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House Committee on Veterans' Affairs
Subcommittee on Health

Hearing on Chiropractic Services
in the Department of Veterans Affairs
October 3, 2000

Letter from AOA President Donald A. Krpan, D.O.,
Opposing Legislation to Expand the Scope of Chiropractic Privileges

September 28, 2000

The Honorable Cliff Stearns
Chairman, Veterans Affairs Subcommittee on Health
U.S. House of Representatives
338 Cannon House Office Building
Washington, DC 20515

Dear Chairman Stearns:

As President of the American Osteopathic Association (AOA), which represents the nation's 44,000 osteopathic physicians, I would like to thank you for this opportunity to submit comments on proposed changes in the Department of Veterans Affairs Chiropractic Policy.

Background

Osteopathic medicine is one of two distinct branches of medical practice in the United States. Osteopathic physicians are licensed in all 50 states. They practice in over 23 specialties and subspecialties, in hospitals and clinics around the country and in several foreign nations. While allopathic physicians (M.D.) comprise the majority of the nation's physician workforce, osteopathic physicians (D.O.) comprise more than five percent of the physicians practicing in the United States and a significant percentage of physicians serving in the armed services. Significantly, D.O.s represent more than 15 percent of the physicians practicing in communities of less than 10,000 and 18 percent of physicians serving communities of 2,500 or less.

We also feel that it is important to outline the education that each osteopathic physician receives and the process that enables a student to obtain the doctor of osteopathic medicine degree, complete post-graduate training and eventually obtain a license to practice. Prior to entering a college of osteopathic medicine, students must complete their undergraduate education. Although the requirements for admission to osteopathic medical schools vary from college to college, there are basic academic standards that must be met. These requirements include an exceptional academic record and achievement of a satisfactory score on a required admission exam. Applicants must demonstrate personal characteristics that reflect the ability to achieve in the rigors of osteopathic medical education and eventually the practice of medicine.

During the first two years of osteopathic medical education, each student must participate and show proficiency in classes that focus on the basic sciences, clinical sciences and social sciences. The third and fourth years of osteopathic medical education focus on the clinical training of student doctors. This clinical training consist of clerkships performed in hospitals, clinics and private offices in the primary care specialties (internal medicine, family medicine, pediatrics) as well as many other specialties and subspecialties (surgery, cardiology, neurology, obstetrics and emergency medicine).

An additional and distinct difference between osteopathic physicians and their allopathic colleagues is the training in osteopathic manipulative medicine (OMM). Each physician that graduates from a college of osteopathic medicine has received didactical and clinical training in OMM. I would like to stress to you that the education of osteopathic medical school students in OMM is not optional, it is a requirement. This training in OMM allows our students to enter the practice of medicine with an additional skill unique to osteopathic physicians. These skills allow D.O.'s to better diagnose and treat patients with musculoskeletal symptoms or illnesses related to musculoskeletal dysfunction. This unique set of skills was a fundamental reason the osteopathic profession was established in 1892.

Upon completion of the four year curriculum, a student receives the doctor of osteopathic medicine degree, and begins postgraduate training in the chosen specialty. Graduate medical education is required for each osteopathic physician.

AOA Position

Mr. Chairman, the AOA is a strong supporter of the Department of Veterans Affairs and the Veterans Affairs Health Care system. We strongly support the Department's efforts to provide quality health care to our nation's veterans. However, we must oppose the proposed language designed to implement the Veterans Health Administration Chiropractic Policy Directive of May 5, 2000.

The AOA supports veterans' access to chiropractic services, but remain concerned about efforts made by chiropractors to expand their scope of practice beyond the bounds of their education and training. The issue of chiropractor scope of practice is heavily debated in the individual states. The AOA remains opposed to any legislation that would allow chiropractors to provide services for which they are not trained. We offer the following responses to the proposed legislative language.

The AOA feels that access to chiropractic services should be governed by the same regulations that apply to all other services such as physical therapy, occupational therapy and speech therapy. By allowing direct access to chiropractic therapy, you would eliminate the important process of physical examination and medical history by an osteopathic or allopathic physician. Any patient seeking care, regardless of symptoms, should first be examined by a physician. This allows for an overall evaluation of the patient's condition, diagnosis and formulation of a treatment plan.

We also are concerned about direct access based upon our belief that chiropractic therapy should be part of a treatment plan for a particular patient, not the sole treatment plan. Many patients may also require pharmaceutical treatment in conjunction with physical, occupational or chiropractic therapy. Hence, the AOA believes that patients receiving any type of therapeutic treatment should remain under the supervision of the primary care physician. This allows for continuity of care that is constantly evaluated by the patient and physician.

Chiropractors are not fully licensed physicians. Therefore the AOA challenges this proposal because we believe that chiropractors lack the proper education and training to be given "full scope of practice" in the care of musculoskeletal or neurological conditions. Many medical and neurological conditions often present as musculoskeletal disease and should not be treated with manipulation. These serious medical conditions, that often present with musculoskeletal symptoms, require an understanding of complicated medical information not generally obtainable from chiropractors.

The AOA believes that doctors of chiropractic do not have the necessary medical knowledge or clinical training to be given a "full scope of practice" in the care of musculoskeletal and neurological conditions. Although many conditions are treatable via osteopathic manipulation or chiropractic treatment, this course of treatment should be prescribed by an osteopathic or allopathic physician after the patient has been thoroughly examined and evaluated.

The AOA adamantly opposes chiropractors being classified as "primary care physicians" under any circumstances. Again, we point out that doctors of chiropractic do not receive training equivalent to osteopathic and allopathic physicians. The AOA strongly challenges their classification as physicians.

We share in the desire of the Department of Veterans Affairs to provide access for veterans in underserved areas to physicians. However, we do not support the concept of access to inappropriate care. The American public has standards and expectations for their "primary care physician." It is our view that chiropractors are unable to meet these public standards and expectations. Again, we base this opinion on the education and clinical training of chiropractors versus osteopathic and allopathic physicians. Furthermore, we feel that the classification of chiropractors as primary care physicians, would constitute a misrepresentation of their qualifications to the public. It would be inappropriate for the Veterans Administration to establish a lower standard of care for those who live in rural or underserved areas.

Summary

In closing, the AOA thanks you for the opportunity to submit comments to this distinguished committee. The AOA does not oppose veterans access to chiropractic services, but we cannot support several proposals that the American Chiropractic Association has submitted. Our opposition is based upon the belief that the expansion of scope for non-physician providers, including chiropractors, prevents patients from receiving the quality of care that they expect and deserve.

We strongly oppose expansion of the scope of practice for non-physician providers and defend this position on the basis of the stark differences in education and post-graduate training that exist between chiropractors and osteopathic and allopathic physicians. Under no stretch of the imagination do doctors of chiropractic receive an equivalent education to osteopathic or allopathic physicians. Their education and clinical training is limited to, and strictly focuses on, chiropractic techniques and treatments. We are unaware of any sufficiently substantiated evidence that establishes the chiropractic community has met the necessary standards to expand their scope of practice.

In contrast, D.O.'s receive an extensive and expansive education in the basic and clinical sciences. They complete two years of clerkships focused on all areas of medical practice followed by a minimum of three post-graduate training years in a field of their choice. This difference in education and training historically has differentiated physicians from non-physician providers. We believe these differences should be the basis of terminating the proposal before the committee.

Again, thank you for the opportunity to share our positions with you. Our Department of Government Relations, located in Washington, D.C., is available to respond to any questions you or your staff may have.

Sincerely,

Donald A. Krpan, D.O. President

cc: Members, Veterans' Affairs Health Subcommittee
    AOA President-Elect
    AOA Board of Trustees
    AOA Council on Federal Health Programs (COFHP)
    AOA Executive Director
    AOA Senior Staff

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This page was posted on October 22, 2000.