183Google Scholar direct access of services,5Bakkum B.W. Green B.N. Chiropractic hospitals in America—a case study of the Bakkum hospital (1936-1950).J Manipulative Physiol Ther. 2001; 24: 34-43Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar, 6Chapman-Smith D. The chiropractic profession. NCMIC Group Inc, West Des Moines (IA)2000Google Scholar coordination of care with other practitioners,5Bakkum B.W. Green B.N. Chiropractic hospitals in America—a case study of the Bakkum hospital (1936-1950).J Manipulative Physiol Ther. 2001; 24: 34-43Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar, 6Chapman-Smith D. The chiropractic profession. NCMIC Group Inc, West Des Moines (IA)2000Google Scholar utilization of a wide range of diagnostic services,8Lamm L. Pfannenschmidt K. Chiropractic scope of practice what the law allows—update 1999.J Neuromuscul Syst. 1999; 7: 102-106Google Scholar and care provided for all age groups.7Fallon J.M. The role of the chiropractic adjustment in the care and treatment of 332 children with otitis media.J Clin Chiropr Pediatr. 1997; 2: 167-183Google Scholar, 9Vallone S, Duenas R. Chiropractic and its role in providing primary natural health care to the pediatric patient. In: Barge FH, Chair. Proceedings of the Lisbon 2000 Symposium, The Philosophy, Art and Science of Chiropractic. Arlington: Foundation for the Advancement of Chiropractic Tenets and Science; 2000. p. 93-100Google Scholar, 10Editors. Chiropractic care for all ages. J Am Chiropr Assoc 1996;Oct:15Google Scholar, 11Thompson CK. Multidisciplinary health-care approach works well at New Jersey long-term care facility, Preaknes hospital establishes chiropractic clinic. J Am Chiropr Assoc 1996;Oct:17-21Google ScholarA point is made of the American Chiropractic Association's (ACA) position statement on the role of chiropractic in primary care. Gaumer cites the 1994 position statement as the profession's view about the preferred role of chiropractic in the health care industry and recognizes this statement as “very inclusive.” Coincidentally, while Gaumer et al1Gaumer G. Koren A. Gemmen E. Barriers to expanding primary care roles for chiropractors the role of chiropractic as primary care gatekeeper.J Manipulative Physiol Ther. 2002; 25: 427-449Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar were preparing their paper for publication, I prepared a resolution statement to revise the ACA's 1994 position statement on Primary Health Care: Role of Chiropractic. Dr. Keith Overland (Connecticut delegate) introduced the new statement at the ACA's fall conference in 2000. The House of Delegates subsequently ratified the resolution in March 2001. This new statement recognizes the Institute of Medicine definition for primary care and reads as follows:12American Chiropractic Association. Available at: http://amerchiro.org/pdf/2002_aca_policies.pdf. Accessed November 22, 2002Google ScholarThe chiropractic profession's role in Primary Health Care is to educate its students and practitioners in providing primary care at the undergraduate and graduate levels of instruction. The doctor of chiropractic is qualified to provide primary health care and may choose to further develop their primary care practice (specializing in family practice, pediatrics, generalist with subspeciality in neurology, sports medicine, or occupational health) providing for a wide range of services with a long-term patient–doctor relationship or choose to provide specialty care (neurology, orthopedics, radiology, rehabilitation, occupational health) providing for a narrower range of services with a short-term patient–doctor relationship.The Doctor of Chiropractic is qualified to provide primary care with respect to the definition from the Institute of Medicine:“Primary care is the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community.”Integrated–incorporating comprehensive, coordinated, and continuous services in an integrated manner throughout the patient's life span.Comprehensive–“addresses any health problem at any given stage of a patient's life cycle.”Coordinated–ensures the integration of health services and information necessary for the patient's health and well-being in a rational manner and including the resources of the community.Continuous–“care over time by single clinician or team of health care professionals (′clinician continuity') and to effective and timely communication of health information (events, risks, advice, and patient preferences) (‘record continuity’).”Accessible–unrestricted direct access for any problem at any time.Health care services–chiropractic service which primarily focuses on the restoration of the inherent recuperative abilities of the body through natural means. Chiropractic focuses on the relationship between structure, primarily the spine, and function primarily coordinated by the nervous system of the human body as that relationship may affect the restoration and preservation of health. Chiropractors also provide patient evaluation and instructions regarding disease prevention and health promotion through proper nutrition, exercise, and lifestyle modification among others. The range of diagnostic and therapeutic services offered by chiropractic is dynamic and will be modified by education, research, technological change, and society's evolving health care needs. Referral to other providers for conditions beyond the chiropractic scope of practice is integral to chiropractic practice.Clinician–responsibilities as a primary care clinician include wellness promotion, health assessment, diagnosis, and the chiropractic management of the patient's health care needs. When indicated, the doctor of chiropractic consults with, co-manages, or refers to other health care providers.Accountable–responsible to the patient and community for the large majority of personal or health care needs by establishing a sustained patient–doctor relationship.Majority of personal health care needs–chiropractors “receive all problems that patients bring—unrestricted by problem or organ system—and have the appropriate training to diagnose and manage a large majority of those problems and to involve other health care practitioners for further evaluation or treatment when appropriate. Personal health care needs include physical, mental, emotional, and social concerns that involve the functioning of an individual.”Sustained partnership–the expected establishment of a patient–doctor relationship over one's lifetime and is inclusive of mutual trust, respect, and responsibility.Patient–the free individual who seeks care from a naturally based and/or chiropractic perspective.Context of family and community–providing care in consideration of the patient as they relate to their family and community and with reference to the community in which the clinician practices.Primary care is the domain of all whole body healing arts professions, providing the avenue by which individuals and their communities may pursue the establishment and maintenance of good health care consistent with their personal ideals and philosophy of life. It is incumbent of all healing arts professionals to cooperatively integrate a respectful utilization of each others expertise in the best interests of the patient and community.The rationale for this revision was to help assure that the profession be guided to continue its centralized role in whole body, naturally based health care and to truly identify the traditions, strengths, and character of chiropractic as it relates to the care of the individual.The profession must recognize its role in any health care system, or even if there is no “system,” as a primary care profession with specialty and subspecialty opportunities for interested doctors. The chiropractic physician should be able to accept the primary care physician role without the need for qualification into a “primary health care” or model. Primary care is primary care and includes aspects relating to the individual and community for encounter-based and preventive-based health care. A firm commitment to primary care will help the profession overcome the barriers to full scope chiropractic practice. I find it reassuring to see that the interest in chiropractic primary care continues to develop. Gaumer et al1Gaumer G. Koren A. Gemmen E. Barriers to expanding primary care roles for chiropractors the role of chiropractic as primary care gatekeeper.J Manipulative Physiol Ther. 2002; 25: 427-449Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar address the issue pertaining to barriers of chiropractic primary care. They find perceptions from the profession, consumer, and third party organizations, as well as scope of practice laws, as obstacles for the practical provision of chiropractic primary care. Initially, they introduce 2 concepts related to the topic that I would like to address. They recognize the differentiation of primary care into primary health care and primary medical care. Primary health care according to Bowers and Mootz2Bowers L.J. Mootz R.D. The nature of primary care the chiropractor's role.Top Clin Chiropr. 1995; 2: 66-84Google Scholar is “community-oriented health care focusing on a public health perspective with services provided by a health care team rather than a physician.” Primary medical care is described as care “focused on the individual in an encounter-based system that uses the bio-medical paradigm, with services provided by a physician or other health care professional.”2Bowers L.J. Mootz R.D. The nature of primary care the chiropractor's role.Top Clin Chiropr. 1995; 2: 66-84Google Scholar They choose to address the chiropractic primary care issue from the perspective of primary health care with the chiropractor functioning “as part of an interdisciplinary health-care team providing coordinated, community-oriented primary care, rather than the individual, encounter-based model of primary medical care.”1Gaumer G. Koren A. Gemmen E. Barriers to expanding primary care roles for chiropractors the role of chiropractic as primary care gatekeeper.J Manipulative Physiol Ther. 2002; 25: 427-449Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar I do not believe that primary care should be differentiated in this or any other manner. Primary care, by its very nature, includes aspects that address the individual and community. This is noted in Gaumer's citation of 7 primary care definitions, including definitions from the Institute of Medicine and the American Academy of Family Physicians. Primary care incorporates the individual's care within the concept of their home, work, and community environment. As the physician provides care to the individual, so too must he/she be aware of the community or public health issues that are influenced by their patient's condition. Furthermore, during the course of primary care practice, the primary care physician (PCP) will naturally establish a broad list or team of providers to which their patients are referred. Thus, the team is in place for the PCP to direct or help direct patient care. To recognize the Doctor of Chiropractic (DC) as a PCP only when the DC is on an established health care team implies an inability of the doctor to carry the full PCP responsibility. It implies the doctor must be in the same facility as the health care team addressing predominantly public health matters as opposed to “addressing a large majority of personal health care need.”3Donaldson M.S. Yordy K.D. Lohr K.N. Vanselow A. Primary care—America's health in a new era, institute of medicine. National Academy Press, Washington (DC)1996Google Scholar I believe it is inappropriate to group the chiropractic profession into the primary health care faction. Chiropractic doctors have traditionally cared for individuals in an encounter-based manner that uses the naturally based biomedical or chiropractic paradigm of care. Historically, the chiropractic profession has provided primary care as evidenced by training,4Council on Chiropractic Education Commission on Accreditation. Standards for chiropractic programs and institutions. Available at: http://www.cce.org. Accessed February 2001Google Scholar conditions treated,5Bakkum B.W. Green B.N. Chiropractic hospitals in America—a case study of the Bakkum hospital (1936-1950).J Manipulative Physiol Ther. 2001; 24: 34-43Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar, 6Chapman-Smith D. The chiropractic profession. NCMIC Group Inc, West Des Moines (IA)2000Google Scholar, 7Fallon J.M. The role of the chiropractic adjustment in the care and treatment of 332 children with otitis media.J Clin Chiropr Pediatr. 1997; 2: 167-183Google Scholar direct access of services,5Bakkum B.W. Green B.N. Chiropractic hospitals in America—a case study of the Bakkum hospital (1936-1950).J Manipulative Physiol Ther. 2001; 24: 34-43Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar, 6Chapman-Smith D. The chiropractic profession. NCMIC Group Inc, West Des Moines (IA)2000Google Scholar coordination of care with other practitioners,5Bakkum B.W. Green B.N. Chiropractic hospitals in America—a case study of the Bakkum hospital (1936-1950).J Manipulative Physiol Ther. 2001; 24: 34-43Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar, 6Chapman-Smith D. The chiropractic profession. NCMIC Group Inc, West Des Moines (IA)2000Google Scholar utilization of a wide range of diagnostic services,8Lamm L. Pfannenschmidt K. Chiropractic scope of practice what the law allows—update 1999.J Neuromuscul Syst. 1999; 7: 102-106Google Scholar and care provided for all age groups.7Fallon J.M. The role of the chiropractic adjustment in the care and treatment of 332 children with otitis media.J Clin Chiropr Pediatr. 1997; 2: 167-183Google Scholar, 9Vallone S, Duenas R. Chiropractic and its role in providing primary natural health care to the pediatric patient. In: Barge FH, Chair. Proceedings of the Lisbon 2000 Symposium, The Philosophy, Art and Science of Chiropractic. Arlington: Foundation for the Advancement of Chiropractic Tenets and Science; 2000. p. 93-100Google Scholar, 10Editors. Chiropractic care for all ages. J Am Chiropr Assoc 1996;Oct:15Google Scholar, 11Thompson CK. Multidisciplinary health-care approach works well at New Jersey long-term care facility, Preaknes hospital establishes chiropractic clinic. J Am Chiropr Assoc 1996;Oct:17-21Google Scholar A point is made of the American Chiropractic Association's (ACA) position statement on the role of chiropractic in primary care. Gaumer cites the 1994 position statement as the profession's view about the preferred role of chiropractic in the health care industry and recognizes this statement as “very inclusive.” Coincidentally, while Gaumer et al1Gaumer G. Koren A. Gemmen E. Barriers to expanding primary care roles for chiropractors the role of chiropractic as primary care gatekeeper.J Manipulative Physiol Ther. 2002; 25: 427-449Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar were preparing their paper for publication, I prepared a resolution statement to revise the ACA's 1994 position statement on Primary Health Care: Role of Chiropractic. Dr. Keith Overland (Connecticut delegate) introduced the new statement at the ACA's fall conference in 2000. The House of Delegates subsequently ratified the resolution in March 2001. This new statement recognizes the Institute of Medicine definition for primary care and reads as follows:12American Chiropractic Association. Available at: http://amerchiro.org/pdf/2002_aca_policies.pdf. Accessed November 22, 2002Google ScholarThe chiropractic profession's role in Primary Health Care is to educate its students and practitioners in providing primary care at the undergraduate and graduate levels of instruction. The doctor of chiropractic is qualified to provide primary health care and may choose to further develop their primary care practice (specializing in family practice, pediatrics, generalist with subspeciality in neurology, sports medicine, or occupational health) providing for a wide range of services with a long-term patient–doctor relationship or choose to provide specialty care (neurology, orthopedics, radiology, rehabilitation, occupational health) providing for a narrower range of services with a short-term patient–doctor relationship.The Doctor of Chiropractic is qualified to provide primary care with respect to the definition from the Institute of Medicine:“Primary care is the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community.”Integrated–incorporating comprehensive, coordinated, and continuous services in an integrated manner throughout the patient's life span.Comprehensive–“addresses any health problem at any given stage of a patient's life cycle.”Coordinated–ensures the integration of health services and information necessary for the patient's health and well-being in a rational manner and including the resources of the community.Continuous–“care over time by single clinician or team of health care professionals (′clinician continuity') and to effective and timely communication of health information (events, risks, advice, and patient preferences) (‘record continuity’).”Accessible–unrestricted direct access for any problem at any time.Health care services–chiropractic service which primarily focuses on the restoration of the inherent recuperative abilities of the body through natural means. Chiropractic focuses on the relationship between structure, primarily the spine, and function primarily coordinated by the nervous system of the human body as that relationship may affect the restoration and preservation of health. Chiropractors also provide patient evaluation and instructions regarding disease prevention and health promotion through proper nutrition, exercise, and lifestyle modification among others. The range of diagnostic and therapeutic services offered by chiropractic is dynamic and will be modified by education, research, technological change, and society's evolving health care needs. Referral to other providers for conditions beyond the chiropractic scope of practice is integral to chiropractic practice.Clinician–responsibilities as a primary care clinician include wellness promotion, health assessment, diagnosis, and the chiropractic management of the patient's health care needs. When indicated, the doctor of chiropractic consults with, co-manages, or refers to other health care providers.Accountable–responsible to the patient and community for the large majority of personal or health care needs by establishing a sustained patient–doctor relationship.Majority of personal health care needs–chiropractors “receive all problems that patients bring—unrestricted by problem or organ system—and have the appropriate training to diagnose and manage a large majority of those problems and to involve other health care practitioners for further evaluation or treatment when appropriate. Personal health care needs include physical, mental, emotional, and social concerns that involve the functioning of an individual.”Sustained partnership–the expected establishment of a patient–doctor relationship over one's lifetime and is inclusive of mutual trust, respect, and responsibility.Patient–the free individual who seeks care from a naturally based and/or chiropractic perspective.Context of family and community–providing care in consideration of the patient as they relate to their family and community and with reference to the community in which the clinician practices.Primary care is the domain of all whole body healing arts professions, providing the avenue by which individuals and their communities may pursue the establishment and maintenance of good health care consistent with their personal ideals and philosophy of life. It is incumbent of all healing arts professionals to cooperatively integrate a respectful utilization of each others expertise in the best interests of the patient and community.The rationale for this revision was to help assure that the profession be guided to continue its centralized role in whole body, naturally based health care and to truly identify the traditions, strengths, and character of chiropractic as it relates to the care of the individual.The profession must recognize its role in any health care system, or even if there is no “system,” as a primary care profession with specialty and subspecialty opportunities for interested doctors. The chiropractic physician should be able to accept the primary care physician role without the need for qualification into a “primary health care” or model. Primary care is primary care and includes aspects relating to the individual and community for encounter-based and preventive-based health care. A firm commitment to primary care will help the profession overcome the barriers to full scope chiropractic practice." @default.
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