February 2004

Report on the Veterans Administration Chiropractic Advisory Committee and its work so far

by Michael S. McLean, DC, FICA, Member, VA Chiropractic Advisory Committee

The profession of chiropractic is on the verge of historic and radical changes as a result of its prospective inclusion in the Veterans Administration Health care facilities. I do not use these words lightly. Health care in general, and at the VA in particular, is about to undergo a significant shift. How chiropractic 'fits' into the new paradigm will be largely up to us. By "us" I mean the conservative wing of the profession, but if we do not take up that responsibility, it will certainly be grasped by the medical‑minded among our DCs.

Congress passed legislation in 2000 directing the VA to begin utilizing DCs. The VA responded by establishing an 11‑member committee to advise the Secretary of the VA on ways to do this. I was appointed by the Bush Administration to be a member of this, the VA Chiropractic Advisory Committee, or CAC for short.

We have met for several sessions over the last 2 years and have come up with a final draft of recommendations which have already been sent to Secretary Principi. The Secretary is not bound by our recommendations, but since they come from a multidisciplinary committee (the CAC is composed of: 6 DCs, 2 MDs, a DO, a PT, and a Veteran's service organization representative) they are likely to have some weight.

Although it remains to be seen what actions and policies will be put into place, I believe Secretary Principi sincerely wants to integrate chiropractic into the VA; I believe he sees not only that Congress is serious about having DCs work in the VA, but also that his charges, the 27 million veterans eligible for services, will be benefitted by having the services of a DC available. The CAC hopes to see DCs hired and working in the VA by the end of 2004.

I spoke earlier of "radical changes" coming as a result of these activities; chiropractic will be affected both internally and in its external relationships with other health care professions as well as the general public. This is so particularly because of the prominent role the VA hospitals play in training doctors. According to the VA, half the MDs in the US undergo training in VA hospitals. This means that the presence of DCs, working side by side with MDs, in the nation's VA facilities will create a new relationship between the professions. It means that MDs trained in a facility in which DCs are also working will not find it unusual to have a professional relationship. It will mean ‑‑ over time, as these newly trained docs come on line ‑‑ increased referrals to our profession. It will mean DCs at work in hospitals and trauma centers nationwide as the VA experience is replicated in public and private hospitals throughout the USA. And it will mean more multidisiplinary clinics.

In the educational world, DCs and possibly senior students will be receiving training at VA facilities just as MDs do now; they must have a comprehensive knowledge of how a hospital runs, of the basic medical skills needed to function in that environment, and where they are most‑needed ‑‑ and the politics of how to get there. These subjects, and others flowing from them, will have to be taught by the colleges, both chiropractic and medical. The chiropractic colleges will also have opportunities to network with local VA facilities, as med schools do now, and will want to make sure their graduates are well‑received by the VA.

If any of this looks to you like terrain in which chiropractic could be in danger of losing its core identity, you are not alone. It is a paradox that we can only function in the hospital if we're a "member of the team" but the real value of what we bring to health care does not fit within the medical paradigm. Only two outcomes are possible: 1) chiropractic becomes just another treatment regimen in the battle against pain and disease, or 2) the medical paradigm shifts and the chiropractic philosophy of above‑down, inside‑out changes the philosophy and practice of medicine. I personally believe the latter will occur. This will be one of, if not our major challenge in the coming decades: the preservation and perpetuation of our unique health‑care philosophy.

The recommendations the CAC made to the VA secretary mostly allow us the chance to have #2 become reality:

A) Minimum initial privileges (that's what scope of practice is called in the hospital setting) are basic chiropractic services: case histories, chiropractic exams, x‑rays (we will probably order them and a radiologist/rad tech will take them), adjustments and manipulations.

B) Other privileges (for instance, PT) will depend on the scope of your state license, your training, and whether a facility has need of you to do those things. In a hospital setting, PT if needed is done by physical therapists, who will jealously guard their machines from us. The VA will not need us to do PT, nutritional counseling, colonics or prescribing ‑‑ they already have people to do those things, thank you very much. The VA will want us for one thing and one thing only: correction of subluxations.

C) Minimum hiring qualifications omit any reference to the CCE, and simply require a state license.

D) ACC definition of chiropractic is used.

E) Chiropractic care is recommended for inpatient care, outpatient care, & outside care (fee basis).

F) DCs are to be co‑managers of care when other health care disciplines are required.

G) Orientation of the staff to chiropractic care is to be provided.

H) Availability of chiropractic care is to be provided to the patients.

I) Sufficient DCs are to be employed so that the wait for care will not exceed VA guidelines for services.

The only criticism I have of the CAC recommendations is of the access. Direct access is allowed only for those veterans fortunate enough to have had chiropractic care in the military before leaving service. All others are at the mercy of the medical staff for a referral. (Referrals in the VA facilities are called "consultations" but don't be confused by the word; it's still "by referral only.")

All other major recommendations were by unanimous agreement; only the access recommendation had a division of the committee. Curiously, all the ACA members of the committee voted to accept access by referral only; only myself and Dr. Fisher, WCA member, dissented from this "referral‑only" recommendation. Perhaps even more curious, given the bitter protestations of the ACA against including a DC from the "chiropractic medicine" camp, the ACA members voted with him and the MDs against the two of us on this issue.

I have grave concerns that as long as we're "by referral only" we will have a strong tendency to act and practice more "medically" in order to gain referrals from our gatekeepers. It is a shame that the DCs could not hold it together on the truly crucial issue, direct access. We may have to pay for this one for years, I fear.