approach to health continues to be shaped by the vitalistic beliefs of 19th Century medicine and its interpretation of Hellenistic ontology.∗ 5 The etymology of “chiropractic” is chiropraktikos, which means “effective treatment by hand” or “done by hand.”6, 7 Manual manipulations of the patient’s spinal column, as well as other somatic systems or Chiropractic Care in California tissues, are the primary modes of treatment. Diagnosis Bram B. Briggance is especially geared toward physical examination, © 2003 UCSF Center for the Health Professions however verbal communication with the patient is also integral. Radiological technology is also utilized by Overview/Description of Workforce some practices and for some conditions.2, 5, 8 With 65,000 practitioners nationwide1 chiropractic is While all chiropractors consider their profession as the third largest “primary” health profession in the US being one of “direct access” and “primary contact,” (behind medicine and dentistry).2 California, which many doctors of chiropractic consider their profession constitutes about 12% of the US population, 3 has just to be within the scope “primary care” due to the over 12,000 chiropractors or approximately 18% of universality of their clinical approach and the wide- the chiropractic workforce. 4 ranging aspects of health they address (see page 6 for further discussion on this topic). The body’s The National Board of Chiropractic Examiners musculoskeletal, neurological, and vascular systems, (NBCE) writes, “Chiropractic is a natural, as well as the patient’s emotional, nutritional and conservative, drug-free and non-surgical form of environmental states all fall within the purview of the 2 health care.”2 Chiropractic is predicated on the belief chiropractor. However, due to its non-allopathic that health is largely determined by the extent to approach and its abjuration of pharmaceutical and which one’s nervous system is functioning properly. surgical procedures, many view chiropractic as a The chiropractic approach holds that a body’s nervous “complementary” or “alternative” form of medicine. system, under proper conditions, has sustaining and While acceptance by both mainstream medicine and recuperative powers to preserve itself in a state of the general public continues to grow, the roles of the health. Chiropractic’s clinical concern, then, is rooted chiropractor as a primary care provider, and as either a in determining the ways in which a patient’s nervous complement or alternative to allopathic medicine, 5 system is being hindered in its normal functions. have not been universally resolved. Chiropractic treatment is aimed at the elimination or sufficient amelioration of those hindrances, or Work/Practice Patterns subluxation, in order to restore the patient to a state of self-sustaining health.2 Chiropractic care views the National survey data shows that chiropractors estimate manipulation and adjustment of the spinal column, the that their work time is fairly evenly divided between primary locus of subluxation, as essential to health direct patient care and all other practice maintenance. responsibilities. Non-patient care activities performed by doctors of chiropractic include patient education, The chiropractic profession recognizes its documentation, research, business and marketing philosophies, orientation and heritage in myriad responsibilities.2 ancient health traditions, including Chinese, Hindu, Egyptian and Greek. However, the origins of the Multiple survey data confirm that for almost all modern profession converge in late-nineteenth century doctors of chiropractic, spinal manipulation pertaining Iowa, where Daniel David Palmer founded the first to subluxation is the most common and fundamental chiropractic college, The Palmer School of treatment performed.2, 5 While surveyed chiropractors Chiropractic, in Davenport in 1897.2 Palmer also report seeing a wide range of conditions, including authored The Chiropractic Adjuster, a book that allergies, high blood pressure, obesity, asthma, played a cardinal role in directing the course of the chiropractic profession. While the profession today is ∗ oriented and driven by empirical evidence, its holistic Vitialism is the belief that mechanical explanations are insufficient for understanding the function of living beings. 1 diabetes, and infections, these were reported as being The NBCE’s 1998 job analysis survey results state treated by them only once or twice a month.2, 5 One that chiropractors’ reimbursement for services study, which utilized patient records, concluded that provided fall into four primary categories, each no non-musculoskeletal condition constituted more roughly constituting about one forth of the than 1% of patients’ symptoms.2, 5 practitioner’s income. Cash payments from the patient or some other private party occur in about 25% of Manual manipulation for the treatment of subluxation, cases, and private insurance accounted for another commonly referred to as “chiropractic adjustment,” quarter of the practitioner’s reimbursement. Personal employs two primary clinical interventions: injury (16.7) and workers compensation cases (9.6) mobilization and manipulation. Mobilization is a joint combined account for another forth of his or her movement performed by the practitioner within the income.2 Ninety-seven percent of surveyed patient’s joint’s normal range (the range achieved chiropractors reported that their state’s law includes under the patient’s own volition), or physiologic chiropractic care in its worker’s compensation space. Manipulation is the movement of the patient’s coverage.2 Much of this reimbursement is from joint by the practitioner beyond its range, or into the automobile insurance.5 Managed care (14%), paraphysiologic space of the joint. Through joint Medicare (10.7) and Medicaid (1.8) constitute the mobilization and manipulation, the chiropractor works remaining forth. However, almost one in three to restore the patient’s proper spinal and respondents stated that he or she had no managed care musculoskeletal alignment. Therapeutic massage, membership.2 acupressure, acupuncture, the application of ice or heat, and other manual techniques are also commonly Judging by the number of referrals both to and from utilized by chiropractic practices.5 chiropractic offices, it would seem that most doctors of chiropractic work in relative isolation from other In addition to manual manipulation chiropractors often practitioners and health professionals. While almost counsel their patients regarding a wide range of range 92 % of surveyed chiropractors reported that they had of lifestyle topics including diet and exercise. In received patients via referrals from other practitioners, keeping with chiropractic philosophy, these services on average, no profession referred patients with a are considered integral to the chiropractors’ role in frequency of more than “one or two per month,” and maintaining the health of their patients.2, 5 most fell well below an average of “one or two per year,” or did not refer at all. One study concluded that At a national chiropractic conference in 1993, the only about 50-60% of medical providers refer patients chiropractic profession made great strides in for chiropractic care.5 While almost all chiropractors establishing a set of practice guidelines based on reported than they refer patients to other health clinical evidence and professional consensus. This set professionals, they do so with similar infrequency. of professional practice parameters, known as the Internists, orthopedic or neurological specialists, and “Mercy Guidelines,” has been widely accepted and its massage therapists were those to whom patients were findings and recommendations have been affirmed by most frequently referred, but none with an average similar evidence and consensus-based efforts in frequency as high as “one or two per month.” Canada and Australia.5 The Mercy Guidelines have been criticized by some as being too “academic and According to a national survey, most chiropractors research oriented,” and non-inclusive of views “from work full time (at least 30 hours per week). Almost the field.” An alternate set of practices was created by half of chiropractors worked 30-39 hour per week. the Council of Chiropractic Practice, which formed in Approximately 30% worked between 40 and 49 hours 1995 in response to the Mercy Conference.9 per week, and only about 8% worked 50 hours or more. About 17% worked 29 hours or fewer.2 Almost 19 in 20 chiropractors work in private office settings, with two-thirds of those in solo practices. The State of California’s Employment Development Those who are not in private practice may be Department reports that, nationally, the annual median employed in chiropractic education or organizations, wage in 1998 for doctors of chiropractic was in multidisciplinary offices, or large care delivery $70,000.10 However, some within the field believe that systems.2 this income estimate is much too low. Survey data from the American Chiropractic Association indicates that in 2000 the average gross income for 2 chiropractors in the U.S. was approximately $220,000 U.S. chiropractors are not evenly distributed with median net income in excess of $89,000.11 In geographically. Ratios of doctors of chiropractic to 1999 the New York Times reported chiropractors to state populations range from about 10 per 100,000 to be among the most high-paying occupations in just fewer than 60 per 100,000.5 Also, chiropractors Chicago, Houston, Denver,