Chapter 10, Part 3 – 1993
1993 commenced with the return of an unanticipated, but all-too-familiar headache for the college. A letter arrived from the Washington Board of Chiropractic Examiners notifying the college that even though its courses satisfied WBCE requirements, the institution would remain on probation until the WBCE completed two on-site inspections, one in May and another sometime in late fall. In his written response, President Dallas challenged the authority of the WBCE to interject itself in this way. Dr. Dallas pointed out the college’s probationary status, imposed a decade earlier, had expired years ago. Dr. Dallas, who had practiced in the state of Washington for 24 years, pointed out to the WBCE that two of its members served on the board of trustees of a competing chiropractic college, a blatant and unacceptable conflict of interest.
Dr. Dallas was a well-known, influential and respected member of the chiropractic community in Washington. He knew most of the active chiropractors involved in state chiropractic politics, including those on the Washington Board of Chiropractic Examiners. Dr. Dallas shared with a few members of the Washington State Chiropractic Association (WSCA) that he would not be held responsible for what was about to happen to the WBCE. In sharing his concerns with members of the WSCA, he divulged that a senior member of the WSCC faculty was planning to drive a bus-load of outraged students to the capitol to protest the WBCE decision. Dr. Dallas shared with his Washington colleagues that the faculty member, a renowned, radical Vietnam War protestor, was going to chain himself to the capitol building doors and conduct a press conference. Dr. Dallas expressed his concern that when the entire story got out, Washington chiropractors would be collectively embarrassed. This revealing information was enough to turn the tide. The WBCE decided against conducting an inspection of the college. This would be the last time the WBCE restricted WSCC graduates from sitting for the Washington licensing examination. The war was over.
1993 marked the beginning of a protracted period of upheaval on campus and across the profession. This crisis was precipitated by the election of William Jefferson Clinton as President of the United States. During his run for the presidency, Mr. Clinton made health care reform one of the central themes of his campaign. He planned to overhaul the U.S. health care delivery system. Shortly after his inauguration, President Clinton announced that his wife, Hillary Rodham Clinton, would be his point-person to advance his health care reform agenda. She wasted no time in crafting what most within the Clinton administration felt was a more efficacious and cost-effective way to deliver health care services.
Pieces of the plan began to surface early in the process, one of which was of particular interest to the chiropractic community. Mrs. Clinton and her advisors suggested that health care in the U.S. could be streamlined by creating a tiered system of care delivery. The centerpiece of the plan would shift more of the burden of health care delivery to “primary-care providers” (PCPs) as “gatekeepers.” The PCP gatekeepers would serve as the initial point of contact for managing patients’ health needs. Patients would enter the health care delivery system through a single portal-of-entry where they would be treated by a PCP or referred. It was projected that cost-savings would result from having fewer patients directly access hospitals and medical specialties. In theory, it sounded like a better use of limited resources.
However, the configuration of the health care system at that time could not support the scale of change required to fully embrace the proposed new direction. Quite simply, there were not enough PCPs available to execute the Clinton plan. In 1993, George Lundberg, editor of the Journal of the American Medical Association, wrote a provocative editorial in which he proposed four approaches that could be taken to realize the Clinton administration’s health care reforms. One Lundberg approach was to provide additional education and training to non-medical health-care professionals (naturopaths and chiropractors) to qualify them as PCPs. Lundberg’s JAMA article re primary care. If chiropractors were to be retrofitted to serve as primary care physicians, Western States Chiropractic College was uniquely positioned to facilitate that process. WSCC already taught much of what was needed to qualify as a PCP; only courses and clinical experience in clinical pharmacology were missing.
Many within the chiropractic profession saw the Clinton administration proposals as a direct threat to them, and for good cause. At the time of the proposal, only medical doctors were recognized as PCPs. It was a distinct possibility that chiropractors could lose their portal-of-entry status if they were reclassified as practitioners to whom medical doctors referred. The chiropractic community recognized immediately that it was unlikely that they would receive many, if any, referrals from their medical colleagues. Others within the chiropractic community saw the Clinton proposal as an opportunity to advance the chiropractic profession along the lines proposed by George Lundberg in his editorial. Of the many questions circulating within the chiropractic community, one in particular attracted attention at WSCC: Why shouldn’t chiropractors enhance their education and training enough to qualify as primary care providers? That very question was put to the WSCC community, initially to the administration, then to faculty, then students and ultimately, the board. Eventually, the question would be put to the chiropractors in the state of Oregon.
Those supportive of chiropractors as PCPs perceived correctly that moving in this direction would invite a fight on two fronts: one with the medical profession and one with the chiropractic profession. Even though the medical profession could not provide the tens of thousands of additional PCPs necessary to implement health care reforms, the chiropractic community did not expect the medical community would warmly embrace chiropractors to serve in that capacity. It had been only six years since the chiropractic profession had successfully litigated the anti-trust suit against the American Medical Association for conspiring to eliminate the chiropractic profession. In spite of George Lundberg’s insightful proposal, if the chiropractic profession wished to educate and train some of its members to qualify as PCPs, it would probably not be at the invitation of the medical profession. It was almost certain the medical community would resist any intrusion of their turf by the chiropractic community. However, even more resistance was expected from the chiropractic community.
A potential roadblock to chiropractors serving as PCPs lay in the prevailing definition of “primary care provider” put forth by the Institute of Medicine (IOM). For the most part, the medical community fully embraced the IOM definition; it had been carefully crafted by a blue-ribbon panel of medical experts. Even chiropractors wishing to serve as PCPs saw the elegance of the IOM definition. For chiropractors, the impediment lay in a reference in IOM’s definition to the use of pharmaceuticals by PCPs. To practice as a primary care provider, one must be qualified to write prescriptions. For a few in the chiropractic profession, embracing script-writing privileges was not a problem; it could be resolved through appropriate education and training. For the majority of the chiropractic profession, however, embracing prescription-writing privileges was tantamount to heresy. Despite a few minor inconsistencies, the chiropractic profession had always defined itself as: “…without the use of drugs or surgery.” The chiropractic profession was no more willing to accept a subordinate role to the medical profession than it was to embrace the use of pharmaceuticals as a viable treatment option. Finding a workable role for chiropractors in the health care paradigm proposed by the Clinton administration was going to be troublesome.
For WSCC, discussions regarding health care reform began as early as the presidential primary election debates, during which most of the candidates expressed dissatisfaction with the existing health care system. Almost all of the candidates found fault with the inefficiency of the system and the escalating costs of health care; it was no longer affordable for many in the middle class to become sick. Each of the presidential candidates advocated for changes to the system, and it was clear to the health provision industry that change would likely come with the election of any of the candidates.
As more details of the Clinton administration’s health care reform plan emerged, the chiropractic profession began to strategizing on how best to favorably position itself. As was customary for the chiropractic profession, it divided on the issue of an appropriate political response. One end of the spectrum of options had the chiropractic profession expanding, while the other end had the profession contracting. Before chiropractors could agree on the best strategy, they had to first agree about where on the spectrum of health care provider types they wanted to be. Should chiropractors be subluxation-based practitioners? Should they be physical medicine specialists? Should chiropractors be primary care providers? It was as though the identity crisis occurring on the WSCC campus had suddenly expanded to encompass the entire chiropractic profession.
The college had struggled to establish its core identity for almost two years and it was still struggling with its identity when the Clinton health care reforms were proposed. The college could not afford the time to debate this issue any longer. Health care reform could annihilate the chiropractic profession; establishing a viable role for chiropractic within the future health provision industry was paramount. If the chiropractic profession could not define itself, it would be defined by others, others who may have had little respect or understanding of the profession.
Without a clearly articulated and supported identity, the college would be unable to position itself for the changes health care reform might bring. The college responded to this crisis by administering a survey about faculty practice preferences. In truth, “identity” is more a function of what one does than what one is titled. In essence, chiropractic could be more accurately defined by how it practiced and provided services than by the abstract concepts (straight, mixer, broad-scope, narrow-scope, specialist, PCP, etc.) to which it aligned itself. The intent of the survey was to find consensus on the “brand” of chiropractic faculty supported. The degree to which consensus was demonstrated by the survey results was surprising.
It was even more surprising to see the “brand” of chiropractic that emerged through the consensus process.
- 87 percent of responding faculty supported a broader scope of chiropractic practice.
- Of faculty supporting a broader scope of practice, 56 percent preferred an expanded scope of general practice, treating beyond just neuromusculoskeletal conditions. Supporters of this model wanted to treat common disorders such as acute pharyngitis, otitis media, gastric ulcers and hypertension through conservative interventions such as manipulation, botanical medicine, diet, exercise, PT, rehabilitation and lifestyle modification.
- Of the 87 percent of faculty supporting a broader scope of practice, 21 percent wanted to practice as primary care providers, relying on conservative treatments and therapies as a first line of intervention, but utilizing pharmaceuticals if clinically indicated.
The survey data supported a “brand” of chiropractic much broader than the one taught at WSCC at that time. Implementing curricular changes supportive of the chiropractic model revealed by the survey data would require substantial modification to the college’s mission statement. The survey results more clearly defined WSCC and what it taught than had all the many years of questions, confusion and debate.
Oregon chiropractors did not want their identity or fate determined by external forces any more than the college did. They too, felt the need to more clearly define the “brand” chiropractic practiced in the state. The Oregon Board of Chiropractic Examiners invited WSCC and the two trade organizations representing chiropractors in Oregon to join with them to craft a statewide scope of practice survey to help find consensus on this topic. The OBCE appointed representatives from the three organizations to a Practice Act Committee. The committee was charged with designing and administering a survey to identify the kind of practice Oregon chiropractors preferred. The survey distributed to the Oregon chiropractors was similar in scope to the one administered to WSCC faculty.
In mid-1993, the Practice Act Committee survey was sent to every licensed chiropractor in Oregon. The results were astonishing in a number of ways. 58 percent of chiropractors in Oregon responded to the survey, a remarkably high percentage for a statewide survey. Most surprising was the level of support for an expanded practice model.
- 89 percent of Oregon chiropractors supported an expanded scope of practice, treating beyond just neuromusculoskeletal conditions.
- 63 percent of Oregon chiropractors wanted to include the use pharmaceuticals such as analgesics, anti-inflammatory medications, and muscle relaxants for the treatment of neuromusculoskeletal conditions.
- Of the 89 percent of responding chiropractors wanting an expanded scope of practice, 21 percent wanted to practice as primary-care physicians with a scope of practice identical to that of medical practitioners.
Dr. Dallas and his administrative team met with the Board of Trustees to share results of the faculty survey and the Oregon Practice Act Committee survey. Unmistakably, the chiropractic profession in Oregon supported an expanded role for itself in the health care delivery system. After much deliberation, the board directed Dr. Dallas to explore ways to reposition the college in response to changes resulting from health care reform. Dr. Dallas appointed a panel of faculty and administrators to draft a “white paper” defining precisely what the end product of a chiropractic education at WSCC would look like in the future.