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Dynamic Chiropractic Canada – November 1, 2008, Vol. 01, Issue 02
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Chiropractic Collaboration and the Doctor Shortage

By David J. Brunarski, DC, MSc, FCCS(C)

What is your position in the Canadian health care system as a doctor of chiropractic? For some Canadians, you are the primary care provider. For others, you seem not to exist. The Canadian health care system is undergoing a significant shift that can open new doors for chiropractic care and narrow this gap.

According to Statistics Canada, nearly 5 million Canadians (15 percent) do not have a family physician. More than 26 million Canadians (79 percent) do not have a chiropractor. This poses a profound problem for governments working to control rising health care costs. After all, the population is aging, and along with this demographic shift comes a precipitous rise in chronic degenerative disease affecting mobility and the activities of daily living.

It is clear that chiropractic has a role to play in the changing environment and represents a valuable health care resource. While 73 percent of Canadians admit to using alternative health care providers, these patients are increasingly turning to massage therapy, physiotherapy, traditional Chinese medicine, naturopathy, osteopathy, homeopathy, nutratherapeutics and other modalities instead of chiropractic. In fact, chiropractic utilization ranges in Canada from a low of 6 percent to a high of 25. Findings from the 2002-2003 Joint Canada/United States Survey of Health reported that the average utilization rate  is only 12 percent.

 - Copyright – Stock Photo / Register Mark Doctors of chiropractic are primary contact health care providers with the knowledge and training to communicate a diagnosis and deliver safe and effective treatment programs. There is an ever-expanding database of powerful clinical evidence for therapeutic benefit from chiropractic treatment of neuromusculoskeletal conditions, particularly of the low back. So, in a climate of increasing demand for health care delivery and disability prevention, why is chiropractic so underutilized?

Chiropractic care is traditionally delivered as an additional (complementary, supplemental, supportive) form of care rather than for primary intervention. The reason medical physicians most often cite for not referring patients for chiropractic care is a genuine lack of understanding of what chiropractors can and cannot treat. Those physicians who do refer to chiropractors admit to having a pre-existing social relationship with a specific chiropractor they know well and trust.

Integrating chiropractic into collaborative multidisciplinary health care models, such as Family Health Teams (FHTs) and Community Care Centres, can do a great deal to increase chiropractic's utilization rate and improve patient care. Chiropractors know this. Surveys of Canadian chiropractors reveal that more than 90 percent think chiropractic should be more fully integrated into the health care system because it would benefit patients. There is widespread support for this by stakeholders, third-party payers and patient advocacy groups.

Consider, for instance, that nearly 60 percent of hospital admissions in Canada are from the emergency department. The Canadian Institute for Health Information (CIHI) reports that 90 percent of those who do require admission to a hospital bed must wait 17 hours on average. Fully two-thirds of those who are seen in emergency are in the less-urgent and non-urgent categories, which means they do not require hospital admission and could have been attended to by a primary care physician (including a chiropractor), if either were readily available.

Consider, too, that wait times are measured from the time of referral to a specialist. This may delay appropriate treatment by weeks or months if a medical physician must make the referral. Here again, doctors of chiropractic are well-trained to make and communicate a diagnosis. If collaboration were improved between health disciplines, electronic records were shared and funding were provided to encourage collaboration with chiropractors, the wait-time gap could be compressed.

Evidence from prospective population research suggest that Canadians would benefit the most through health promotion, preventative strategies and mechanisms to improve timely access to treatment while new health concerns are still in the earliest stages. Health care professionals in rural and urban communities are encouraged by government bodies, health care managers, patient advocates and others to participate in collaborative multidisciplinary and interdisciplinary models of care to better deal with complex cases and chronic disease. There would seem to be great opportunity for doctors of chiropractic to contribute their skill to the team approach.

The multidisciplinary team conforms best to the chiropractic model of care and is already in place and working quite well in a small number of communities across Canada. A multidisciplinary team is generally structured to work on a common problem, such as low back strain, headache, whiplash, etc., but is autonomous in that providers retain discipline-specific control over decision-making and treatment delivery. Patient information is shared and referrals flow back and forth between health care professionals. However, team members are not required to share the same location, there is no common electronic record, and payment for service is often structured differently between providers. Other limitations of the multidisciplinary team are the absence of regular contact with other team members and the initial resistance or ignorance on the part of all health care professionals and health insurance payers to become educated on the role and responsibilities of other providers with special skills and services that would benefit the patient, improve outcomes and hasten the application of the most appropriate treatment in a timely fashion.

Interdisciplinary teams are a step up in complexity in that members of the team actually work together and share some roles and responsibilities. Clinical decision-making is evidence-based and establishes predictable outcomes according to an algorithm, so that treatment goals are predetermined and can overlap multiple disciplines. Collaborative models of care transcend and even transgress the old-school hierarchy of protected treatment domains. Specialists learn to relinquish absolute control over decision-making and are willing to train team members in specialized tasks to expand other team members' capabilities and follow best practices. Imagine the value chiropractic could bring to such a model.

According to a Conference Board of Canada forecast for 2008, Canada ranked in the bottom half of 17 countries with comparable standards of living when comparing six assessment categories. Health performance in Canada ranked 9th. Our high mortality rates from heart disease and diabetes are accompanied by an alarmingly increased incidence of childhood obesity and diabetes. It is a sad commentary on the future when the youngest generation is predicted to have worse health outcomes than their parents and grandparents. The national consciousness may be focusing on methods of greening the planet and preserving it for our children and grandchildren, but they may not live long enough to enjoy it.  According to the September 2008 issue of the Canadian Medical Association Journal,  unhealthy Canadians consume 10.3 percent of Canada's gross domestic product, with health care expenditures averaging about $150 billion annually. Prescription drugs, long-term care and visits to emergency departments account for a large proportion of added expense. The Canadian health care system has systematic problems and the time is ripe for change.

The inclusion of chiropractors in a collaborative model of health care delivery in Canada would allow patients to continue to access their practitioner of choice, but to have that coordinated with their family medical doctor and other care providers. Chiropractic collaboration would relieve family physicians and emergency departments of the burden of diagnosis and care of conditions for which chiropractic has demonstrated expertise and established evidence for beneficial outcomes. This would enable provincial governments to provide all Canadians with more power and choice within the system to reduce barriers, improve timely access to care by the most appropriate health care provider, and thereby improve outcomes in the continuum of care.


Dr. David Brunarski, former associate editor of DC Canada, graduated from CMCC in 1977 after completing his undergraduate educa-tion at the University of Alberta. He is president of the Ontario Chiropractic Association and practices full time in Simcoe, Ontario. To learn more, visit www.dynamicchiropractic.ca/drbrunarski.

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