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Alabama State Chiropractic Association

Debate on Pharmaceuticals in Chiropractic

June 4, 2017   Montgomery, Alabama

Participants:  Brad Russel, President  ASCA

Jeff Miller, ASCA lobbyist

Stephen Perlstein, DC, APC   Chair, New Mexico Chiropractic Association PAC

Ron Hendrickson, Executive Director, ICA

 

Brad:  It’s been a real pleasure.  We’re going to do a roundtable discussion.  Now, we’re going to deal with something that we are really passionate about or some of us are really passionate about on both sides.  So we are going to have a collegial, respectful, academic discussion about this.  I do want to take a second to thank the Board of Examiners for allowing us to do this.  It’s a little outside of what we do and we needed their permission to do it.  We’re going to talk a bit about scope and the future of chiropractic.  Obviously, we have members of both sides.  The format is going to be this:  we’re going to ask each of panel members to start with 5 minutes.  Just introduce themselves and talk a bit about scope expansion and how they see it in chiropractic today and after that I’m going to turn the microphone over to our moderate, Jeff Miller, and we’re going to ask a series of questions of each panel member and they will each have 3 minutes to answer the questions uninterrupted and then we will move through a series of questions.  At the end, if we do have time for questions, we’d love for you guys to offer up questions.  You can direct it to one or both and each will have a 3-minute period to answer the question.  I have a standard disclaimer that I’m supposed to read.  There are no opinions expressed here today that represent a position of ASCA.  All right, Mr. Hendrickson, would you like to start with your 5 minutes?

[00:01:55] Ron:  Well, the laws of almost every state are very vague regarding nutritional supplements and nutritional advice.  And, to the extent that there are standards or there are issues, they revolve around the treatment of disease through the specific application of nutritional approaches and nutritional substances.  And that gets into a gray area, and there have been instances where practitioners have been challenged on that.  But as the founder of our organization and as doctors of chiropractic worldwide have understood that what you do in terms of spine care takes place in a context.  It takes place in a lifestyle context.  And the components of a healthy lifestyle context include those obvious things from nutrition to a toxic environment or a non-toxic environment to exercise…you know, it’s been said many times that the spine is a structure that was built to be in motion and the workplace has changed from one where the body was in motion to where people sedentarily sit and type away at a computer.  Likewise, the process of eating has changed dramatically, whereby intake of processed foods, the intake of manufactured foods has taken the average individual out of a natural nutritional strain and not only are they subject to being bombarded with preservatives and coloring and additives and flavorings, some of which have been proven to have highly carcinogenic processes.  Also, the fundamental nutritional component has eroded.  And so, doctors of chiropractic, within the scope of their practice, many, many people, I wouldn’t even have to speculate the majority of doctors of chiropractic offer to their patients vitamins and minerals and other kinds of supplements that they feel will help bring the human body back to a healthy balance.  And in our federal policy world, there have been efforts over the decades by the pharmaceutical industry to bring the regulation of food, if you will, as vitamins, or as considered by federal policy, they are considered food, they are not considered medicine, to bring those products under the purview of the food and drug administration and that has historically been resoundingly rejected by the policy process with the support of the ICA, by the way.  Because that industry that is so dominant in the public health process, you know, could only seek to make the whole process more problematic with approvals, with running the cost up, with a very strong anti-competitive addition.  And so, about 12 years ago, the ICA established a counsel on wellness science and Dr. James Chestnut is the Chair.  How many people have been to one of Dr. Chestnut’s seminars and have seen what he teaches?  He provides a program where all of the issues of a wellness approach (unintelligible) through your practice in a very balanced way.  And, by the way, the program that the ICA sponsors through wellness counsels have been the most heavily attended continuing education, post-graduate program in the history of the profession…16,000 of your colleagues have been to one of Dr. Chestnut’s seminars.  And so, there is a clear dividing line between food and, as nutritional substances are characterized, food and substances and other things in the pharmaceutical realm, and I see it very clear and very comfortable and will seek to preserve that distinction.  Thank you very much.

[00:06:59] Steve:  Good morning.  My name is Dr. Stephen Perlstein.  I live and practice in Santa Fe, New Mexico.  I want to thank the ASCA and especially Brad and Layne for having me here.  I think that this is an extraordinary event.  I am very pleased, very honored, very humbled to be a part of what I consider to be a very important debate, and I also want to say before I tell you a little about myself that what I have been present to here is hospitality, is generosity of spirit.  I have enjoyed my short time here and meeting many of you and it has touched me and I am going to bring this back to New Mexico and let them that Alabama is good, Alabama is great, actually.  And what also impressed me is that we are all chiropractors.  Even though we may be on opposite sides of the fence, we’re all chiropractors and I love being around chiropractors.  So, I’ve been in private practice for the past 35 years in Santa Fe.  My focus in practice has been neuromusculoskeletal.  My primary means of treatment, and I do mean this, is the adjustment.  That’s my primary means of treatment, even though I am able to do a lot more than that.  I have certain credentials.  I am a Fellow in the American Academy of Disability Evaluating Physicians.  I hold Diplomate status in the American Academy of Pain Management.  I am also a Fellow of the International College of Chiropractors, and I have been involved in the politics of my profession in New Mexico for the past 33 years, and I have served in all capacities of the New Mexico Chiropractic Association, including President.  I am currently the Chair of the New Mexico Chiropractic Association PAC, and I have been the Chair since 2006.  I am what is known as an Advanced Practice Certified Chiropractic Physician.  That credential is something that is given by our state board, and we passed a law to make that so.  I am certified given that I have taken the law’s education that we created, and the requisite examinations, and by law I am qualified to do certain things that most chiropractors either don’t want to do or are not qualified to do.  I co-authored the New Mexico Advanced Practice legislation and I was the expert witness in all the committees and on the House floor and the floor of the Senate, and this was signed into law by Governor Bill Richardson in 2008.  So as far as some chiropractors, and about 150 of them in New Mexico, there are about 50 more outside of New Mexico, but they can’t practice it unless they have dual license in New Mexico and come to New Mexico.  This has been going on for the past 9 years and I am very well aware that some people know this and some people don’t.  I have also participated after the law was passed in the Formulary Task Force Committee, which was composed of chiropractors, pharmacists from the Pharmacy Board, and members of the Medical Board in which we hammered out a formulary.  So the formulary is actually on line.  It is no secret.  I have been aware that people have a whole lot of different ideas on what we can and can’t do.  It’s all online.  All you have to do is go to our state board and look up the rules and it’s all there.  I am also President of an international organization that is a few years old.  It’s called the Academy of Advanced Practice Chiropractic Medicine, which I know for some is a jumble of words that doesn’t sit well with you.  It sits just fine with me and all of the members that we have.  And I said that this is an international membership organization.  It supports those chiropractic physicians who advocate for Advanced Practice in various forms.  Advanced Practice can mean a little, it can mean a lot.  And our mission statement is the advancement of chiropractic medicine to meet the needs of our patients.  So what does scope expansion mean?  It means whatever you want it to mean.  In New Mexico, it means a particular prescriptive privilege and we have a formulary that we can do and the education to do it.  It has been said, and I have been in testimony when it has been said, that we are not smart enough to be able to have some degree of prescriptive privilege as chiropractors.  Our basic education does not support that.  You have to have additional education and we have had that additional education.  You can have a little bit of additional education for a little prescriptive privilege, you can have a lot of education for a lot of prescriptive privilege.  It depends.  And the one thing about Advanced Practice is that you don’t have to do it if you don’t want to.

[00:12:12] Jeff:  Ok.  Welcome to Alabama and we’re going to have a good time over the next couple of hours.  We will delve a little bit deeper into the practice areas.  On the up note, I have had the pleasure of representing this association now for over 20 years.  It’s been my life endeavor.  (My) preferred home health here is an adjustment by a chiropractor.  I had mine done this morning by Dr. (  ), my chiropractor.  So my head’s on straight and I can tell that you two guys’ heads are on straight, so as we move through the question period, which is what we are going to do first, please take notes because there will be an opportunity at the end for you to ask questions.  And I want to thank Layne and the entire staff who have made my job so easy because I have my script, so your staff does a great job here in Montgomery and we over the years have had a tremendous amount of success in the Alabama legislature, so I appreciate the comments that you have made about being PAC Chair.  That’s always very important and we have a PAC here that participates in the process.  And again next week on June 5th is our state legislature so we can start making chiropractic contributions.  So Ron since we started the introductions with you, we will start the first question with Steve.  What is chiropractic’s defining characteristic and what of these characteristics sets the profession apart from others in the healthcare field?

[00:13:46] Steve:  I do believe that this is a great question and it has to do, very much linked to our identity.  And as I’ve said I’ve been in practice for 35 years.  When I started out, the chiropractic distinguishing characteristic/identity to me, what I was told, was that chiropractic was a healthcare profession that did not use drugs and did not use surgery.  That’s what I was told.  And it was very clear to me and that seemed to make an awful lot of sense.  Things have changed for me in my practice, things have changed in the world of chiropractic.  I think that the distinguishing characteristic is no longer that, for one reason New Mexico, some New Mexico chiropractors can actually prescribe medications, be they topical or oral.  I am actually able to do, some of you know what prolotherapy is.  So I am actually able to do injection procedures for pain management when it is appropriate.  I think the defining characteristic of chiropractic is the adjustment.  No matter what type of adjustment we do, and some chiropractors don’t do adjustments, but that to me is a defining characteristic.  You may say that osteopaths do adjustments.  I’ve trained with a lot of osteopaths and they don’t do adjustments like we do.  They have a whole other set of manipulations.  I think what we do is distinct, it’s different, we are the masters of adjustive procedures.  That’s how it works in my book.  The fact that chiropractic for so long has been a drugless profession is no longer, in my world, a distinctive characteristic.  You can’t hold onto it.  One can argue that the use of…in fact, let’s go to the definition of drug.  Basically, it’s anything you put into your body that alters your physiology.  So we’re splitting hairs here.  We’re talking about you do supplements and vitamins, technically, by definition, those are drugs.  So that really muddies the water for me.  And the fact that, if we’re going to say that no drugs in chiropractic is a distinguishing characteristic, I just don’t think at this point in our history it really has as much validity as our distinguishing characteristic of the adjustment.

[00:16:25] Ron:  What’s chiropractic’s distinguishing characteristic?  Well, you know, chiropractic’s defining characteristics are established by state legislatures and those characteristics are very clear.  Chiropractic is a science, art, and practice separate from the practice of medicine that focuses on the structures of the human, primarily the spine.  The role of the doctor of chiropractic is to provide procedures to restore the body’s normal capacity to heal itself.  And for me the defining characteristic of the chiropractic profession is that exactly.  It is a natural healthcare pathway, apart from medicine, that utilizes the body’s capacity to heal itself and the doctor of chiropractic’s role is to reduce and eliminate the barriers to that natural healing process.  And you know I’ve been a chiropractic patient all my life.  I’ve been with the International Chiropractic Association for 35 years.  I started out as their lobbyist.  Was present in the process whereby chiropractic was recognized in the Medicare program and everything that has or hasn’t happened subsequently.  And the idea somehow that vitamins or the discussion of vitamins has blurred the drug situation and made the issue of drugless less relevant I think is absolutely wrong.  And that if anything the crisis that this nation is facing through the tidal wave of pharmaceuticals that is washing over men, women, and children by the tens of millions is perhaps a firebell in the night of just signaling the absolute need to provide the public with one truly drugless healthcare pathway.  Chiropractic is that healthcare pathway.  If you look at the statistics, if you look at the reports, if you look at what public health officials are saying, prescription drugs, you know every 17 minutes somebody dies from prescription drugs.  If you look at the human cost, if you look at the emotional cost, if you look at the financial cost.  Real quick.  Last month the California Senate passed a piece of legislation that banned the giving of gifts by pharmaceutical companies to physicians in order to promote this or that drug.  California drug companies were giving physicians 1.4 billion dollars in quote gifts.  Why?  Why?  It’s a crisis and the public deserves a truly drugless healthcare pathway.

[00:20:02] Will chiropractic lose its identity if chiropractors prescribe drugs?

Steve:  I also think that’s another excellent question and going back to when I was a new chiropractor I thought what a blasphemous thing to do, that chiropractic’s identity is a healthcare profession that distinguishes itself from medicine by not using drugs.  In the 9 years that I have been prescribing a limited formulary of pharmaceuticals, I have been very clear that I use pharmaceuticals as a tool in my chiropractic practice, and that it has never and does not displace chiropractic.  So, if chiropractic’s identity is not the absence of drugs, then the judicious and conservative use of medications in specific, for specific reasons, does not detract from chiropractic’s identity as a natural healthcare method.  It’s just another tool in the tool box.  The whole argument of the anti-drug argument, I have issue with that.  I don’t think that drugs are bad.  I think the way they are administered is bad.  And I think the medical profession, as a profession, using drugs as a first course, which is their right to do, this is where they get into trouble.  The…if chiropractic is going to lose its identity as the questions asks, it’s going to because there may be chiropractors who think I don’t want to do chiropractic, I just want to prescribe drugs.  That’s not the way that I practice my practice and as you know there are chiropractors who don’t even do adjustments.  So has the chiropractic identity…you know I think that chiropractic has an identity crisis.  And I think that there are those who hold to one position, drugless, there are those who hold to another position, of course, because of what we did in New Mexico, you can’t say that chiropractic is drugless.  So what is chiropractic’s identity?  It depends on what you think the identity is.  I think that chiropractic can grow and move forward by taking a look at its identity and by having dialogues like this in which we have the potential to create essentially a new identity to see what is possible for chiropractic.  Can chiropractic work with certain pharmaceuticals and also utilize chiropractic procedures.  I am living proof that over 9 years that is definitely possible.  So for me chiropractic has not lost its identity and I think that it is completely up to us to define that.

[00:23:05] Ron:  Identity can be a very personal thing.  How do you identify yourself?  And that’s up to each of you how you conceptualize your approach to chiropractic practice.  You are obliged to meticulously follow the rules and the regulations that are established for your practice and if you don’t you get into trouble.  And too many of your colleagues don’t.  There are people that are in states across the country, engaging in things that are simply against the law and they deserve to be held accountable.  And I see this maintained across the decades zero tolerance for violations of the rules and regulations that have been established for your practice and will continue to do so.  The issue of identity is really kind of a side bar thing that can track us off into discussions about oh gee you know how is this going to help us, how is this going to hurt us.  But what do your patients perceive, but more importantly what do public policy makers perceive when proposals are put before them that are very difficult to justify and to address.  The issues that distract and divert very scarce resources in this profession from things that are urgent create confusion, create division, and the whole issue of drugs as an official part of the chiropractic scope of practice is divisive.  And it is highly controversial.  It has by and large with a couple of exceptions completely rejected in the public policy process and will continue to be so.  And largely for reasons of public health and frankly economic motives that most legislators and public policy makers don’t respond to very positively.  But the issue of chiropractic’s identity goes back to what the public needs and what the public deserves.  The public needs clarity, they deserve a truly drug free healthcare pathway, and I think that the marketplace has sustained the chiropractic profession in the face of a lot of ugly stuff, a lot of anti-competitive activities on the part of the medical establishment, a lot of hostility on the part of the third party payment industries both public and private.  And so what is in the public interest is vital, and as I’ve said initially the issue a drug free healthcare pathway has never been more urgent, and I think the identity of the chiropractic profession as such is critical to our continued success.

[00:26:28] What effect will the ability to prescribe drugs in a chiropractic practice have on the patient?

Ron:  Well.  You know every patient is not just different, they are unique.  And most pharmaceuticals are prescribed and purchased over the counter by the patients themselves.  The sheer tonnage.  That’s the case.  In terms of potency, that table gets turned because the medical physician prescribes increasingly potent and increasingly potentially dangerous medications, etc.  What impact will it have on the patient?  Well, my guess is that… well, let’s put it this way, the data would show that the pattern of patient response and reaction both good and bad as is followed by medical prescription and the notion somehow that the DC is going to be more wise and more judicious and more conservative is an assumption that I think would need to be tested and I don’t think that the psychology is going to be any different, the procedures are going to be any different if the DC has full prescriptive rights.  But I think that the costs are the same, the risks are the same, the potential dangers are the same, and to be honest if the education and the testing is the same that’s one thing, but again I think the issue of public safety, I think the issue of the fact that every system in this country, every state in this country has established a clear pathway to seek through education and testing prescriptive rights and given the fact that there is no evidence whatsoever in any state on any basis that there is a need for any kind of jury rigged, back door, prescriptive professional.  There’s just absolutely no indication whatsoever that there is any need for that.  I think the impact on the patient is going to be one more of confusion than anything else.

[00:29:00] Steve:  I’m bringing a unique perspective to this question because I have been practicing with prescriptive privilege in New Mexico for 9 years.  And I’m a chiropractor.  So I can sight numerous examples, given our formulary of medications, where patients have thanked me for providing them with say, a muscle relaxant or an NSAID, or doing a procedure that they didn’t have to wait two weeks to go to their primary care physician for, that they could get it right away, and it was part of the practice.  I have had not one patient in 9 years questions…why are you giving me a prescription, you’re not allowed to do that?  No one cares.  You are a doctor who is providing healthcare to a patient, and if you decide that a prescription of a pharmaceutical is appropriate, and, with the proper training, you are educated enough to do that, as I am, then you are providing a service, you are providing a tool for a patient.  Now this kind of bleeds into, I think, am I just gung ho just providing prescriptions to my patients.  No, in 9 years I have used one prescription pad.  No, because chiropractic is first, and adjustments are first.  But there are cases, there are instances where a prescriptive drug for a short period, depends on what it is, has enormous value, enormous value.  So it is a positive effect.  The idea seems to be that we are displacing chiropractic for prescriptive drugs, prescriptive drugs doesn’t seem to have a place in it, but in the clinical sense, in my experience, and this is the experience of all the chiropractors in New Mexico who have this privilege, that we use it conservatively and we do use it judiciously, because I’m a chiropractor first and we all are.  So there are instances where there is enormous value to a patient for short term relief, like in a muscle relaxant, not as the first course of treatment, but as the second or the third course of treatment, as a tool.  So the ability to prescribe drugs brings another dimension to a chiropractic practice.  If you can just simply suspend the idea that chiropractic should not have drugs as a part of it, then you can begin to see that the use of a prescriptive medication is the same as the use of any other modality, like ultrasound or stimulation, or anything like that.  It’s odd, but it’s true.

[00:31:58]

What prescriptive drugs would and would not be appropriate for a chiropractic practice?

Ron:  None would be appropriate.  Emphatically so.  None would be appropriate.  You know, again, there is absolutely no evidence to indicate the need for another prescriptive professional.  The educational pathways in every state are clearly established education and testing to obtain prescriptive rights.  And as I have engaged at the state education level, I have seen members of state, senate, and house healthcare committees sit there shaking their heads saying what in the wide, wide, world of sports whatever make you think that this committee would think that what you are proposing makes sense.  Because we’ve got in our state ways and means to test, to educate and test, and what you are proposing is some unaccredited, unrecognized post graduate course taught in some Quonset hut out by the airport by lord knows who.  And I’ll tell you what, I’ve had it in my face.  And I was there representing the opposition to legislation and in the issue of prescriptive drugs, my answer is clear.  None.  None are appropriate.

[00:33:58] Steve:  Again, I bring the unique perspective of actually having the privilege to provide prescriptive drugs.  In New Mexico, we have a very limited formulary, like I said before, you can look it up.  So, for example, one of the drugs that I am able to prescribe is an oral drug, and it’s cyclobenzaprine.  That’s Flexeril.  That’s a muscle relaxant.  So without any training in that, one would think well why would I need to prescribe that?  What situations would be appropriate to prescribe that and if I’m a chiropractor first, why would I even bother, and if somebody really needs it they would go to their medical doctor or nurse practitioner.  So, for example, somebody in a lot of pain receiving a couple of visits, their history is they’re not sleeping well.  They have lack of sleep due to pain, they turn over, they wake up, and it is interfering with the ability of the adjustment to its work.  In numerous cases, I have seen that providing, say, 2 nights, 3 nights, possible, of taking a muscle relaxant so that it facilitates a better sleep pattern that actually facilitates better ability of the body to absorb the value of the adjustment and that’s when they thank me.  Gosh, I got a really good night’s sleep, thank you.  And it’s a very short term prescription.  So that’s, in a neuromusculoskeletal practice, that’s where it is of value.  You can talk all you want about the principle, and many here in this room are principled chiropractors, so drugs do not have a place.  And I honor and respect that.  But when you go into a clinical setting and you see the value of short term use of a limited formulary, and you see it’s effect on the patients, the positive effects on the patients, and again I emphasize in a limited way, in a very limited way, to where it is a second or third tier treatment, not the first, it is more than appropriate.  And we’re talking about NSAIDS.  We also have in our formulary topical NSAIDS.  We also actually have testosterone in our formulary.  I don’t do that.  I’m not a functional medicine doctor.  That’s something that got in our formulary and I actually, many don’t know this, I have a DEA license in order to do that because it is a controlled substance.  That’s the only controlled substance in our formulary.  So there’s also homeopathic injectables in our formulary, and that has proven very effective in cases that go way beyond what chiropractic can do.  I just have a lot of clinical experience in this, and have found it to be very, very helpful.  So, there’s a variety of prescriptive drugs that do work in a chiropractic practice.  It just depends on what you want to do.  Like some people are straight chiropractors, adjustments only, some people have numerous modalities.

[00:37:05]

Moderator:  Before we move on to education, we have one last question and we will start with Steve.  Will malpractice rates go up if chiropractors prescribe drugs?

Steve:  Ok.  So I’ll give you the answer direct from New Mexico.  When we passed our law and we developed our formulary, again, a very limited formulary.  Not primary care practice, but a very limited formulary, mainly related to neuromusculoskeletal conditions, NCMIC said, well, you know, we can’t provide you 1 million/3 million coverage, we’re going to knock you down to 100,000/300,000 and you’re going to have to get the rest from the New Mexico insurance pool, because they did consider us a risk.  OUM said I don’t see a risk here, and everyone moved over to OUM.  So my malpractice rates have not gone up because of my prescriptive privilege.  Now, could malpractice rates go up depending on what your formulary is?  Of course.  But this is…you have to put this into context.  If you want prescriptive privilege, then what comes with that is the responsibility to take on the risk of that.  So if you, you may decide I don’t want my insurance rates to go up so I’m not doing this at all.  Or I’m going to stick to a limited formulary.  The formulary, the amount of drugs, the type of drugs, is determined by your statutes and rules.  If there are those in Alabama or whatever state who want to have prescriptive privilege, you map that out.  You decide what you want and then OUM or NCMIC or any other malpractice company is going to decide how much of a risk you are.  So they could go up and I’m telling you in New Mexico they have not gone up.

Ron:  Well, the jury is still out on that and there are a number of major malpractice companies that will not cover pharmaceuticals for obviously, you know, actuarily driven analysis has shown that there is added risk.  The data on the cost of pharmaceutical errors is mind numbing.  17 years ago a major study on the cost of the average pharmaceutical error was determined that the average cleanup cost for the average pharmaceutical error was between $4-6,000.  And there is (status?) going on to redo that study and the preliminary indications are that costs of the cleanup exponentially increased.  All of those will be passed through the malpractice system and whether you do it or not the ripple effect is very likely to be a negative one and it’s going to cost you.  Now, is it worth it?  Are you making a lot more money out of the deal?  You know, the jury’s out on that one as well because the whole culture is going in a really new direction and the advent of the internet, the advent of the wherewithal for, you know, the average person to sit down and look stuff up is really pretty amazing and as a patient myself and as a parent of children who have had healthcare crises you know the ability to look stuff up and to come in armed to ask questions and to be on watch and to have a personal approach that you want to minimize the risk that you and your family members are being put to that is an emerging new element in our culture and it has served me and my family personally very, very well.  Bottom line, the jury is still out, but all of the evidence that you look at from the current pharmaceutical establishment you know given the error and the death rate as a result that’s very scary to me.  Especially in the context of a lot of chiropractic practices under financial pressure as it is.

[00:42:04]

Do chiropractors need additional training to be able to prescribe prescription drugs?

Ron:  Well, chiropractors should get an additional license.  I mean, the bottom line here is again our credibility as a profession very often goes on the ropes when people show up at state legislatures and say well we’re going to have this program, most recently in the February hearing in New Mexico, a college president shows up in front of the state senate and says we’re going to have this program, it’s going to teach all these people and a somewhat skeptical senator responded saying well are you doing this in your state.  Well, the answer is no.  And I had a very interesting experience in the state legislature where a very similar dialogue took place many years ago.  And the chairman of the health committee said let me get this straight, this is like a deal where like you’re going to dance more like Fred Astaire and you’re going to look more like Robert Redford, but you don’t now, but you want me to put you in our movie anyhow.  I’m sorry, but that’s just unacceptable.  Education and testing.  Even if the gold standard has produced a crisis in this nation.  It’s produced a human crisis. It’s produced a financial crisis, and again, I get back to the bottom line.  There is no evidence whatsoever that the public needs another half-baked, round the corner, back door prescription professional.  And I am dead serious when I say that.  In the chiropractic education (is) provided the ways and means to address a wide range of healthcare conditions for people of all ages.  In what I consider especially in light of where this nation is on an optimal basis.  On the optimal basis.  And it should stay there.  Now that’s not to say that there isn’t room for tremendous growth and expansion in what chiropractors do and how they do it.  Now, the ICA is working very hard on a fall risk and prevention program for the DC.  If you have elderly parents, heck, I’m an elderly person all the time.  Dan Murphy said you can reduce your fall risk by 80% by using a cane.  Thank you, Dan.  Not to mention getting on an airplane early.  Healthy sleep.  Fall risk assessment and prevention.  Concussion.  Our council on upper cervical care, Scott Rosa and Curt Erickson and Ted Karick are working very hard on clinical protocols and pathways to address emerging issues in healthcare in this country.  So the idea somehow, and all of which are extremely education intensive, I mean, the upper cervical diplomate program is like 480 hours of real serious stuff, way over the head, my head, I was a political science major.  So I think that the distracting, divisive discussion about education and pharmaceuticals really distracts this profession from some really exciting growth areas that are totally consistent with chiropractic.  They are not divisive.  They are totally consistent with the foundation of chiropractic education and I say is absolutely committed to exploring and making those happen.

Steve:  Ron, I’m going to take issue with what you said about the education, about the half-baked, back door education.  My training and the other chiropractors in New Mexico were trained in over 120 hours of pharmacology and toxicology and pharmacognosy.  These programs were put on by Texas Chiropractic College and National University of Health Sciences.  These are chiropractic schools that put on the educational programs.  They had to pass muster with the New Mexico Medical Board.  These were not half-baked programs.  In addition, in order for me to do procedures, injectable procedures, and we had clinics as part of the programs that were taught by nurses, I have trained with the Hacket Hemwall Foundation in prolotherapy.  I have trained with the American Association of Orthopedic Medicine and those are not half-baked, backdoor courses.  So my training is top notch.  My training is excellent.  Additional training to prescribe drugs?  Absolutely.  It has been said in testimony in New Mexico that chiropractors are not smart enough to prescribe drugs.  That’s insulting.  We are smart enough to take additional training to do it.  You have to take additional training.  We in New Mexico have, and if any state wants to, the training has to be commensurate with anyone, medical doctor, osteopath.  It has to be the same quality of education.  Your state legislature won’t have it any other way.  So I take issue with you in that regard.

[00:49:10]

Ron:  The courses that you are referring to are accredited by whom?

Steve:  Texas Chiropractic College…(interrupted by Ron)

Ron:  No, what federally recognized medical accrediting agency?

Steve:  What are you talking about?

Ron:  Who were the courses that you were taking accredited by?

Steve:  Are you talking about the courses by the Association of Orthopedic Medicine and the Hackett Hemwall Foundation?

Ron:  No, the courses, the 120 hours that you say were sponsored by National or Texas, who were they accreditated by?  Who were they recognized by?

Steve:  First of all, they had to approved by the New Mexico Medical Board and they are accredited by the CCE.

Ron:  Show me the minutes of the Texas, um, the New Mexico Medical Board where that approval actually took place.

Steve:  Wow.  Ron…

Ron:  It is a yes or no question.

Steve:  It is and I have it and I will give it to you.  I don’t have it right now.  It’s there.  I have it at home.  I do.

Ron:  Put it all on the internet.

Steve:  It had to be approved and it was approved.  Sorry.

Ron:  I would challenge everybody to look to see that this in fact has taken place.

[00:49:27]

Are there sufficient training and educational programs available for chiropractors to reasonably prescribe drugs?

Steve:  Well, as I described the educational programs that we in New Mexico had to do are there, and I did say that the programs of the schools had to be approved by the medical board.  The training that any state that wishes to pass a law to provide prescriptive privilege for their chiropractors, they have to create the training.  The training isn’t just sitting there.  The training that we went to was actually sunset in 2012.  It began in 2008.  We sunset it in 2012.  We thought that we would be moving on and so those programs don’t exist, but they can be revived.  Essentially, the answer to this question is sufficient training, it has to be generated and created.  And my point on it is you don’t get that privilege without the sufficient training.  As far as continuing education, in New Mexico, we do have continuing education.  Because our advanced practice is broad, we also include functional medicine in that.  The specific training in which we practice with injectables, injectable practice in clinics, and also pharmacological, yes, we have that continuing education.  I’m actually one who teaches that because of my additional training.  So sufficient training and continuing education programs are available, but it’s only state specific, because in New Mexico, we have that, so we seek that out and we have our training.  There are several colleges, most notably University of Western States and National, who are in the process, as need arises, of developing additional training programs, but it’s sort of like the chicken and the egg.  It costs a lot to develop training programs, and if there’s no need there, that essentially becomes a waste of money.  So we’re working with those colleges. If we decide to expand or any other state that wants to, those are the colleges specifically that are very supportive on developing and providing the education.  This is so new that it’s not like an establishment training program and then the training program, as I said, has to be tailored to whatever state’s needs are.  So, the short answer, yes, there has been sufficient training, there will continue to be sufficient training, and the end of the question about responsibly prescribe drugs, yes, that’s the whole point of the training.

Ron:  Yeah, I’m gonna look more like Robert Redford and I’m gonna dance more like Fred Astaire.  That’s one way to answer this question.  On the other hand, yes, there are recognized educational and testing pathways to secure prescriptive rights through schools of medicine, through schools of nursing, etc.  And ICA has been very proud of its members including its leaders who have gotten additional degrees, who have gotten medical degrees, have gotten masters of public health, have gotten other advanced degrees that have expanded their capacity to act.  But within a gold standard pathway, and I think that has to be the emphasis, and again, I think that all the data is out there and all of the cards are on the table, the public is entitled to the highest level of education and testing in our testimony we talk about the gold standard level.  And my personal opinion, that hasn’t been obtained in the chiropractic profession and, as I have been fairly emphatic and fairly clear, I don’t think it should be.  Thank you.

[00:53:38]   Can prescribing chiropractors coexist with non-prescribing chiropractors?

Ron:  Well that’s a cold war kind of question.  Can they co-exist.  It’s completely speculative and hypothetical for vast…and all the people in this room and for the overwhelming majority of doctors in the country. I mean, they’re not going to take up arms against each other, so I guess strictest construction of that question and the most honest answer is yes, they probably won’t kill each other, but does it divide this profession?  Does it divert attention away from what I consider to be much higher priority issues?  Does it waste very scarce resources?  Yes, it does.  And rather than focusing on securing greater legislative protections, on securing patient’s rights, on securing personal freedom, on securing fairness of the insurance process…oh I am delighted to report that after an 8 year campaign where ICA was really pretty much the solo voice in the chiropractic profession, the House of Representatives passed legislation to repeal the McCarren Ferguson Act.  Does anyone know what the McCarren Ferguson Act is?  The McCarren Ferguson Act was a piece of legislation passed by Congress in 1946 that exempted the business of insurance from the federal anti-trust laws.  And that means that in the context of insurance, the insurance industry can get away with predatory trade practices, discriminatory pricing, black listing, and all the kinds of things that have been dumped on the chiropractic profession to the maximum economic advantage of the insurance industry with no federal exposure, no federal penalties.  And hopefully that will pass the Senate and that is something that will really be a sea change in how the third party industry in this country is obliged to deal because you have legal recourse federally when they engage in the kinds of things that hurt us so badly, where they have a copay that is $25 more than your office visit, etc.  when you are obliged to operate under different standards than other recognized doctor providers.  Again, it is a distraction and we have got a lot more important things to do that are urgent in terms of the profession and also the patients interests.  So, not that I have strong feelings.  Thank you.

Steve:  The short answer to this from someone who is in New Mexico where there are prescribers and non-prescribers is yes.  Of course.  Depends on each of us.  I also want to mention that as Chair of the PAC in New Mexico, we have far more on our agenda than advanced practice.  We always have.  And we work to those ends.  Insurance parity, things like that.  So, other items, other very important items, and I agree with you, Ron, do not take a back burner because advanced practice is this prominent thing in New Mexico.  We in New Mexico I can say having, it’s been 9 years, so I don’t think you have heard of the blood bath in New Mexico, and you haven’t heard of you know dead chiropractors being found in places…we get along.  We agree to disagree.  We value chiropractic above all else.  And we have always put the message out in New Mexico that we are all chiropractors, and that chiropractic is first.  So if you were to come to our state convention, which we had in May, you wouldn’t know that there was a problem.  You wouldn’t see chiropractors staying away, you know, prescribers staying away from non-prescribers.  The prescribers don’t hold it over the non-prescribers and the non-prescribers don’t hold it over the prescribers.  We agree to disagree.  So I think as far as if advanced practice expands to other states, and I will tell you that Idaho, I’m waiting on word, I believe that the Governor is about to sign that bill into law.  They have, they got some advanced practice for themselves.  And I have been in touch with them.. Again, we don’t split ourselves apart.  We agree to disagree.  And I think that it is up to us individually how we get along.  You know, in our profession, we have super straights and we have people who use modalities and so can those people exist?  The point is we all want to exist together and drugs is just another modality, so the question is can we as chiropractors exist when we practice differently?  And I think the answer is yes, and I think the answer is yes we want to and we always want to.  And we will.

[00:59:23]

Moderator:  How do you see the move to prescribing drugs will improve or damage the profession?

Steve:  OK. I think if you have been hearing this, you can figure that I think that it is an improvement to the profession.  It’s an improvement because it is another tool that we can very smartly and judiciously use with our patients.  As I was speaking in the last question, if you are somebody who uses ultrasound, and you have another chiropractor who doesn’t, hopefully you can get along.  But is ultrasound an improvement in treatment modality to our patients.  To the super, ultra straight chiropractor, the answer may be no.  No.  Just adjust and to some just adjust the atlas.  But to the one who does ultrasound who has clinical experience doing it, it’s very obvious to them that ultrasound is a good modality.  Does it detract from chiropractic?  Hopefully not.  Same thing with drugs.  So with that context, I say that judicious, smart use of prescriptive drugs of whatever variety a state and the chiropractors in that state wish to pursue, small or large, is an improvement completely analogous to the use of accepted modalities in our chiropractic profession.

Ron:  Well, I think that this is a phase that the profession is being put through by a minority.  It’s a situation where the tail is trying to wag the dog, and I don’t think that the dog is going to be wagged.  I think that’s increasingly clear to me as I see the vital center, you know, the 80% of the chiropractic profession that’s clearly anchored in the traditional definitions and sense of chiropractic science and practice.  I think that this will go by the wayside as we have many things do in the past, and I think it’s a good thing that we go through, we expunge it, and we move on.  There is a difference, there’s a fundamental, differential definitional difference in this or that modality and prescriptive rights for controlled substances.  There is a fundamental difference.  And I am pretty confident, based on my 35 years of not just observing, but being a participant in this profession, that following what the public needs and what the public will respond to, that this notion somehow that the profession needs to be medicalized and that this whole process of becoming a prescriber on a medical basis is urgent somehow, or even of significant value to the chiropractic profession I think is going to go by the wayside.  And that’s going to continue to be highlighted again by the nature of our state and the state of our culture and our society awash in a tidal wave of drugs, prescription and non-prescription that are killing our children, that are bending young minds, that are turning our old people into vegetables prematurely, and that to be in a big hurry to hitch chiropractic’s wagon to that falling star I think is sad.  I think it’s unfortunate, it’s divisive, it’s time wasting, and it’s sad, and the realities of that situation should be lost on no one.  From the opioid crisis to children abusing the prescription drugs in their parent’s medicine cabinets to physicians writing prescriptions for narcotics for frankly for money just like the Columbian cartels.  I think this too shall pass and the chiropractic principles are really pretty enduring and durable and I have a very high confidence level in that.  Thank you.

[01:04:18]

Moderator:  OK.  Thank you both for that very lively panel discussion and I can see why you do so well in your profession.  Kind of reminds me a little of the legislative session, you know, where you hear both sides of the story, so a little different from the legislative session we don’t have a chance to go on the floor and ask legislators questions.  So today we’re going to ask you if you have questions if you just want to come right up front and we’ll let you talk right into the microphone and ask our two panelists some questions and try to keep your questions short, because hopefully we have the long questions.

[01:04:57]

Audience question #1:  I can’t promise it will be that short.  Did you start the timer yet?  I think it’s inevitable that,  What’s your name, the doctor from New Mexico?

Steve:  Steve

Questioner:  …our profession is likely going to adopt some form of prescription rights sometime at some point in the future.  I don’t necessarily agree with that, but I wouldn’t lambast another chiropractor for it.  What I disagree with is the nomenclature.  Advanced chiropractic implies that other chiropractors are not advanced.  And that’s a problem.  And the advertisement, so to speak, by performing certain injectables or prescribing NSAID drugs that you can get at the drugstore, that is an advanced either clinical decision process or the treatment itself is somehow superior.  We’re about to use a study possibly for advertisement for our profession promotion that outlines that adjusting for low back pain, we’re not talking about disc extrusion or anything shy of that, is superior.  Why is that not advanced?  And the clinical decision it takes to manage a patient with acute low back pain over a 6 week period using nothing but your hands and rehab to me is far more complicated than to take Aleve.  So I disagree with the nomenclature of advanced chiropractic, okay.  If we’re going to speak for 10 years about evidenced based practice, when we get information about evidenced based practice, we turn and so no, I want to do advanced chiropractic, which is basically the pathway for some limited drugs.  I don’t follow the nomenclature.  I won’t support that.  And if it’s just a modality, then let it be so.  Your name shouldn’t change.  You shouldn’t be able to advertise that you are advanced.  I don’t feel less advanced because I don’t intent to prescribe drugs.  I have got 2 or 3 medical practices nearby that I can send my patients to.  We get along, we communicate, that kind of thing.  They don’t need to invade my treatment either.  So I want to mention losing identity.  The identity that we need to create is in evidenced based practice, which is what the studies says.  They are already telling us what we can do that is the most successful.  Sadly, most of us aren’t doing it.  So if we want to develop trust with the public, let’s do what all of the PhD nerds are telling us to do already.  We’re doing a lame job of it.  We can claim rehab for ourselves.  We can claim to be spine people, extremity people, and take on all of those avenues for treatment and own them completely.  Invading another modality will not solve the crisis of identity or the trust of the public that does not have for us.

Steve:  The nomenclature that we came up with in New Mexico is just nomenclature.  It does not have to be the nomenclature that Alabama or any other state would use to describe itself.  What we have here is the beginning of a movement to explore the possibility of having prescriptive rights for those chiropractors who want it, and any state is able to call it whatever they wish.  The argument that advanced is almost insulting to other chiropractors I completely understand that.  We adopted advanced practice.  It’s not meant to be insulting to anyone, and, as I said, you can call it anything you want.

Ron:  Well, I think we have to come back, and I think that the doctor who spoke was very insightful.  Prescription of medication is the practice of medicine and it is not the practice of chiropractic.  The blurring of professional lines is inherently confusing to the public and again the public is entitled to certain clarities.  And I think that that was very, very well put.  I commend the doctor for his insights.

[01:09:49]

Audience question #2:  First, I’d like to thank you all for coming down here.  I think that this has been a very healthy debate.  And as government affairs chairman of this body, mine is not necessarily in the interest of do or do not, but more practical application of whatever policy is set forth.  So, this question is specific for Dr. Perlstein and I would like for both of you to weigh in on it.  It seems almost a daunting task if we were to change our scope, so I would like for you to expand upon the hurdles, both financially and to accomplish such a goal.  And also I would like to hear some things from the other side of the coin as well.

Ron:  Well, you know, the bottom line here is that there needs to be confidence on the part of public policy makers that whatever any healthcare profession is being authorized to do is done so in an appropriate gold standard.  You know, when it comes to pharmaceuticals, folks, our country, including every state legislature and the Congress of the United States is sitting there tearing their hair out over how to address the situation this country is in.  Let me read you a little something here.  This is very relevant to the discussion.  Gerwitz, Field, and Harold, in a study done for Archives of Internal Medicine, published the following:  The average cost per patient to correct medication errors in US hospitals is $2-4,000.  This was in 2000.  The average jury verdict due to medication errors in 2001 was $636,844.  In the same year, the Journal of the American Pharmaceutical Association reported that $177 billion in excess costs in healthcare can be attributed to medication errors.  And the authors of that study also went on to say that, sadly, estimates indicate that more that 80% of life threatening medication incidents are the result of physician error.  In order to have the confidence of your public policy, you are going to need to overcome the realities of where the medical system is right now.  And you’re going to need to devote a great deal of energy and a great deal of persuasion to somehow convince very skeptical legislators that, oh dear, we’re going to a lot better than those guys.  And I think that’s close on to being a fools errand, to be completely honest.  And, again, you’ve got malpractice issues, you have got certification testing, education issues, you’ve got credibility issues with the public, and is it worth, is it worth the energy, the effort, especially in the context of my beginning premise, there is no evidence whatsoever that this is needed by anybody.  Is it worth it?  And that’s a decision that you all will have to make.

Steve:  My answer is is that it is very much worth it.  I’ve been in the process, I’ve been in the trenches.  I think I mentioned that I have been the expert witness for all the legislative activity in the New Mexico state legislature.  It is not an easy task.  I just want that to sink in.  It is not an easy task.  You’ve got to really want it.  And the most important piece of information that I can pass on to you, if you wish to pursue it, is you’ve got to generate relationships in the legislature.  There’s nothing new there.  Any kind of legislative activity you’ve got to generate the relationships in the state legislature.  You’ve got to educate the legislators, not only on chiropractic, but on this issue if you are talking about wanting to add prescriptive privilege into the statutes.  You’ve got to go through the process.  I’m very aware of what the law is here, and I don’t have the answers of how you would actually and specifically do it.  But you have to gather enough people in your state who wish to advocate for it.  You’ve got to gather those people who know how to live in the legislature, know how to be with the legislators, know how to converse with them such that you enroll them in an idea which they are not familiar with.  That’s what we did.  In New Mexico, we had as our sponsor the Speaker of the House of Representatives, the second most powerful person in the state legislature.  We also met with the Governor before that, and he said as long as the medical board doesn’t squeal, I’ll sign it.  And we met with the medical board and the medical society so we worked everyone and we got support, we got the support for what we wished to do.  To generate the actual formulary was a formulary task force committee.  That was tricky.  That was difficult.  But we worked it out.  It’s just a matter of working it out, taking as much time as you need, understanding that it is a difficult process, never giving up, and always moving forward with it.  I hope that helps you understand, and I did mention just briefly that I’m the President of the Academy of Advanced Practice Chiropractic Medicine and that’s what that academy exists for, to assist other states who wish to pursue, I’ll call it advanced practice, you can call it whatever you want.  That’s what we’re there for.  And for anybody who wishes after this is over to get any information on it, I have something to give you.  So just see me.

[01:16:15]

Audience question # 3:  I’d like to thank you gentlemen for coming here and speaking with us today.  Two quick questions.  One has to do with the identity.  I’m sure many years ago the osteopaths had a much different identity than they do today, and they lost that identity under the ability to deal with prescriptive medications.  I would like that to be addressed.  I don’t know how you’re going to prevent that from happening to the chiropractic profession.  The other thing that I would like to know is what is the impact that the pharmaceutical industry will now have on the chiropractic profession in the state of New Mexico seeing that this door’s been open and especially since they have historically always been adversarial to anything that is not a patent medicine.  This whole thing that they have control of and is really there has been a very concerted effort by them historically to eradicate and displace anything that is either natural or a patent medicine.  Those of you who don’t know a patent medicine means that it has to be a molecule that does not occur in nature.

Steve:  Ok.  That’s a really great question and there’s really kind of one answer to both of those.  I’ve been aware in all the years of me being a chiropractor, there’s always been that issue, the osteopathic issue, look what happened to them.  So, I want to make a point here.  When you are talking about this issue, you’re talking about them, you’re talking about they did this, they did that.  What’s become very apparent to me having this privilege is I’m talking about myself.  What I do and what I feel, and each person in this room has to decide for themselves if they want to establish prescriptive privilege for themselves how they individually and then as a group are going to deal with that issue.  So I say that it’s possible for chiropractors to have prescriptive privilege and not lose the profession.  I don’t know why the osteopaths lost their identity, but I say that it’s possible for a profession to not lose its identity, but to have both, and it depends on you individually.  If you’re conversation is, as mine is, chiropractic is first and I will never, I will never let the profession down just because I have prescriptive privilege, then we have something different.  Then we have a chiropractic profession which is the chiropractic profession and has added another tool in the toolbox, but has never pushed chiropractic aside.  So I say that it’s up to you how this profession proceeds.  For some, it’s easier, it’s just easier to say just keep the drugs out and then we don’t have to mess with that question.  But I think it’s far more dynamic and I think that the possibility is tremendous as I’ve experienced for 9 years to be able to do it and not go the way the osteopaths.  It’s up to us.

Ron:  Osteopathy is very interesting history to it, and I don’t think that the identity of osteopathy was ever particularly clear nor was the profession well organized, or clearly motivated.  And it was a surrender, a surrender of a profession in decline, a very significant decline, and I think the fundamental difference of where osteopathy was it approached the systems of organized medicine and asked, in effect, asked to be absorbed and where this profession is is like night and day.  Chiropractic is in the ascendency based on its unique principles and values and natural approaches to health and healing and then again I see this whole pharmaceutical thing as a phase we’re going through that will be over in a relatively near future for a host of very valid reasons and something that of course our association can’t wait to see happen.  But the chiropractic profession is large and dynamic and quite well organized and between the Foundation for Chiropractic Progress and the ICA and other organizations, there are very clear voices, and I think that that vital center, that 80% of the profession is very firmly anchored and the likelihood that chiropractic is going to drift, especially as osteopathy did, that is just not a possibility.

[01:21:31] Audience question #4:  Good morning.  Again, thank you for being here.  As a trustee of the board, I have a more financial question directed at you.  You said that you got your doctors together and you worked together, but as someone who has worked on many, many bills in Montgomery, every bill has a cost.  How much did your state association put into this bill, how long, and did you have any support from the pharmaceutical industry?  Part two, how much did your classes cost you, personally, to get to this stage?  Part 3, does your staff have any additional training and do you have any cost increase from that and has your malpractice increased?  So it’s a multi-faceted question, as you say, for this privilege.

Ron:  Well, these are very specific questions.  I would pass on these.

Steve:  The cost is very simple.  We have a lobbyist.  I think the cost of the lobbyist is about $30,000 a year, $35,$36, something like that, depends on what the session is.  We have 30 and 60 day sessions.  That’s it.  That was the monetary cost.  And the lobbyist, we did have a special lobbyist for advanced practice.  It’s our lobbyist, the PAC lobbyist, the association lobbyist. So there was no additional cost.  The only other cost that I can think is I have had to take lots of time from my practice, as have other PAC members, to attend legislative sessions, that kind of thing.  But I don’t even consider that.  I have no idea what that cost is.  Could you go over….you had 4 questions there.  Oh, the classes.  This is a long time ago.  I believe we had 9 modules and then there was an examination.  I know the examination cost about $800, I think, or $900.  The classes were modules that individually cost about $500 or $600, so we’re talking several thousand dollars.  We’re talking 3,4 thousand dollars at most to do this training that we got in New Mexico.  And then continuing education, we have additional hours besides the 16 hours that the standard chiropractor has to do, we have 10 additional.  So there is cost to that.  No additional staff training because they essentially have nothing to do with it.  If I provide a prescription, I provide the prescription.  We copy the prescription.  There’s nothing more to do about it.  There’s really no additional cost, and I can’t speak for everyone, but in my office there’s no additional cost for any kind of thing that a staff would do, and I’m not really sure what you’re getting at.  If you’re talking about certain procedures that staff would have to present, I don’t have that.  I don’t do that.

[01:25:19] Audience question #5:  Dr. Perlstein.  Thank you for your trip.  As a professional, do you have any image concerning, let’s say, strokes and in concert with any manipulations and cervical adjustments (not sure of those words)?  So, the fact that somebody, whether they suffer a stroke whether it’s on the table, whether it’s 4 days after the manipulation, whether it’s two weeks after the manipulation, it doesn’t matter, it’s in the papers and its nationwide.  My question is is that with public ( ) being the third leading cause of preventable death in the United States, not if, but when someone dies, that’s going to be a public issue with our profession, our national, global.  How do we handle that?

Steve:  I think we handle that the way we handle any death from cervical manipulation.  We’re talking about something very new, and for everyone in the room here you don’t have any experience of using that in your practice.  I remember the first time I prescribed medication, the first time that I put a needle into somebody in a procedure that I did.  I was absolutely terrified.  Kind of much the same way, although it’s been so long, as I was when I did my first adjustment.  So I think each chiropractor in this room and every chiropractor in the entire world has a responsibility to be the best that they can be, and there’s really no difference.  I hear what you’re saying.  You don’t…it doesn’t sit well with me or anybody in this room when somebody dies from a cervical manipulation, nor would it sit well if a chiropractor prescribed a drug that had an adverse effect.  What I can tell you is that in 9 years in New Mexico, there have been no adverse effects.  So again the procedures that we do whether they be chiropractic or the addition of medications has to have the commensurate training.  You have to have the proper training.  And only then with the proper training are you able to do the procedures if you wish to. So we would handle what you are suggesting in the same way that we have been handling those unfortunate deaths from manipulation.  The implication…maybe you’re not saying it, but the implication, is chiropractors shouldn’t be doing that because it’s not their domain.  But if they have the proper training, it is their domain.

Ron:  According to a 2001 report from the Journal of the American Pharmaceutical Association, more than a $177 billion in excess costs and healthcare supply chain can be attributed to medication errors.  Sadly, estimates indicate that more than 80% of life threatening medication incidences are the result of physician error.  Those people who have engaged in the prescription and administration of controlled substances and medication, I guess we can thank our lucky stars that the kind of incident that Dr. John Allen Smith hypothetically made reference to hasn’t come to the fore, but I can tell you this.  Having been in the position of some responsibility for the ICA for 35 years, I have dealt with crisis after crisis after crisis where this profession was battered on the pages of every newspaper, at the news hour, at the hands of commentators in feature articles very often times when the so-called incident wasn’t even, didn’t even take place at the hands of a doctor of chiropractic.  The bias, the anti-competitive sentiment, the control of the media, has been one of the chiropractic profession’s greatest challenges, and if you think somehow that the chiropractic profession, if it embraces in any significant way, prescriptive rights, authority, is going to escape responsibility and accountability, except magnified exponentially because of the hostile environment in which we are obliged to operate you are being exceedingly naïve.

[01:29:59] Audience question #6:  I probably don’t need a microphone, but I have 2 questions, but before I ask them, the comment was made earlier about coexisting.  I’d like to comment about that because and but this nomenclature thing, advanced chiropractic, well, we’ve got groups that are splintered off, best practice, wellness practice, advanced practice.  Fellows, I’m going steal a phrase from our present president.  Make chiropractic great again.  (loud clapping) If you are a doctor of chiropractic, you need to proud to be a doctor of chiropractic.  You need to be excited to be a doctor of chiropractic.  You need to be aware that with the great physician in heaven, you’re able to help people get well.  And it’s time that we quit worrying about trying to add to all of that.  Now, I’m not a straight chiropractor or I guess I’m a mixer, I don’t know.  I use some nutritional things and I use some modalities.  I even use an Anatomotor or a relaxing table, a chiroflex table for them to lay down on before I work on them.  And that doesn’t make me lesser than anybody in the room.  And it doesn’t increase my DC degree.  We’ve got problems in this state learning how to co-exist.  We’ve got a divided state just because of the cost of seminars.  We’ve got a divided state because the board won’t, this board of examiners fault on every turn, and tried to introduce legislation without working with us and we need to learn to co-exist.  I 100% agree that we need to co-exist.  Now, divided we fall, united we stand.  If you think that we can have divisive issues and stand as a profession, you’ve very delusional.  It is time that we learned to embrace our brothers no matter what their practice is, but try to encourage them to have confidence and pride in what they went to school to learn.  And I went to school to learn how to help sick people get well and hurting people feel better.  All right.  Now, my two questions.  I’m sorry for my rant, but.  My two questions.  I’m a rebel.  I knew Dr. Sprockley and Dr. Miller extremely well when I was at Palmer College because I was definitely a rebel and you can tell at these meetings I am a rebel, okay?  So I don’t mind asking questions, but what I don’t understand is why we as a profession don’t push more and this is my question to y’all, why do we not push more for multidisciplinary practices that learn to get along with the people who are in the healing arts professions that already do these things?  A second question would be are there any statistics of a percentage of patients that truly do not have a primary MD who can already handle these things?  That’s all I’ve got.

Ron:  Well, indeed.  I think what it’s important to interject here that a lot of the so-called advanced practice legislative proposals that are floated, you know, it’s just not so down and dirty, but that we want to expand chiropractic scope to include prescriptive rights.  What legislative proposals include is to change terminology and to change every reference to chiropractic in the state statute to one of chiropractic medicine.  And we have seen this in a number of states including New Mexico and the International Chiropractors Association does take exception to that because there is no such thing.  The practice of medicine is clearly defined in statute and education and licensing process.  There’s no educational institution in the world that offers a degree in chiropractic medicine.  And it’s inherently confusing to the public and in my opinion and in certain people’s intentions that’s inherently their intent is to somehow confuse the consumer, to confuse the public into believing that people hanging out a shingle are something that they’re actually not.  That’s very offensive to me, that crosses a medical line in my opinion.  And the moving forward and the understanding and the acceptance and the getting along and all that sort of thing can take place provided that the profession remains anchored and that behaviors remain responsible and ethical and in the public interest and there are incidences where those lines are blurry and oftentimes get crossed.  It’s a concern to me.

Steve:  I want to make sure I understand your questions, doctor. I think one of your questions had to do with we need to emphasize getting along with medical doctors, other professionals, and that’s an easy answer.  Of course, we should.  How we do that, I think that is done on an individual basis.  I also think that can be on a national basis.  There are those medical doctors who wish to cooperate with chiropractors.  We all have relationships with them and then there are some medical doctors who want to have nothing to do with us.  That’s an ongoing process, I think.  I’m not sure what your first question was about…(audience member:  the percentage of patients that do not already have a primary care physician that can do what you’re doing)…that’s right.  I don’t know what percentage, I don’t know what studies there are, but I do know that there is a problem with primary care physicians in this country, and of course like in New Mexico, we’re not primary care physicians, meaning we have full prescriptive authority.  But the issue is can a patient get a medication that someone says they need right away. Do they have to go the emergency room and clog the emergency rooms.  I’m talking about the 9 years of experience where it has been my pleasure to provide a simple medication and again I’m talking about very simple medications.  One may say that no medication is simple, but we’re talking about prescription strength NSAIDS, you can take Motrin or 4 ibuprofen, or you can take one Motrin, that kind of thing.  That’s the kind of thing I’m talking about.  To where to get that prescription for Motrin, they’re going to have to go to their primary and they may not be able to get it in that day.  I can provide it for them.  So that statistic of a shortage of primary care physicians, there are statistics like that, and in New Mexico, we are on the bottom rung, well, 3 above the bottom rung of the ladder for shortage of primary care physicians.  I hope that addresses your question somewhat.

Ron:  The process of delivery of healthcare in this country is about to undergo a seismic shift because of the age wave and the need to address the caring for the aging population of which I am one.  Senior citizen population is going to top out at 88 million old people on the downhill phase of their life, and course getting into that phase of life in this country where maximum utilization of healthcare services is going to take place.  And that’s gonna oblige us to totally change the way we do pretty much everything in this country because there aren’t enough nursing home beds.  Even if you opened up a thousand medium care beds a day for the next 10 years you’re not going to be able to have institutional care.  So the notions of how people are cared for and frankly what care is going to be available is going to be up for reconsideration.  But in terms of the accessibility of people in the United States to primary care coverage, whether you love it or hate it, the Affordable Care Act opened up coverage to care to another 30+ million people.  And so you have to look at it in two terms.  Number 1 is the work force sufficient to take care of everybody who need and want care.  The answer is it’s under pressure, cause we raided the third world.  We’ve collected close onto a million FMG’s, foreign medical grabs, come to the United States, you know, put them to work in addition to home grown, you know, medical professionals.  We’ve expanded the role of the physician’s assistant, we’ve expanded the role of the nurse practitioner, in part, in relation to the demands of the aging population.  But is there some huge shortage where people who have resources and desire can’t get a prescription.  Certainly not.  By no means.  There is no need to look at the chiropractic profession as some kind of fire brigade coming in to address some huge, urgent need.  Thank you.  That’s simply not the case.

[01:41:16] Audience question #7:  OK. Call it ( ).  I feel that everyday.  I am always in for the cause of whatever that person’s problem is….so that I can   ( ) not a cure, but a remedy for that person.  So they are coming to me for my expertise in that area.  They can go, we are underserving the population with that premise.  We are overserving the population with using drugs.  A lot of problems that I have seen in my office are from prescription drugs.  To be blurred into that identity by the public would be very detrimental to our profession as far as I’m concerned.  Right now, many people are turning their backs on the prescription medications because they are seeing detrimental effects not only for themselves but for multiple family members and they are looking for anybody that has an answer other than most prescription drugs.  I have, I know we are not doctors of osteopathy, but in history, if we do not learn from history, we are doomed to repeat it.  So I am looking at a profession that is separate and distinct and I am looking at one that is completely obliterated as far as any of their original philosophy and I have personal testimony to that, my husband’s brother is a DO.  Now, he didn’t want to be a DO. Didn’t even understand what a DO was, but he was born and raised at a time when it was not popular to go into medical school if you were a valedictorian, if you were a white male, so he was put down the list and he ended up having to go get his master’s degree and a long story, but anyway, so he was finally accepted, even as valedictorian, in a DO program and he accepted that because he wanted to be a doctor.  So he did that, and he is a very good doctor as doctor’s go that do the traditional kind of medicine.  But, um and he’s a wonderful man, really good heart, went to it for all the right reasons.  But he’s dying of cancer.  Doesn’t know how to help himself.  From a simple, supposed to be curable cancer [audience member:  what’s the question?]. I’m getting there.  So, if everything has a positive effect, right? why would we want to be part of something that causes more problems in the population right from where we are beginning to make a change in the paradigm?  We’re making a paradigm shift.  If we open that door a crack, you might be (  ) and do and have a really model practice with what you including in yours, but what will the next generation do with that?  And what will the next generation do with that?  There’s a logical progression to things, and just because we can, doesn’t mean that we should.  So how do you, once you’re gone, how do you control where that goes?  There is at least one profession right now that is ready to take off that natural mantle and run with it if we relinquish it.  So where is it going to go next generation and next generation?

Steve:  Yeah, I’ve kinda answered this question before.  I said it’s up to you.  The, I believe the confusing aspect of this is, when we look at drugs and we look and we make statements such as “drugs are bad”, etc. etc. and we look at the opiate epidemic and it’s terrible and we look at medical doctors and osteopaths whose primary mode of treatment is drugs.  And ours, of course, is not.  How do we reconcile that?  Well, the way we reconcile that is that we, if you choose to, become prescribers who only want to use certain drugs in certain ways.  We are not entering into the same territory as those who are overprescribing, who are prescribing opiates.  What’s to stop us from prescribing opiates?  You are.  I can’t overemphasize that.  You are.   I know that there is a point of view that says well, don’t even enter that world.  I’m saying that there are certain levels of prescriptive authority which are much safer than others.  And in New Mexico, as we expand, and you’re talking about the future, as we expand, we’re steering clear of the problematic opioids because we also agree that they are overprescribed, and we don’t want to enter into that world.  Where is it going to go into the next generation and the next generation?  It’s up to you and it’s up to those who take on that mantle. Again, I know, that it seems that it would be easier to just leave it alone.  But it’s not being left alone.  New Mexico is not the only state. Oklahoma has some prescriptive authority.  Idaho does.  This is an expansion of chiropractic and this is not a takeover of drugs into chiropractic.  So, your concerns are very valid, but it is up to us how we drive the profession.  For you, it may be don’t even enter that world.  But I have to say that there are others that want to enter that world very carefully, very judiciously.  And I think that the best answer to your question is how can we be responsible when we take this on.

Ron:  I think that the doctor summed up in a nutshell quite eloquently the situation and my personal advice and the position of our association is that the profession should not.  And the reasons behind that are clear and massively compelling.  Thank you.

[01:47:39] Audience question #8:  This will be a simple one.  You know, the practice of chiropractic is a science, an art, and a philosophy and when we first started talking about the differences in prescribing medicine and not prescribing medicine, I really wanted to be scientific if those that do further on.  I don’t think that chiropractic is going through an identify crisis, I think certain chiropractors are possibly can be going through an identity crisis.  But making chiropractic number one a science, I’m concerned that since you said doctors in New Mexico that there is no established training, you had to establish your training, therefore other states would have to establish their training, I would like you to elaborate and Ron can follow up with the CCE accreditation vs. sponsor.  Like chiropractic college sponsor seminars, but for it to be included in a chiropractic college which is not, it really concerns me for the simple reason of our patients.

Ron:  Well, you know, again, gold standard recognition of critical education is something that the public is entitled to and something that healthcare policy makers and legislators are pretty serious about, thank goodness.  Thank heavens.  The Council on Chiropractic Education standards (that) will go into effect in January, 2018 make reference to a course in toxicology.  And it does make a great deal of sense for DC’s to have some understanding of the kinds of situations that patients that may come in like the doctor that spoke before you about patients coming in, many of whom have problems that stem from their use of prescription drugs.  But there’s a difference between understanding being able to recognize and consult with issues related to drug use, prescription and non-prescription drug use.  And maybe it will lead to somehow hold yourself out to the public as being qualified to the gold standard and that’s a grave concern.  But, you know, I’ve worked for the ICA for 35 years, and what impressed me more than anything else when I first came to work for the association was that, in every discussion at the governance level, and I’ve never seen this before, in every discussion on issues of policy or legislation or business, the discussion very quickly centered on what was the right thing to do, what was the right thing to do, and I must say that that has historically and consistently been the basis on which decision making and use by my employers has been based.  And I think what has been said indeed it is up to you.  And from my perspective as a patient, as a parent, as your employee, and as has been echoed in the official policies of our association, to maintain chiropractic as a drugless science is the right thing to do.  It just boils down to that.

Steve:  I mentioned before that one of my titles is President of the Academy of Advanced Practice Chiropractic Medicine, an advocacy group, a clearinghouse for the advanced practice issue.  What I didn’t mention is that AAPCM is an affiliate of the Association of Health Sciences Colleges and Universities, AHSCU, it’s called.  AHSCU.  And that is a group comprised of several chiropractic colleges whose mission is to create educational programs, and these of course are all CCE accredited schools, to create educational programs not just for advanced practice, but to create educational programs in association with other disciplines, medical, osteopathic, acupuncture, to elevate the standard of education of chiropractic and associated programs as they join together with other institutions.  So we’re an affiliate of them and our focus is advanced practice.  So your concern about education.  There are no courses nor will there ever be any courses of any, whatever you call it, advanced practice or not, that do not go through our schools, our accredited schools.  And that’s good news because, in one sense, it stays within our profession.  You know, there are some chiropractors in New Mexico who wanted to be primary care providers, and they went on and became nurses and nurse practitioners.  They wanted it that badly.  And I think that we can do it within our profession and I think that one of the musts is that we work through our schools so it stays within our profession.  So I hope that helps answer your question that this is founded in CCE accredited schools and the programs that come from them.  So any kind of advanced practice program that may be developed is coming through the same schools that create the educational programs for basic chiropractic.

[01:53:57]

Education

Multiple pathways through CCE accredited institutions for advanced scope of practice.

Legislation

Modeling of legislative initiatives for expansion of chiropractic licensure.

Participation

Intra and interprofessional collaborative efforts yielding extraordinary results.

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