July 2004

What is chiropractic? A professional dialogue

In May, World Chiropractic Alliance President Terry A. Rondberg, DC, sent an e‑mail to all chiropractic college presidents. In it, he discussed the American Chiropractic Association's "Chiropractic Clinical Healthplan Integration Program (Blue CCHIP)," which emphasized neuromusculoskeletal conditions and chiropractic as a treatment for pain relief. The e‑mail also referred to written statements by Dr. Joseph Brimhall, who succeeded Dr. William Dallas as president of Western States Chiropractic College in 2003. Dr. Brimhall is also a member of the Council on Chiropractic Education Commission on Accreditation and for three years served as Commission Chair.

The initial e‑mail led to the following lively exchange of opinions about chiropractic research, education, and policy. Since the e‑mail was "cc'd" to numerous others and eventually distributed through the Internet, The Chiropractic Journal feels its publication here does not violate the privacy of the correspondents.

From Terry A. Rondberg, DC, to all chiropractic college presidents, May 22, 2004

Thank you for sending me a copy of the ACA Blue CCHIP Summaries.doc. It's interesting that the ACA has chosen to build their model on such a limited concept. Using a pain model to justify our purpose for practice reducing chiropractic to another procedure, to quote David Chapman‑Smith "we offer nothing special." Is chiropractic really just another drugless technique to reduce pain?

Such a position is completely at odds with the mainstream of the chiropractic profession and represents the most radical medical fringe elements. According to a 2003 study on "How Chiropractors Think and Practice: The Survey of North American Chiropractors," published by the Institute for Social Research at Ohio Northern University, "For all practical purposes, there is no debate on the vertebral subluxation complex. Nearly 90% want to retain the VSC as a term. Similarly, almost 90% do not want the adjustment limited to musculoskeletal conditions. The profession ‑‑ as a whole ‑‑ presents a united front regarding the subluxation and the adjustment."

The ACA/WFC/FCLB have always tried to justify their desire to practice medicine by attempting to take the high moral position on patient safety. If you don't practice full‑body allopathic diagnosis, you are a risk to the public health, safety and welfare. How they have the audacity to compare a chiropractor's training with a medical doctor's is beyond me. How many hospital rounds have most chiropractors performed? No statute in the U.S. permits chiropractors to practice full body diagnosis ‑‑ medicine ‑‑ or diagnose disease.

The irony and hypocrisy could not be more obvious. In his desire to redefine chiropractic Dr. Joseph Brimhall, President of WSCC writes in: "For the Good of the Patient Opportunities, Challenges, and Possibilities in Chiropractic" Federation of Chiropractic Licensing Boards, Dr. Joseph Janse Lecture, May 7, 2004:

"To adequately provide for our future, we need a few essential elements. We need to know who we are. We need to know where we are going. We must agree to disagree, and we must seek to understand our differences. We must learn to respect honest opinions that disagree with our view. Lastly, we all need to direct our conduct with integrity and reliability."

This sounds like live and let live to me and this concept was already presented in the original ACC Paradigm.

He also states; "We must learn to respect honest opinions that disagree with our view."

Then why doesn't he do this? All of his rhetoric sounds tolerant until he declares we must change the profession and move beyond reporting unusual findings to the patient, we must all practice according to what he believes is the responsible thing to do.

The core issue is simply that Dr. Brimhall and his kind oppose any chiropractors who may choose to limit the scope of their examinations and care to that which is consistent with their practice objective and clinical proficiency.

Brimhall continues: "The need to provide a competent and accurate diagnosis for the patients we serve is self‑evident. Diagnosis represents an ethical imperative, a professional privilege and responsibility, and a legal obligation. We cannot limit the profession to the analysis and correction of spinal subluxation. As doctors of chiropractic, we are responsible to our patient as a whole person, not simply as another subluxation. Clinical findings must be interpreted for the patient, not merely reported. If we allow the profession to regress to the point that we limit our services to only the detection and adjustment of spinal subluxation, we have demoted our professional status and in fact become mere technicians. As an integral component of protecting the health and welfare of the public, chiropractic regulators must maintain and enforce the requirement that doctors of chiropractic provide a complete and competent diagnosis."

It is bad enough this chiropractic college president would like to use patient safety as his reason to practice medicine but his continued declaration of respect for each other's honest opinions and how we must agree to disagree is so transparent it's obnoxious. This is a college president who sponsors vaccination programs and teaches minor surgery on his campus.

Brimhall infers that doctors of chiropractic who diagnose and correct vertebral subluxation are less responsible because they view each patient as another subluxation is a false accusation, unfounded and irresponsible. Is this how he respects honest opinions that disagree with his own?

The CCP Guidelines, which are the only evidence based international guidelines approved by the United States federal guideline clearing house, and does an excellent job dispelling these views. In addition, the Guidelines have just been revised and approved for an additional five years and are utilized by thousands of doctors in practice throughout the U.S. and around the world.

Besides, what Brimhall proposes is illegal in most states. In California, where over 20% of the doctors of chiropractic practice, the law is very clear on this issue. On page 6, the "Laws And Regulations Relating To The Practice Of Chiropractic" state:

(7) A duly licensed chiropractor may only practice or attempt to practice or hold himself or herself out as practicing a system of chiropractic. A duly licensed chiropractor may also advertise the use of the modalities authorized by this section as a part of a course of chiropractic treatment, but is not required to use all of the diagnostic and treatment modalities set forth in this section.

It is also illegal in California for doctors of chiropractic to refer to themselves as a primary care physicians.

In one case (Attorney General v Beno) the Supreme Court of Michigan held: "We do not believe the Legislature intended to authorize chiropractors to engage in general diagnostic techniques. Had such a result been intended, it could have been clearly stated... Rather than authorizing general diagnostic techniques, the statute limited chiropractors to those methods, which might reveal the existence of misaligned or displaced vertebrae. We fail to see how taking urine samples or throat cultures will reveal the existence of subluxations." (373 N.W.2d 544, 422 Mich. 293).

In Wisconsin (Kerkman v Hintz), the State Supreme Court noted: "The legislature has recognized the practice of chiropractic as a separate and distinct health care discipline... By limiting chiropractors to the use of chiropractic adjustments and the principles or techniques of chiropractic science in the diagnosis, treatment or prevention of disease while prohibiting the use of traditional medical tools, e.g. drugs and surgery, the legislature has recognized that the practice of chiropractic is distinct from the practice of medicine." (418 N.W.2d 795, 142 Wis.2d 404)

Another Wisconsin case arrived at a similar decision. In Goldstein v Janusz, the Court of Appeals of Wisconsin relied on Kerkman when it ruled, "Chiropractors have no duty to recognize medical problems." The rationale was that "to do so would require chiropractors to make medical determinations which, under Wisconsin law, they are not licensed to make." The Court further noted, "Although chiropractors may take and analyze x‑rays, they only do so for diagnostic or analytical purposes in the practice of chiropractic." (582 N.W.2d 78, 218 Wis.2d 683)

Another relevant case is Kuechler v Volgmann, in which the court held, "When a chiropractor assumes to diagnose and treat disease he must exercise the care and skill in so doing that is usually exercised by a recognized school of the medical profession." (192 N.W. 1015, 180 Wis. 238, 242‑43)

Finally, in Treptau v Beherens Spa, Inc., (which involved a chiropractor who examined and treated a patient's foot using bandages and diathermy) the Wisconsin Supreme Court stated: "Plaintiffs do not claim there was malpractice on the part of the defendant while Beherens was engaged in the practice of chiropracty (sic) by chiropractic manipulation or adjustments of the spine. Instead, plaintiffs contend there was malpractice when he and his associates went beyond the practice of chiropracty (sic) and entered into the general field of the practice of medicine...in so far as there was thus an invasion of the general field of that practice, the methods thus used by defendant's employees in diagnosis and treatment were subject to the rules applicable to the practice of medicine and surgery." (20 N.W.2d 108, 247 Wis.438)

There are many other such cases on the books to demonstrate that doctors of chiropractic are neither expected nor permitted to perform full‑body medical diagnoses of diseases or medical conditions. Their scope of practice is limited to the diagnosis of those specific conditions, such as vertebral subluxation, that are "associated with the functional integrity of the spine."

The CCP guidelines define chiropractic as a profession similar to the original ACC Paradigm based on the best available evidence allowing practitioners to offer wellness care to asymptomatic patients. No one expects dentists to perform prostate exams or optometrists to diagnose heart conditions. Why would Brimhall insist that doctors of chiropractic call themselves primary care physicians?

Who is Brimhall trying to fool ‑‑ the public, the legislators or the medical profession? This is the biggest source of embarrassment within our profession. This is the result of weak‑minded individuals who lack self esteem resulting in a desire for social self esteem and creating the illusion that we practice medicine.

Chiropractic has an identity given to us by the developer BJ Palmer. Joe Janse did not discover chiropractic. DD Palmer did. What's wrong Joe? Was this paradigm not fair and balanced enough for you? Nothing has changed since Bill Dallas signed off on this. There is room for everyone one to practice as they choose. So your whining about the paradigm is really nothing more than your attempt to pervert chiropractic care into third rate medicine.

The ACC Paradigm identified has already identified the chiropractic profession:

====================

Principle: "The body's innate recuperative power is affected by and integrated through the nervous system."

4.0 THE SUBLUXATION

Chiropractic is concerned with the preservation and restoration of health, and focuses particular attention on the subluxation.

A subluxation is a complex of functional and/or structural and/or pathological articular changes that compromise neural integrity and may influence organ system function and general health.

A subluxation is evaluated, diagnosed, and managed through the use of chiropractic procedures based on the best available rational and empirical evidence.

2.0 Defining Chiropractic Scope

Since human function is neurologically integrated, Doctors of Chiropractic evaluate and facilitate biomechanical and neuro‑biological function and integrity through the use of appropriate conservative, diagnostic and chiropractic care procedures.

Therefore, direct access chiropractic care is integral to everyone's health care regimen.

3.0 Defining Chiropractic Practice

A. DIAGNOSTIC

Doctors of Chiropractic, as primary contact health care providers, employ the education, knowledge, diagnostic skill, and clinical judgment necessary to determine appropriate chiropractic care and management.

====================

Primary contact is not the same thing as calling ourselves primary care physicians! Brimhall will never be satisfied until we are all doctors of chiropractic medicine dispensing drugs and performing surgery. The least he could do is stop pretending that he cares about mutual respect or live and let live. It's really offensive to hear this sanctimonious crap. He doesn't care about anything but institutionalizing and promoting his concept of a Primary Care Physician.

Instead of one more study on hip range of motion or low‑back pain, we need research and clinical science which establishes the value of care based on objective outcome measurements centered on markers that detect and justify correction of vertebral subluxation the same as a dentist would detect a cavity and correct the problem.

Acceptance is important to all of us, but why abandon the old ACC Paradigm when our future chiropractic research can provide the evidence that will demonstrate why lifetime care is so beneficial? A wellness model centered on the correction of vertebral subluxation repositions chiropractic as something which has the potential to enhance performance, function, the immune system and every life support system in the human body for every one.

This kind of research will validate lifetime chiropractic wellness care once and for all, establishing the highest standards for practice based on scientific evidence which will include vertebral subluxation correction as the cornerstone of wellness to improve the quality of life for every human being. We should not limit the concept of chiropractic just because we can sell the uninformed public or because Paul Shekelle or Steven Barrett or Joseph Brimhall say we will never be accepted by medicine unless we agree with them.

Our research simply hasn't caught up with our philosophy of vitalism and our profession has not yet received the funding necessary to demonstrate our professions potential. It would be a great loss to give up our core values and principles thus allowing the public to define who we are before we can fully investigate the vertebral subluxation syndrome.

Dr. Christopher Kent, WCA Vice President stated: "It is clear that they are attempting to reframe chiropractic as a musculoskeletal specialty within the allopathic system. What they do not realize is that without something unique to offer, any provider is a competitor. Witness the failure of the Trigon suit and the Medicare memorandum. What they don't seem to care about are the millions of people without musculoskeletal complaints whose quality of life has been enhanced through chiropractic care. They are prepared to 'blow off' these individuals for acceptance as a half‑baked therapist. Under their plan, there will be no babies and families saved from slavery to ineffective medical interventions. They will remain subluxated. Chiropractic 'miracles' will be mere historical curiosities, dismissed as 'myths and legends.'"

We must renew our resolve.

Terry A. Rondberg, DC

President, World Chiropractic Alliance

From Dr. Joseph Brimhall, May 24

Dr. Rondberg,

I remain willing to discuss your issues openly. To date you have declined. True to your usual form, your communication is replete with error and misleading innuendo, and you choose to whine and whimper rather than to directly open a discussion. I will ask you to refrain from reactions that are libelous. Otherwise, your mindless rhetoric merits no response.

Joseph Brimhall, DC, President,

Western States Chiropractic College

From Dr. Terry A. Rondberg, May 25

Dr. Brimhall,

You have not addressed the issues I have raised.

It is incongruent to speak of "live and let live," while simultaneously calling for regulators to enforce one perspective.

In my essay, I cited the ACC Paradigm, and case law as examples. Your essay failed to provide any evidence that subluxation‑centered chiropractors are "technicians," or that they are in any way irresponsible.

Disclosure of unusual findings to a patient, so that they may seek the opinion of another practitioner is a reasonable course of action. In my opinion, it is a far safer course of action than attempting to name a specific condition, given the limited clinical experience of a chiropractic college. It simply cannot be compared to two years of rounds typical in medical training, followed by a three year (or longer) period of residency and fellowship training.

This in no way diminishes the value of the chiropractor. Our training IS adequate to determine the safety and appropriateness of chiropractic care. Any unusual findings should be disclosed to the patient.

The case law is clear. The law recognizes the differences between the diagnostic responsibilities of limited versus limited licensees. Further, the law recognizes that a practitioner who exceeds their scope and engages in the practice of medicine may be held to the standard of a medical practitioner.

Where is the evidence to support your position?

My experience in the malpractice insurance industry has shown cases where DC's have been accused, and found liable for misdiagnosis. Had the DC disclosed their clinical objective, obtained informed consent (using a "Terms of Acceptance" document), and documented disclosure of unusual findings, liability could have been avoided. More importantly, the patient would have been advised to seek the services of an appropriately qualified provider for follow‑up.

This is why we are able to offer lower premiums to DC's who do so. Our highest premiums are for DC's who elect to engage in the general diagnosis and treatment of disease.

Terry A. Rondberg, DC

President, World Chiropractic Alliance

From Dr. Joseph Brimhall, May 26

(Note: In his response, Dr. Brimhall repeated sections of the preceding message. Those sections are deleted here for space considerations but Dr. Brimhall's response is otherwise reprinted verbatim)

Thank you for your reply. I will respond to your points of view.

I encourage regulators to uphold the laws and rules of the jurisdictions they serve, not to enforce any perspective. The practice of chiropractic is regulated in the United States by individual statutes, independent of philosophical perspectives.

The ACC Paradigm, as any other pattern, is merely a diagram; it is not reality. The reality exists within statutes, administrative regulations, accreditation standards, and other recognized references. My use of the term "technician" was applied to those individuals that choose to limit chiropractic practice to only the detection and adjustment of subluxations. Your term "subluxation‑centered" could likely be applied to most chiropractors, in the sense that probably most chiropractors adjust subluxations as a primary function of their professional services. This is the technical component, and those individuals that restrict their practice to only the technical aspect should arguably be referred to as "technicians."

A technician discloses findings. A clinician or physician interprets findings. Using your language, the mere characterization of findings as "unusual" would require some degree of judgment or interpretation. Because a patient is seeing a doctor of chiropractic without a referral as portal of entry, the interpretation of findings should be sufficient to at least direct the patient toward a specific provider with a provisional impression of the potential implication of the findings, even if that is only a "rule‑out" diagnosis. Certainly the purpose for referral to another provider is to help the patient competently manage their health concerns.

The training of a doctor of chiropractic exceeds merely determining the safety and appropriateness for chiropractic care. The current educational standards require a graduate of an accredited program to be competent in diagnosis and case management. The evidence can be found in the current CCE Standards. This is not about comparing educational preparation with other professions; it is about providing adequate and competent service to the patient.

First, "the law" as you reference is selected case law interpretations from two states concerning civil matters. Administrative law application and interpretation is often vastly different than civil law as applied in malpractice cases. Scope is defined state by state. It is not accurate to imply that practice scope is universal.

State practice statues and rules, along with administrative interpretations including attorney general rulings. Each state regulates the profession with its own laws and regulations.

I don't have disagreement with you, in the sense that every practitioner has the obligation to practice within their own legal scope of practice and ability. A chiropractor that is not competent to meet the legal requirements of practice in the state he/she practices in is a risk to the population and should not be licensed. Misdiagnosis is a significant offense and should be dealt with seriously at an administrative level. As you know, it often involves civil proceedings as well.

The area I would disagree with you is in using an informed consent document ("Terms of Acceptance") as an instrument to attempt abrogation of the legal obligations to diagnose. The doctor of chiropractic's ethical responsibility to diagnose seems self‑evident. The legal responsibility is a matter of law in many, if not most, jurisdictions. The evidence again is contained in practice statutes and regulations, which are often independent from philosophical perspectives or personal belief systems.

The goals of malpractice brokers are not necessarily compatible with the objectives of the chiropractic profession. The obvious question to your comment is, how do you classify a spinal subluxation? Is it not classified as a disease by many sources? I'm not asking about the philosophical frame, but rather about its use in the generic world of law, insurance reimbursement, and chiropractic regulation.

Also, who owns chiropractic? Who determines the definition, scope, ethical obligations and professional responsibilities? The line of reasoning and destination of inquiry in these matters is certainly dependant on establishing the answers to those questions.

I appreciate the opportunity to respond to your opinions and will look forward to your reply.

Sincerely,

Joseph Brimhall, DC, President

Western States Chiropractic College

From Dr. Terry A. Rondberg, May 29

Dear Dr. Brimhall,

I find the title of your lecture ("A Response to 'For the Good of the Patient

Opportunities, Challenges, and Possibilities in Chiropractic") fitting considering the bulk of your lecture is centered on the issue of diagnosis and professional responsibility in clinical practice, regulatory affairs, accreditation and education.

You stated:

As a regulated and accredited profession, we have already established that a doctor of chiropractic is a primary care physician. For some, this statement generates unexplainable fear and consternation. Yet, the Standards of the Council on Chiropractic Education, the only nationally recognized chiropractic accrediting agency in the country, specifically includes this description, and it has been part of the CCE Requirements for Accreditation for almost a decade. Our educational standards have been recognized by the United States Department of Education and virtually every licensing jurisdiction in the country. Every accredited chiropractic college in the United States has voluntarily accepted this definition as a condition of accreditation. However, some college representatives have publicly denied our role in primary care, and some have openly objected to our designation as chiropractic physicians. The inconsistency revealed by such conduct is troubling.

I would ask you to provide evidence that we, as a profession "have already established that a doctor of chiropractic is a primary care physician." The only evidence you provide is the Standards of the Council on Chiropractic Education. The fact that you acknowledge that college representatives have denied this role and designation is evidence to the contrary. The fact that several chiropractic professional organizations disagree with this role and designation is further evidence to the contrary. Further evidence to the contrary is found in the Fall 2002 issue of the Journal of Chiropractic Medicine where Duenas states the results of his review of the legal ability of chiropractors to practice primary care:

"The review of the practice acts and the survey on chiropractic scope of practice revealed a varied degree of chiropractic scope of practice with 23 of 53 of the jurisdictions limiting the ability of the chiropractic doctor to fully provide IOM defined primary care."

Duenas concludes:

"The varied practice act definitions for chiropractic practice...reveal an inability of the chiropractic profession to respond to a call for a standard, nationally based, primary care policy that could be readily achieved by all chiropractic practitioners throughout the Union. This void of primary care qualification in many State and Commonwealth practice acts will need to be addressed by the leaders of the profession..."

In the same issue of JOCM Wickes states:

"The adoption of the primary care physician and clinician status by the CCE has been a relatively new development and the many chiropractic institutions and programs within the U.S. are at varying levels of implementation. In some cases, there has been marked resistance to the primary care status."

Considering your admonition that FCLB member Board's duties include the protection of the public health ‑‑ how could any Board in good conscious enforce a primary care physician and diagnosis mandate given the explicit admission of those involved in accreditation processes within the CCE that students are not graduating with the requisite knowledge, attitudes and skills required to practice in such a fashion?

Your assertion that "Every accredited chiropractic college in the United States has voluntarily (emphasis mine) accepted this definition as a condition of accreditation" is dubious at best. Since you were the Chair of the Commission on Accreditation when Life University's DCP was stripped of its accredited status you are no doubt aware that the issue of primary care and diagnosis was a central theme of the Commission's argument against renewing Life's accreditation.

You are also very aware that a Federal District Court Judge issued an injunction against the CCE after finding that there was indeed a legitimate difference of opinion in this regard.

The unfortunate fact of the matter is that the states have accepted CCE's authority and in many if not most cases incorporated graduation from a CCE accredited institution as a prerequisite for licensure. As you well know, attempts at establishing competing or complementary accrediting organizations have been subverted thus far through political action leaving the institutions with contrary views from the CCE with no effective choice but to succumb to the dictates of the CCE. Some have gone so far as to change their fundamental missions as a result of CCE strong‑arming. No other professional accrediting process or organization is as prescriptive as the CCE is with its Standards and CCE's enforcement of those Standards. This reality makes the following statement by you "disingenuous and deceptive":

"If a chiropractic college does not wish to accept and comply with established accreditation standards, it should voluntarily surrender its accreditation status. To function otherwise is disingenuous and deceptive."

You portray the Council on Chiropractic Education as an organization of the profession, however as Wickes states in the same JOCM article:

"Although the Standards evolved partly from the work done by subcommittees with representation from chiropractic institutions, it can be argued that the CCE Standards are those of an independent accrediting body and are not a consensus document developed by the chiropractic educational community. That there is no such consensus document is most likely the reflection of the disparate philosophies held by the various institutions."

Regarding the issue of diagnosis you state:

"The need to provide a competent and accurate diagnosis for the patients we serve is self‑evident. Diagnosis represents an ethical imperative, a professional privilege and responsibility, and a legal obligation. We cannot limit the profession to the analysis and correction of spinal subluxation. As doctors of chiropractic, we are responsible to our patient as a whole person, not simply as another subluxation."

First, your implicit contention is that someone or some entity within the profession is attempting to limit everyone else regarding both the extent of scope of practice and diagnostic latitude. Speaking for the WCA, nothing would be farther from the truth and I would challenge you to provide a single piece of evidence that supports such a notion. What the WCA and other like minded organizations will fight for however, is the right of individual practitioners to limit their scope and restrict their diagnostic latitude.

You seem to support such an approach through your quoting of Dr. Janse:

"We should legislate as broadly as we are able to, so that everyone may practice as narrowly as they want to."

And you go on to offer:

"Each doctor of chiropractic should retain the right to limit his or her practice to specific areas of interest and expertise."

I could not agree with you more. However, the remaining portion of your statement on these issues is where things begin to come apart:

"Clinical findings must be interpreted for the patient, not merely reported. If we allow the profession to regress to the point that we limit our services to only the detection and adjustment of spinal subluxation, we have demoted our professional status and in fact become mere technicians. As an integral component of protecting the health and welfare of the public, chiropractic regulators must maintain and enforce the requirement that doctors of chiropractic provide a complete and competent diagnosis."

This appears to be a contradiction of sorts from your statement that every DC should have the right to limit his practice. Again, who is asking the entire profession to do so and where is the evidence for this?

In fact, the contrary is what rises through at this point: the organized effort to force all chiropractors to practice a broad scope and to extend their diagnostic practices to include everything contained in the Merck Manual. What evidence can you provide that graduates of all the chiropractic colleges are able to interpret each and every clinical finding for our patients?

Wickes is again clear on this point:

"Although most chiropractic degree programs include the pathology and diagnosis of these conditions to varying degrees, there is often little emphasis placed upon the management of such. The clinical experience at many institutions provides little exposure to non‑musculoskeletal conditions. Students become sufficiently knowledgeable to pass National Board of Chiropractic Examiners (NBCE) examinations covering differential diagnosis of common illness and disorders; however, 2 major flaws exist within these exams. First, the Parts I, II, and III tests are exclusively single‑answer multiple choice questions with 4 distracters. This type of test satisfactorily assesses factual knowledge but is poor for evaluation of clinical reasoning skills. Second, these NBCE exams do not adequately assess management of any condition, at a primary care level, other than subluxation. Even the Part IV examination does not address management, other than referral, of complex or serious disorders."

Kremer in the same issue of the Journal of Chiropractic Medicine lends further argument against your contention that "we as a profession" have agreed on the issue of primary care physician and diagnosis:

"Do we as a profession practice primary care or medicine in the context of the above referenced definition? The reality: few can and do; other don't know how and can't due to legislative and managed care/third party payer restrictions accepted by the medical mainstreams. The profession has created an illusion that doesn't line up with reality. They have created a mirage of primary care that seems to be defined and understood only from within. An insider, questioning this reality is often treated as an agnostic or infidel."

Kremer continues:

"Chiropractic education and clinical training is in crisis, suffering from a deficiency in primary care exposures, gaps in didactic and clinical training and inadequate clinical tools available to effectively manage conditions commonly seen in the primary care setting."

While you might maintain that it is the minority of the profession who are either ill equipped or simply not desirous of practicing as a primary care physician with broad diagnostic responsibility, your colleague Kremer clearly disagrees stating:

"The majority of the profession has failed to accept the educational challenges and requirements of primary care."

I would disagree with Kremer only on one point and that is regarding his framing of this as a failure to accept these educational "challenges and requirements." Quite the contrary. I think it is the conscious decision to reject this role that is evidenced by its lack. Your implied assertion that it is many against the few is further evidenced by your statement:

"Some in the profession confuse the need to diagnose with the requirement to manage disease or pathology. On the contrary, the obligation to diagnose the potential cause of a patient's presenting complaints provides the opportunity for referral and/or co‑management of the patient."

I don't think they are confused and again I think they are making a conscious choice. It is clear that there is management of the patient and management of the disease or pathology. Restricting diagnosis and management to those areas that are within the expertise of the chiropractor, recognizing those situations where diagnosis and management is clearly outside our expertise and informing the patient of these findings is perfectly consistent with protection of the public.

In fact, I am relatively certain that any objective third party weighing the evidence on the diagnostic expertise of a chiropractor would agree that mandating every chiropractor to render a "complete" diagnosis is in fact the real danger to the public health. The opportunity for referral and/or co‑management does not arise from guessing about the actual cause of a patient's diagnosis ‑‑ it arises from recognizing deviations from the normal and those situations that fall outside our area of expertise.

If a regulatory body has decided that a chiropractor licensed within that jurisdiction is qualified to practice in a broad scope fashion and a chiropractor elects to do so ‑‑ I have no desire to interfere with the right of that chiropractor. In the same vein there should be no obstruction to a chiropractor who chooses to limit his/her scope to the diagnosis and adjustment of subluxation while reporting unusual findings and incorporating a clear informed consent. This is the true embodiment of "Live and Let Live."

Terry A. Rondberg, DC, President,

World Chiropractic Alliance

From Dr. Joseph Brimhall, June 1

Dr. Rondberg,

As there was no name at the end of the recent stream of remarks, I assume you take responsibility for them since the message arrived from your e‑mail address.

The evidence for the designation of primary care can be found in the CCE Standards. The evidence for acceptance of CCE as the only accrediting agency for chiropractic programs in the United States can be found in the laws and regulations of almost every state, and in documentation from the US Secretary of Education. I'm certain you are as capable of finding those particular citations as I am.

Accreditation is a voluntary action. The evidence for that can be found in USDOE regulations, CCE Standards, CHEA documents, and the standards of any nationally recognized accrediting agency, both specialized and institutional.

You freely cite Wickes, Kremer and Duenas to support your views. Since their quotes were taken out of context, I suggest we assemble these individuals along with you and I and let's have an open and honest discussion of the issues.

Your comments regarding CCE and Life University are inappropriate and inaccurate. Your characterizations of Life University are unfair to that institution. Until you have factual data to support your comments, I invite you to reserve your opinions regarding specific accreditation matters. Your unsubstantiated estimations serve no one.

You, representing the WCA, take the position that doctors of chiropractic are only qualified to "diagnose" subluxation. Any other clinical findings, according to your approach, are to be merely "reported" to the patient, but not interpreted. Those positions contradict several licensing laws. The evidence can be found in many state statutes and rules.

You failed to respond to the two questions I posed for you.

1) Who owns the profession?

2) Who determines the definition, scope, ethical obligations and professional responsibilities?

Joseph Brimhall, DC, President,

Western States Chiropractic College

From Dr. Terry A. Rondberg, June 10

Unfortunately, your circular reasoning is making this dialog less than productive. Every time I ask a question about the state of chiropractic, you refer to the CCE Standards, as though they were the arbiter of all things chiropractic.

The short answer to your questions about who owns the profession and who determines the definition, scope and ethical obligations and professional responsibilities is: chiropractors.

Not an elite group of power holders at the CCE, FCLB WFC or ACA. Not the dozen of so chiropractic college presidents who signed the ACC Paradigm and then tossed its meaning out the window. Not the attorneys who seem to be exercising increasing control over our profession. Not the general public, who look to us to provide those elements. And definitely not you nor I.

It's the thousands of doctors of chiropractic who work day in and day out to bring subluxation correction to their patients and who ‑‑ despite the CCE and its allies ‑‑ still believe in the power of chiropractic to enhance quality of life beyond mere pain relief.

There's a great saying: "Knowledge speaks, but wisdom listens." No one denies you have knowledge. But do you have the wisdom to listen to the growing army of doctors out there in the trenches who want to save chiropractic from oblivion?

Terry A. Rondberg, DC

President, World Chiropractic Alliance