October 2005

When it comes to chiropractic, you can't make assumptions

by Dr. Terry A. Rondberg

In August, a large chiropractic and "rehab" clinic was charged in a $1.8 million fraud case. The owners were accused of filing inflated chiropractic invoices for "excessive and/or non‑existent and/or unwarranted chiropractic treatment."

Clearly, chiropractic clinics that provide rehab services are deceptive and fraudulent and cannot possibly uphold the highest standards of professionalism expected of chiropractic practices.

In an earlier case, a Boston chiropractor and his wife were found guilty of insurance fraud by overstating patients' injuries and by running up patients' bills with unnecessary tests and treatments. According to court documents, the practice was almost entirely dependent on referrals from personal injury lawyers.

The reasonable conclusion is that chiropractic offices that handle a large percentage of PI cases are fraudulent and should be considered dangerous to patients and damaging to the reputation of chiropractic.

Are these rational assumptions? Of course not! Yet, a recent statement by Richard E. Vincent, DC, past president of the Federation of Chiropractic Licensing Boards (FCLB) drew a similarly illogical conclusion when he stated that high volume practices "cannot provide the patient with the quality of care associated with excellence, and they may be a hazard to the public health."

How did he come to that conclusion? Did he review complaints from patients or investigate malpractice claims? Did he work side by side with high‑volume practitioners to see how they handled their patient load? Or did he merely make an unfounded deduction based on his uninformed and prejudiced opinions about such practices?

One thing I've learned after more than three decades in the chiropractic profession is that, when it comes to chiropractors, you can't make assumptions. There are many highly ethical doctors who run PI practices, working closely with attorneys to make sure accident victims receive the highest quality chiropractic care. And there are a few who try to cheat the system. There are very medically oriented doctors who give excellent adjustments to correct subluxations, and there are some "principled" DCs who are in fact very unprincipled.

The problem with people like Dr. Vincent ‑‑ and organizations like the FCLB ‑‑ is that they tend to make assumptions based on their personal bias and ignorance and then try to impose those prejudices on the entire profession. That's precisely what Dr. Vincent urged during his keynote address at this year's annual FCLB Educational Conference. His speech contained numerous references to the need for a chiropractic "cultural authority." At one point, he told FCLB members that, "If there are doctors in your jurisdiction who do NOT serve the best interest of their patients then you MUST be proactive in remediating the problem."

There's only one way to interpret the term "proactive in remediating the problem" ‑‑ regulating them out of business before they do anything wrong.

And who does Dr. Vincent think falls into that category of dangerous chiropractors? His list includes doctors who:

***  fail to diagnose "as intended" ...

***  treat 2000, 1500, 1000, 700 patients each week ...

***  see patients "as an opportunity rather than an opportunity to serve" ...

***  provide "excessive and unnecessary treatment" ...

***  treat patients "based on a schedule established by a management consultant" ...

***  manage patients "strictly on the basis of their insurance plan."

Who gets to read chiropractors' minds to determine whether they see their patients as opportunities rather than opportunities to serve? Who decides how many patients a DC can "safely" see each week (perhaps the same people who think a DC can only properly provide six visits per patient). Which board or regulatory agency should be authorized to decide which management consultants may give advice on schedules?

According to Dr. Vincent, who received the FCLB's 2005 George Arvidson Award in recognition of "excellence in chiropractic regulation and public protection," a chiropractic license is "an implied social contract and an absolute moral covenant with the public and demands that all these attributes be present in the fiduciary relationship with the patient."

I do not agree. The chiropractic license is proof that a person has completed the required educational prerequisites and passed the appropriate tests to ascertain clinical competency. Labeling it as a moral contract ‑‑ with the boards and FCLB given the authority to regulate the "morality" of chiropractors ‑‑ is to place too much control in the hands of a small group of doctors who, by their very nature as human beings and competitive colleagues, will be swayed by personal and professional bias.

No other profession expects its boards to be the arbiter of morality or intention. Do medical boards hunt down MDs they feel are not abiding by their "moral contract" with the public? Do they "proactively remediate" to make sure DOs are viewing their career as an opportunity to serve?

Dr. Vincent summed up his presentation by saying: "There are far too many chiropractors who compromise these values and violate the intent of the laws under which they practice. They go unnoticed, unchecked and unbridled until such a time that a complaint is filed. The public deserves far better ‑‑ they need to be assured, by your proactivity, that the compromise of professionalism will not be tolerated. Your commitment to the well being of people served."

The idea that boards can "proactively" judge doctors of chiropractic should be frightening to every doctor of chiropractic. It is like telling the police they should "proactively" arrest people they think might commit a crime in the future. That might work if all law enforcement officers were infallible and completely impartial, but we know that, in reality, it can't work. Neither can allowing chiropractic board members to decide what they feel constitutes morality in practice.

The vast majority of chiropractic patients are intelligent enough to judge for themselves whether or not they wish to receive care from a high‑volume clinic or go to one that doesn't claim to make medical full‑body diagnoses. They will file complaints or lawsuits or switch chiropractors if they encounter any practice they deem inappropriate or unsafe. The boards and courts will be able to determine if the doctor in question is acting unprofessionally or not in the best interests of the patient ‑‑ based on the facts of the case rather than on unfounded assumptions.

I am not suggesting that we ignore unethical or dangerous practices or that we fail to maintain the highest standards of clinical competency for all doctors. I am, however, vehemently opposed to any attempt by the FCLB members or their fellow travelers to impose their biased notions of "morality" or "safety" on the entire profession, or to jump to wholly unsupported assumptions about an entire class of practitioners based on ignorance or prejudice.

In addition to protecting the public, the role of the chiropractic licensing board must be to protect the profession ‑‑ from itself if need be.