A Chiropractic Perspective

I have not chimed in very often to this website, but John knows me rather well from our interactions at the University of Pittsburgh (PITT) where I am completing my PhD in rehabilitation science. When I read that bizarre "article" (or whatever one might call that futuristic rambling) about the future where only one DC is left standing, I felt that I needed to give a lengthy commentary on what I feel is the likely future for both DPTs and DCs. Tony Delitto and I have often discussed the future possibilities for the chiropractic and physical therapy professions, and have come to similar conclusions about what the future holds for our respective professions. But first a little bit of background information.....

I believe that chiropractic is in the midst of a downward spiral due to a failure to establish any unified professional identity. There are four basic subdivisions of the chiropractic profession (1) musculoskeletal specialists who are only interested in treating the spine and extremities (2) "holistic" or "functional medicine" specialists who like to treat functional internal disorders with nutrition, dietary interventions, homeopathy, etc. (3) DCs who consider themselves to be "alternate primary care physicians" and (4) the "subluxation" based DCS who promote spinal manipulation as the panacea for all mankind's illnesses. There are no hard data on what percentages of DCs fall into these 4 categories, but my main point will be focused on TYPE 1...i.e. the musculoskeletal specialist....while at the same time recognizing that the other 3 types are constantly fighting each other as to what the "real message" of chiropractic should be, ad nauseum.

The DC who practices as a musculoskeletal (MSK) specialist is typically one who has embraced the principles of evidence based care, has learned active care techniques such as spinal stabilization exercises and other rehab protocols, knows several "PT techniques" such as the protocols promoted by McKenzie, Mulligan, Butler, Maitland, Cyriax, and others. This DC practices a combination of manual methods, teaches his/her patients how to care for themselves at home, and does not promote chiropractic as a panacea for all illness. S/he has a very fine understanding of musculoskeletal diagnosis and conservative treatments, as well as a good sense of when other medical interventions are required, such as injections and surgery. His/her diagnostic skills are the envy of most medical physicians, who are extremely unqualified to perform musculoskeletal diagnosis that requires mechanical reasoning and provocative physical examination procedures that logically deduce which tissues are the pain generators.

This sounds a lot like a description of the current DPT graduates that I have encountered. And therein lies my point....I believe that we will see a certain segment of the chiropractic profession gravitate toward the version of clinical practice that looks very much like the practice of physical therapy. And we have already seen the PT profession gravitate toward improving its manual skills, especially thrust manipulation (oh, I meant to say Grade V mobilization) and integrating those skills along with traditional rehab and active care protocols. So the chiropractic and physical therapy professions are on a collision course wherein MSK based DCs are not content with manipulation only and are embracing rehab priniciples, whilst MSK based DPTs are not content with rehab and exercises only and are embracing more manipulation and manual therapy principles.

In the past, some people like Dick Erhard who were excellent clinicians and superb at differential MSK diagnosis became frustrated as PTs, and obtained a DC degree in order to become a "physician" and break free from the MD referral nonsense. Now with the DPT program and direct access, the need for PTs to obtain DC degrees is going away. Instead, the reverse situation has started to surface...i.e. some DCs who are gravitating in this MSK specialist direction are interested in obtaining a DPT degree, to complete their understanding of all aspects of rehabilitative care and to potentially practice under a different license/profession. They are becoming disenchanted with all of the nonsense espoused by the "subluxation removing" DCs who claim to treat all sorts of non MSK conditions. They are ready for a split from the remainder of their colleagues who can not seem to make any stand on who they are and what they do. And sliding over to the PT profession may become a future trend for a select group of DCs.

The DC who now obtains a DPT degree is no longer "stepping down" from "doctor" status to "therapist" status. It can be considered a lateral move. Tony Delitto and I have met with a few DCs in the Pittsburgh area who are planning to apply to the DPT program at PITT, in order to make this very lateral move a reality. I believe this could be the beginning of a long term trend, if those MSK specialist DCs can not find any voice of reason within the American Chiropractic Association or other national organizations. I am committed to stimulating more like minded DCs to consider enrolling in DPT programs, and would like to see other institutions besides PITT offer such programs to DCs. Of course, many of you know that Stanley Paris was the first person to make a DPT program available to DCs in a mostly online format. I have met with Stanley and found that he too senses a great potential demand in the future by DCs to take DPT programs, which explains his rationale for taking the risk of an outcry from his own profession to make this bold move.

It is my personal opinion that the chiropractic MSK specialists and PT profession have so much in common, that the synergistic relationship of having them blend together into some new type of hybrid clinician that possesses the best of both worlds would be an awesome combination. This is likely to happen, if a substantial subset of MSK specialist DCs decide to bail out of the chiropractic profession, and make a lateral move over into the PT profession. I  have stated publically at chiropractic meetings and conventions that it is wrong for the chiropractic associations to be suing PTs over the right to perform spinal manipulation. I think this only serves to divide our professions further, and must make a lot of AMA delegates quite pleased when our two professions waste precious economic resources on legal fees, fighting each other instead of them. We should be pooling resources to improve NIH funding for MSK conditions that are treated by both of us, and fostering more evidence through clinical research...for the ultimate benefit of the patients we treat...and not to protect professional economic territories.

So now we come full circle...back to the futuristic article that started this discussion. That DC's opinion piece represents (in a distorted way of thinking) the opinion of a large segment of the chirorpractic profession which feels threatened by the emerging DPTs who they feel will "take away manipulation". Hence the legal battles to save manipulation as the exclusive domain of chiropractic. Without exclusive rights to the one thing that defines the chiropractic profession, DCs feel they will become irrelevant and expendable. And you know what...this is probably correct! What future thinking DCs envision is a day where DPTs who are skilled at manipulation will become the one-stop shopping center for patients with spine pain. DPTs have full integration within the medical community, and the chief reason for chiropractic's survival over the years has been the fact that we were the only ones performing manipulation....no one else really cared to provide this service, and when nothing else worked....manipulation often gave dramatic results.

But that all can change when DPTs are able to see patients without medical referral, provide manipulation as well as rehab exercises, and insurance starts to reimburse them via direct access. The corrollary fear is that insurance companies will some day see PT and DC services as mutually exclusive or redundant, and because there are twice as many PTs as DCs, we will loose the battle due to a shear numbers game. So all of these fears are wrapped into one bizarre story by a DC who is probably trying to scare his colleagues into taking some sort of action. Some DCs will take action by contributing money to lawsuits that attempt to block PTs from manipulating the spine, and others like me will take action by trying to stimulate DCs to get a DPT degree and practice as a MSK specialist. I hope that this information is useful for stimulating some further debate and discussion about the respective futures of our professions.

Mike Schneider, DC, PhD (c.)

Comments

[Jeff Hebert]

Mike,

I was happy to see your post here and believe that you have summed up the situation quite well. Our profession will either be forced to change, assimilate or be overrun. I wish you all the best in your endeavors at PITT.

Jeff

[Britt Smith]

Mike,
Excellent summary of the the chiropractic (and DPT) situation. Interesting development. Some of my friends in manual therapy became DCs in the 1980's for 2 reasons: 1. get out from under referrals and 2. learn more manipulation than was being taught in CEU courses. They are excellent practitioners functioning as what you have called 'MSK specialists'. I remember discussing with Dennis Morgan PT,DC in the late 1980's the possibility of a convergence of the professions. I don't recall the details of the conversation, but the direct access issue was a giant barrier for PTs, in Dennis' opinion.
Thank you for the clarity of commentary.
Britt

[Dave Morrisette, PT, PhD, OCS, ATC, FAAOMPT]

Do any of the "elderly"PT's who read this blog remember the arthropractic movement that was so diligently promoted by David Lamb in the 80's? At the time, a group of PTs and chiropractors were working together to start a "new profession" that would combine the best of both worlds. The current discussion sounds very much like David's vision. I believe David would have agreed with Dr.Schneider's comments and would have promoted the collaboration in training / education between these groups of musculoskeletal specialists.

I am not sure why anyone would object to a chiropractor becoming a PT. I am more concerned with what I perceive as what the majority of PTs are not doing.

Dave Morrisette

[Peter Huijbregts]

Hi Mike,

Like you, I have been thinking a lot about the current interaction and future relationship between chiropractic and PT. I have read an abundance of chiropractic texts and have become quite familiar with the history and theories of the profession, all as part of me teaching an online course (yes, in Stanley Paris' program) that includes a section on the history of manual medicine. You may have read my musings on this in the form of an editorial on the chiropractic subluxation and its relevance to manual medicine at large (available full-text at http://jmmtonline.com/past/vol13no3.php)...

As the editor of an evidence-based manual medicine journal that caters to all professionals active in this area, I am very interested in getting a dialogue going between the two professions. So my question is, would you be interested in writing an opinion piece on this topic? I am sure it will stimulate some discussion...

Regards,

Peter

[Scott Newton, PT, DPT, OCS, CWS]

Mike, Thanks for the insight into the DC profession. Any suggestions for dealing wtih the fears you mention in the last paragraph? Last legislative session we attempted to remove many of the restriction to our state's direct access bill. The ortho's, and the medical association agreed to the changes but the DC's were opposed because of the "safety of the patients" PT's can not perform "X-Rays" thus we might miss a DX. The bill had safeguards for patients that were not improving that the majority of the medical profession felt comfortable with(along with explaining the extent of PT's current training). The DC association did not wish to discuss the bill with us until the morning of a committee vote at which time they offered to remove their opposition in return for changes to the defination of manipulation in our bill. In the end the bill was pulled. As it stands we will prove your comments correct--both sides will spend a lot of money. Any suggestions or insight would be greatly welcomed.
Scott

[Mark Boncser]

I appreciate Mr.Schneider's comments and his openness to this discussion. I honestly would be worried about being associated in any form with the chiropractic profession at this time. I believe that there is a public perception that the majority of chiropractors are "quacks". I have worked hard to maintain a personal and professional reputation of integretity and I believe as a whole our profession has as well. I don't want to be anywhere near something that would taint my profession. At this point and time I believe the chiropractic profession needs to address the issues that cause the some of the public to believe they are quacks. Then and only then do I believe the PT profession can risk be associated in some way.

[Chris Baker]

Well said Dr. Schneider. I could not agree with you more. Here I am, in my last clinical prior to graduation with MSPT, and am excited about what the near future holds for me. DPT next I presume.

I have practiced for almost 16 years as a DC, and have practiced from a evidence-based position. Unfortunately, not much evidence has been promoted via Chiropractic which has been disheartening over the years. Yet, in spite of low evidence, my manual-based chiropractic practice has done very well, seeing patients an average of 3 visits per incident. We all know the manip works, and recently the evidence supports its use in specific situations.

I see the movement exactly as you have described, those evidence-based chiros moving towards DPT and manual-oriented PTs moving towards a "chiro"-based approach ("chiro" meaning "hand-on manual.") Having a research background, I am impresed with the quality and evidence associated with the teaching of manual techniques within the PT profession right now.

Now, a very interesting thing happened yesterday in the clinic where I am completing my final clinical. A patient shared some of her concerns with me regarding her care. Keep in mind, she does not know that I am a practicing DC completing my 3rd clinical.

She (call her name "Mary" thought she needed to see a chiropractor for additional care. I asked her why, and she explained that she thought a chiro could help improve her symptoms better(history of MVA with multiple site spinal strain, general deconditioned, depressed). She admitted that she was improving since injury, ie increasing her cardio with aquatics, active rehab, and manips. However, her concern was whether it was legal or not for "us" (referring to clinic DPT's and me as an intern) to manipulate. She said it scared her becasue chiro's were trained to manip, not PT's. "Mary" and I further discussed what could a chiro do that was different than our clinic, and her response was that she thought she would be safer with a chiro manip and maybe get better faster.

After further discussions Mary stated that "you guys" probably do not get along with chiro's. I felt it time to "spill the beans" and share with "Mary" that I was a practicing Chiro since 1991, and that frankly, I do not see any difference in one manipulation from another referencing practitioner type. I explained to her that the goal of the manip is to restore the dysfunctional movement patterns, and that the techniques used by our DPT's or my DC were very similar if not the same. In fact, due to my involvement in teaching with Texas State University, I can vouch that the methods taught to the students are very sound and same as those taught to me as a DC.

Funny how her attitude changed and she could not wait to tell all her friends that this clinic utilized both Chiro and DPT in the treatment approach to MSK disorders. Interesting patient perception and importance to educate our patients regarding the manual treatment approach.

In summary, Dr. Schneider, good comments. Our profession in in for some serious changes, and those not evidence-based may have some difficult times ahead supporting why they need to treat the subluxation or other "mankind illnesses" in their practice.

More later, as my CI is in looking for me :).

Christopher Baker, MS, DC, DACBN, CCN, SPT

[Cameron MacDonald]

Mike & All,

This is certainly an interesting discussion. The 'trend' of DC's enrolling in DPT programs has been noted by others, and also by myself. I personally see this as the MSK DC's attempting to be able to redefine themselves as evidence-based, and more mainstream than the stand-points taken by many of their colleagues who would fall into groups 2-4 that Mike listed.

As it takes a lot of personal effort, expense and time for a DC to complete a DPT program, these practitioners appear to be putting considerable effort into expanding their education and changing their status. I give these DC's a lot of credit, but what is driving this change??

I feel we all have some ideas as to this: professional disatisfaction, a desire to be able to base practice on research not simply what they were instructed in school, a resentment to the negative asscoiations of quackery which is sometimes associated with the chiropractic profession or other reasons which escape me.

I personally do not wish to see the DC and PT professions form an alliance. I would prefer the DC's who wish to be recognised as MSK specialists to go the DPT path. As EBP DPT's develop entry-level skills which embrace the utilization of manual PT skills as needed, in combination with good differential diagnostic skills, is another type of MSK provider needed?

The growth of the PT profession through the DPT, the work of AAOMPT, residencies and fellowships in orthopedic/manual PT will generate a direct access provider that encompasses all of the needs of a patient with MSK dysfunction, including referral for non-mechanical presentations. I suspect many in the DC professions see the extensive overlap, and are looking to protect a niche in this market in holding onto manipulation.

The kicker in all this is that the research generally does not support manipulation in islolation (unless you want a life long patient........), manual PT based patient managemnt requires in-depth MSK evaluation, differential diagnosis, an exercise intervention program (nearly always), and a path to patient independence. This is the outpatient OMPT at work. For those who wish to own manipulation in isolation, and provide only manipulation, isolation from clients may be what you get.

It is possible that the growth of the DPT will be a catalyst for change in the DC profession, and it probably already is, but this is not likely to be a major change. I feel that there are to many deeply entrenched beliefs which will not change. I still have many clients who present receiving ongoing subluxative intervetnions, and it is difficult to see any real positive client management occuring in a lot of these individuals. I do also see clients who I feel have received very good prior care with a DC, but the care given certainly sounds like OMPT to me; including all the billing.

We shall see what the future doth bring.
Cameron

[Jon Newman]

The MSK specialist is being bandied about lately on a number of discussion forums. I was originally attracted to PT "to help people". My education made it more clear as time went on that I was trying to decrease disability and improve QOL. To my mind an MSK specialist is too specialized for that purpose. Actually MSK specialists already exist in my opinion--orthopedic surgeons and rheumatologists.

What we have a dearth of are pain specialists. Especially those describing and prescribing science anchored non-pharmalogical approaches to pain relief. I think this is ironic since it is the primary presenting complaint as well as a significant player in disability.

I don't see how a marriage of PT and DC is going to change things much as far as that is concerned as they are largely redundant, especially as it pertains to relevant MSK knowledge. The diversity of opinion on this topic leads me to believe that such a move would have to be an arranged marriage with the wishful thought for something wonderful in the future.

People will profession hop as they feel they must and for their own unique reasons. I'll try my best to make this the profession to hop to and not from.

[Leigh Langerwerf]

Dr. Schneider,
Your response to the article was phenomenal. I didn't know that there was such a lack of unity in the chiropractic community. Additionally, it was very interesting to hear your prospective on the two professions going on more similar paths. We shouldn't be at odds with the MSK DC's, we should be working together, as you seem to suggest. I actually was talking with a DC the other night at my fantasy football draft and when I told him I was a PT, he kind of gave me a weird look. I told him that I wasn't a chiropractor hating PT, on the contrary, I think that they do a lot of good. Anyway, glad to have read your post and really looking forward to sharing ideas with you and your colleagues in the future.

Sincerely,
Leigh Langerwerf, DPT

[CHris Baker]

I do not think the two professions of DC and PT will merge. Having studied both professions, I think the health models are different.

Chiro is more patho-anatomically based, ie disease, subluxation, diagnostic whereas PT is functionally oriented. These are two different paradigms. As DPT approaches direct access, I do think that it is important to diagnose and differential diagnose which certainly includes blood work, imaging, etc. Of course I am influenced by prior training as a diagnostic doctor. I have experienced multiple occassions where I have received a referral of back pain, and thankfully my ability to refer for advanced imaging, proper bloodwork enabled me to properly diagnose cancer, missed fracture, etc.

I digress though. It is challenging to be working with a patient on my clinical and know that there are some unanswered questions which I could resolve with a proper diagnostic work-up, however hands tied as a PT. Yet if my goals are to restore functional use, I really do not concentrate on the pathology, as my goal is to restore functional use and meet the patient's goals regardless of the patho-anatomical diagnosis.

Said another way, as a chiropractor, I diagnose and "fix" the patho-anatomical problem with the manipulation. Unfortunately, with the absence of traditional rehab and active patient participation, the patient will most likely be manipulated over and over due to lack of stability or lack of addressing the deficits of the other bodily systems. As a manually oriented DPT, you would still address the structural (joint) dysfunction (probably resolved within 2-3 visits) yet address the functional deficits as well, ie stabes, conditioning, HEP, independence. I think chiro in general tends to promote patient dependence where-as the DPT approach promotes patient independence.

My reason to incorporate PT into my DC practice is simple. The only profession to offer manual approaches in the 1980's was chiro. It was the alternative non-surgical approach to correct dysfunctional problems. Functional rehab was not a part of the education. I have practiced EBP, though not to the detail as taught in EBP DPT programs. I personally really like the evidence, and have really had my eyes opened to true EBP model with this MSPT education.

Summary, PT is different than chiro and I think will remain so because the emphasis on the educational model is different -- patho-anatomical on the one hand and functional model on the other.

My thoughts, would love to hear others. Great post.

Chris

[Louie Puentedura]

Chris:
I was more than a little perturbed to read that you considered yourself to be a "diagnostic doctor" presumably courtesy of your prior training as a DC. You went on to say that you had had "multiple occassions where I have received a referral of back pain, and thankfully my ability to refer for advanced imaging, proper bloodwork enabled me to properly diagnose cancer, missed fracture, etc."
Now, as a student completing your MSPT you mention that there are times where you feel a "proper diagnostic workup" would resolve some unanswered questions but you feel your "hands are tied" as a PT.
Here's my question to you. When you graduate with your MSPT and then, presumably go on to get your DPT, will you support the idea of DPT's being able to order some of these extra diagnostic work-ups or should that be a special perk only available to dual degree (DC/DPT) MSK specialists?

[Michael Schneider]

Louie,

You bring up a very interesting point about a major difference between chiros and DPTs...at least at the present time.

DCs have extensive differential diagnosis coursework in chiro college, including lots of skeletal radiology. This comes from a history of being required to be portal of entry providers, in which we would see patients right off the street without the luxury of having them pre-screened for red flags by a medical physician.

The history of PT has followed a different path. PTs have always been part of the mainstream medical system, and traditionally have required referral from MDs who supposedly pre-screened patients and found they had a MSK lesion requiring PT services.

Now the emerging DPT program may change the old ways of doing business in PT. With direct access will come new the responsibilities of more serious differential diagnosis, referrals to other specialists, and referrals for diagnostic imaging and lab work.

From what I see in the present DPT curricula that I have reviewed, there is not an intensive array of such diagnostic coursework. Are there plans to incorporate more differential diagnosis into the DPT curriculum of most PT schools?

Mike Schneider, DC, PhD (c.)

[Louie Puentedura]

Michael:
Thanks for your post. From a personal experience as an Australian trained PT, where we are portal of entry providers and do see patients off the street, I can fully appreciate the need for differential diagnostic abilities. I certainly felt well prepared to handle those situations when I practiced there for 15 years as a direct access provider for musculoskeletal disorders.
I recently completed a Post Professional DPT program and, yes, there was a significant component of differential diagnosis for physical therapy. I believe that all Post Professional or Transitional DPT programs have that as a requisite component.
I am also a clinical instructor for several of the DPT schools in AZ, NV and CA, and from what I see from the students I have had, they are getting some very good differential diagnosis skills to use as PTs. The greatest emphasis really is to be alert for those red flags that could signal more serious medical pathologies and referring them back to their physician (MD/ DO), but what I am wondering is what EIM bloggers think about us (PTs) being able to order diagnostic tests. I'm not talking about blood work or other medical tests, but simple plain films, diagnostic ultrasounds and maybe CT/ MRI scanning as a prelude to working in a collegial manner with our patient's physician or surgeon.
And of course, the other question that I'd like us to discuss/ debate is whether a dual professional DC/DPT should have any significant right to feel better qualified to differentially diagnose musculoskeletal disorders than the DPT.

[David Browder]

I think differential diagnosis is a bit of a misnomer here. In the case of pathology that mimics musculoskeletal complaints my experience has been that both DCs and PTs in direct access roles (such as the Military) do not differentially diagnose outside the neuromusculoskeletal arena. If a DC suspects a non musculoskeletal lesion do they take the steps to diagnose the lesion? I think in most cases they (should) refer back to a physician. What direct access physical therapists must be able to do is recognize red flags and be able to recognize when a condition is not consistent with a musculoskeletal condition. In addition to this PTs must be able to recognize when consultation or referral to another provider (or back to referring physician) is indicated.

As far as concerns of delayed diagnosis due to patients seeing therapists as a portal of entry- most clinical practice guidelines for physicians do not recommend radiographs/ESR labs until 30 days from initial evaluation.
Most practice acts also still require a patient to see a physician if they fail to improve.
In LBP, for example, failure to improve with conservative care (LR=3) (in this case physician care (nada) but no reason it could not apply to physical therapy intervention) was shown by Deyo and Diehl (J of Gen Int Med, 1998) to be more discriminatory than any finding other than previous history of cancer (LR=14.7). I think the idea that an active cancer screening process is missed if the patient does not see their physician with acute LBP is probably not reflective of reality.
The previous post included this sentence "With direct access will come new the responsibilities of more serious differential diagnosis, referrals to other specialists, and referrals for diagnostic imaging and lab work." I disagree- Screening for conditions not appropriate for physical therapy treatment is already an integral part of practice. Musculoskeletal differential diagnosis/classification is an everyday part of practice for the orthopedic physical therapist. Differentially diagnosing (as opposed to screening for) conditions outside our scope of practice is umm, outside our scope of practice - and direct access does not need to change that.

Several other comments have been made in this discussion about the model of PT health care being different (non patho-anatomically based?) than chiropractic and another about we need to be pain management specialists because the orthopedic surgeons and rheumatologists are already musculoskeletal specialists? I take exception to the parts of that I could understand. Physical therapists have an integral part to play: WE are the experts in non-surgical management of musculoskeletal conditions. We have the appropriate knowledge base (Childs et al. BMC Musculoskeletal Disorders, 2005) and Military PTs have been seeing patients in direct access roles since the 1970s without problems. EVS.

[Ben Hando]

I've been following this post with some interest and have been disappointed to see the chiropractic input mischaracterize PT's skill-set and scope of practice.

Here is a quote from Chris that I think needs vetting:

"Chiro is more patho-anatomically based, ie disease, subluxation, diagnostic whereas PT is functionally oriented".

My experience with Chiro is that they indeed do use a patho-anatomic model. Unfortunately, when this model has been subjected to the rigors of scientific inquiry, it has been shown to be an unreliable, invalid, and an overall ineffective paradigm for evaluating msk diseases.

PT's certainly evaluate a patient's functional status in their evaluation, as well as address patient's functional limitations in their plans of care. But this doesn't mean we neglect other areas of the evaluation that would lead us to an accurate diagnosis. To the contrary, investigating the functional aspect of a patient's presentation can provide valuable insight into a diagnosis.

Here's another of Chris's comments that I took issue with:

"Said another way, as a chiropractor, I diagnose and "fix" the patho-anatomical problem with the manipulation".

After studying manipulation for years and years; the scientific and healthcare community is not any closer to understanding the underlying mechanism of manipulation and why it "works". Said another way: if you're under the impression that you're diagnosing and "fixing" a patho-anatomical problem with your manipulation, you are simply mistaken.

Here's one from Mike that I wanted to comment on:

"DCs have extensive differential diagnosis coursework in chiro college, including lots of skeletal radiology".

I didn't go to Chiropractic school, but I have worked fairly closely with more than one chiropractor. So I can only comment on the ones I've worked with, but my impression is that their idea of "diagnosis" is often a pathoanatomic description i.e. a subluxed segment. This extends to radiology, where patients are told over and over again that their spine is "out of alignment". This again, is an inaccurate statement for many reasons that have been well covered on this blog.

I'd like to address more of the comments from our chiro friends, but I'll stop for now.

I'd also like to point out that PT's have been seeing patients w/out physician referral for years, with great success. As a physical therapist in the military, I see a bulk of my patients without physician referral. I certainly feel my education prepared me well to do this. I do utilize my imaging privileges on occasion to rule in or rule out a diagnosis, but I would refer readers to the recent Deyle editorial in JOSPT to address Chris's comments about "diagnosing cancer".

One last point. There is emerging evidence in peer reviewed medical literature that physical therapists possess a better musculoskeletal knowledge base than our colleagues in medicine (with the exception of Orthopedic surgeons). There's also evidence that our ability to order accurate and appropriate imaging studies is second to none in the healthcare community. To my knowledge, Chiro's have not subjected their musculoskeletal competency to scientific scrutiny. Maybe the chiro comments on this post would hold more sway if they had.

Ben

[Chris Baker, MS, DC, DACBN, SPT]

Sorry I have been away from this post recently to miss some of the exciting posts made. For clarity, I think that some of my comments are misinterpreted. Recognize that I am a DC who has practiced 15 years MOVING in the direction of a DPT - My comments are intended to be constructive, not devicive. My comments, firstly, are about our two professions in general.

I do think that those of us who read and post here are like minded in that we have some concerns with how and where our professions are sometimes headed, ie chiro being less "competent to scientific scrutiny" as Ben has said.

Louie, who is a "little perturbed" at the "diagnostic doctor" comment. My intent is to state that my DC training prepared me to be a patho-anatomical diagnostician, rather than a functional provider as in PT. Having completed both training paradigms, I can assure you that DC is more diagnostic oriented, and PT more functional treatment oriented. There is some differential diagnosis emphasized to enable the PT to "recognize red flags" as David says.

David, I DO agree with you that as PT, "WE are the experts in non-surgical management of musculoskeletal conditions." I DISAGREE with you in that a DPT merely "recognize"; you SHOULD be "differentially diagnosing outside the neuromusculoskeletal arena" if you are portal of entry and have direct access. Once you diagnose the problem, THEN refer to proper clinician. I feel the DPT will be more than adequate to diagnose, rather than "recognize" that a red flag is present and thus a need to refer. I prefer the route of diagnosing the problem and making the responsible correct referral to our peers who more correctly treat the problem.

My intent is to state that although DC's (I can speak for myself) diagnose, PT's (contrast to DPT) "recognize" red flags. My feeling is that the DPT WILL bring this together to differential diagnose and treat whether manips or functionally which is why the DPT will have such an advantage. I can see that with the development of the DPT programs, the importance of diff diagnose is being emphasized as well as radiology.

Yes, Louie, the DPT should be able to have all the access a DC does (probably more due to the extensive acute care training) to imaging, portal of entry, etc. This is what I am trying to portray and why I support the move to DPT. I sense that some of the comments posted take issue with the comments I have made by misinterpreting them as I may be suggesting DC to be better clinically than a PT. Quite the contrary. MOST DC's are better diagnosticians than BsPT or MSPT's. I do not think that of DPT's. This is why I think that the previous BSPT and MSPT will need to have some approriate diagnostic and radiological training to become proficient as a direct access provider.

Louie, you state "And of course, the other question that I'd like us to discuss/ debate is whether a dual professional DC/DPT should have any significant right to feel better qualified to differentially diagnose musculoskeletal disorders than the DPT." No, I do not think that.

David, I disagree with you on "I disagree- Screening for conditions not appropriate for physical therapy treatment is already an integral part of practice." While "screening" is an integral part of a PT's practice, it is not what a DPT does. A DPT will be a doctor (physician status) and you will be one of the best diagnostician's there is, especially for MSK issues. You will be able to diagnosie and recognize the various arthritides, cancers, blood disorders, etc. That is what you will do, and you will need to do that as a portal of entry, direct access provider which many families will put faith in you to do. I do not imply that DPT's will have problems doing that, I just am stating what I have seen as the facts, that BsPT and MSPT will need to learn how to better diagnose, and the DPT has learned how to do that.

Ben, you state "I've been following this post with some interest and have been disappointed to see the chiropractic input mischaracterize PT's skill-set and scope of practice." I need you to clarify where you see this. Understand, I am completing the MSPT program because I see the deficits in my DC training in the field of EBP functional therapy.

You state that "Unfortunately, when this model has been subjected to the rigors of scientific inquiry." I disagree with you. The model of diagnosing is well proven. Maybe you refer to the practice of adjusting the subluxation as not well proven with which I would agree with you. Is "a subluxed segment" on a radiograph questionable? yes. What I refer to is scientific diagnosing utilizing blood, imaging, etc - not the search for the ever alluding subluxation. You state, "if you're under the impression that you're diagnosing and "fixing" a patho-anatomical problem with your manipulation, you are simply mistaken." This is correct. This is why is use quotation marks. The comment is that where I think a DC is an excellent diagnostician (not merely find the "subluxation"), the DC falls short in the functional model. Where the PT is an excellent functional provider, they fall short in the diagnosis department (which the DPT makes up.) You are correct stating "To the contrary, investigating the functional aspect of a patient's presentation can provide valuable insight into a diagnosis." However, this is not diagnosing. But the info you state (functional) is what makes the DPT diagnosing more accurate than the provider making a diagnosis without functional info, much like received from many DC's and MD's.

Ben when you state "To my knowledge, Chiro's have not subjected their musculoskeletal competency to scientific scrutiny." This is partly true. We actually have same and more of the textbooks used in PT school, so the competency is well proven, maybe the treatment techniques are not.

I fail to see the connection to your comment of " Maybe the chiro comments on this post would hold more sway if they had." Overall, with the improved communication and understanding of the two professions, these many misconceptions will continue to resolve, so that judging one's "comments" will be by merit and the evidence, not merely by the pre-conceived misunderstood degree.

Hope this clarifies some intent of my posts.

Chris

[Jon Newman]

What MSK diagnosis are people making when the they manipulate someone?

[Michael Schneider]

Chris,
Thank you for your comprehensive explanation of the chiropractic perspective on the DPT program. I would concur with everything that you said.

I do feel that some additional commentary is necessary to clear up some misconceptions.

1. Direct access in the military setting may not generalize to direct access in the civilian population...I don't know for sure...but it is an important concept. As a DC, patients come to me "off the street" without any referral from MDs. I still see patients who do not have a family physician and when I see red flags, the buck stops here. Meaning, I become the physician in charge of ordering diagnostic work-ups to find the pathology. I don't like being in that role...but that is the reality of real direct access in the civilian population. I agree with Chris that the emerging DPT model willl prepare DPTs for this type of practice scenario, but at present the BsPT and MSPT level graduates are probably not prepared for full diagnosis under the type of direct access I mentioned. Are DPTs ready for the challenge of being in a position where no MD is in charge, and all the responsibility falls onto the DPTs' shoulders? Does this happen in the military population?

2. I think the point Chris makes about the differences in the PT programs and DC program is critical to this discussion. Chiropractic colleges were designed to produce "alternative physicians". PTs were trained to be "therapists" who worked under direct order of a supervising MD. Of course the DPT model is changing this older model, but none the less, the historical model of PT education was to "screen" for red flags not to "differentially diagnosis for pathology". This is not meant to be a criticism, but rather a point of distinction between our respective educational backgrounds.

As such, DCs' education included a full coursework of all body systems and full differential diagnosis. We were being prepared for the true "direct access" of being an alternative physician to MDs. This means a hell of a lot of responsibility, to truly hold yourself out as an alternative to the MD. This is one of the 4 models of chiropractic I discussed in my first post, still being promoted by people like Jim Wintersteing, the president of National College of Chiropractic.

3. The question was asked "should a dual DC/DPT give that person any sig. right to feel better qualified in differential dx of MSK problems". I agree with Chris, NO.

4. Another comment was made that orthopods and rheumatologists are already MSK specialists. I would disagree with that comment. Most of us know that these MDs are not very well trained in FUNCTIONAL MSK diagnosis. They can find MSK pathology, but very often they do not have the mechanical reasoning skills that DCs and DPTs possess with respective to selective tension testing, repeated movement testing, nerve mobilization testing, etc.

5. We seem to be tip-toeing around a really big question...that is, how will the physical "therapist" morph into the "doctor" of physical therapy role? Chiropractors already have the "doctor" title, which has put us in a different light within the health care industry. I am in full support of the DPT program and seeing PTs move in this direction... but I wonder if your profession understands the long road ahead to gain cultural and professional authority as "doctors".

The real gatekeepers are the patients out there in the general public. As long as they continue to view PTs in the "therapist" role...the longer they will continue to seek out an MD for a diagnosis.

I don't know about this group, but I find the terminology "Doctor" of physical "therapy" to be somewhat oxymoronic. What I mean is that in the same title you are holding yourself out to be both a doctor and a therapist. Which is it? This is what I am hearing from some of my patients when they ask "what is this DPT thing?"

6. The idea of blending the best attributes of both chiropractic and physical therapy is the wave of the future. I think that Chris is a fine example. He recognized the limitations of his DC education and now seeks to fill in the gaps with the PT education. I think that PTs should recognize that DCs like Chris and I have a lot to offer the PT profession. We were trained in a slightly different model, and have a lot of experience to bring to the table. We are trying to find common ground and improve MSK care for our patients.

[Jason Silvernail]

I would like to thank our chiropractic colleagues for posting.

I have a question. Mike mentioned that "...DCs' education included a full coursework of all body systems and full differential diagnosis."
Do you mean that, as a portal of entry practitioner, you are fully diagnosing a nonmusculoskeletal problem if the patient does not have a family physician? I wonder how your DC education can qualify you for that, since MD/DOs who are board certified in family medicine don't do that. They order what tests are in their scope of responsibility, make what preliminary diagnosis they can, and then they refer to the relevant specialist.

I think this "primary care provider" thing is completely overblown. There is no need, and in fact a significant risk to patients, for a PT or DC to be attempting to work up a nonmusculoskeletal problem. Screening and referral yes, diagnosis no. The purpose of any diagnostic tests that may be ordered would simply be to determine if there was suspicion of a condition outside the scope of expertise. And if such is found, to REFER IT to the appropriate provider. NOt attempt to work up something one doesn't have the education to approach. It's the same basic scheme that those in family medicine use.

When Chris mentioned he is a "diagnostic doctor" I hope (for his patient's sake) he was referring to conservative musculoskeletal diagnoses only. Is this right, Chris?

I am a military therapist and have imaging and limited prescription rights. I have not found a great use for those privileges in most cases, though they are critical for direct access. I have found in the medical system a lack of understanding of pain and poor managment of chronic musculoskeletal pain syndromes, as Jon Newman mentions. I have not found a lack of diagnostic tests and differential diagnosis labels.

J

[John Ware]

Michael,
You may hear "what is this DPT thing" from your pt's. What I hear from my pt's about chiropractors I'll refrain from repeating on this blog out of respect for you participation in this discussion. Generally, and this has been referred to already, the perception of chiropractic as quackery is widespread. The fact that PTs are referred to as "therapists" does not mutually exclude us from becoming a "doctoring" profession. It just depends on how you define "doctor". Chiropractors view themselves as "alternative" to allopathic physicians, whereas PT's view themselves as having a specific role within the healthcare system. We're not trying to break off into some sect or alternative group of practictioners. We're just trying to make the whole system better. And that includes a lot of cooperation with our physician colleagues. By and large, I have a tremendous amount of respect for MDs and DOs. For the most part, they're very well-trained, intelligent, hard-working people. Furthermore, medicine is a profession that's grounded in science, not fanciful theories about "subluxations" and "nerve flow."
As far as our role in diagnosis goes, I think what's being talked about here by my PT colleagues is differential diagnosis of conditions which may mimic or present initially as a musculoskeletal syndrome. We don't aspire to diagnose conditions outside of the movement system. Perhaps that's why I just don't understand chiropractic-what is the foundational science of your profession?
John

[Chris Baker]

Jason -

"Do you mean that, as a portal of entry practitioner, you are fully diagnosing a nonmusculoskeletal problem if the patient does not have a family physician? I wonder how your DC education can qualify you for that, since MD/DOs who are board certified in family medicine don't do that. They order what tests are in their scope of responsibility, make what preliminary diagnosis they can, and then they refer to the relevant specialist."

Asking how a DC education can qualify us to do that is similar to asking how can a PT education qualify you to gait assess? Diagnosing is an inherent component of Direct Access. Having a detailed understanding of appropriate blood work, advanced imaging, nuclear studies, stool sampling, etc. is so critical for Portal of Entry, unless you restrict your practice to MSK disorders as John says as "We don't aspire to diagnose conditions outside of the movement system." If direct access means only diagnosing "movement system" ICD's, then one definitely does not need the other diagnostic tools to do such. However, I was trained to be portal of entry direct access - and diagnose. Part of that responsiblity is to make the appropriate referral to a specialist for the appropriate treatment. Our patients trust our thoroughness. Probably the most frequent "missed" diagnosis I find is cancer. I am simply stating that when you accept the responsibility of direct access, you accept the current standard of care to perform as such. And a major component of that standard of care is to ensure a correct diagnosis.

"NOt attempt to work up something one doesn't have the education to approach. It's the same basic scheme that those in family medicine use." I would disagree somewhat with your perspective. I think we may in many ways be saying something along the same lines, Jason, however, maybe wording it differently. In no way would I ever condone "attempt to work up something one doesn't have the education to approach." Yet I continue to be baffled why many on this post feel that DC is "uneducated" to diagnose anything BUT MSK, and is not a "very well-trained, intelligent, hard-working people." as the MD and DO. I would like to see what source you gain your info from. I can recall my 3-day National Board exam and 2-day State Board exam in which I was required to diagnose many non-MSK ICD's, and to determine which approriate testing to perform to confirm and diff diag from other potential ICD's.

"When Chris mentioned he is a "diagnostic doctor" I hope (for his patient's sake) he was referring to conservative musculoskeletal diagnoses only. Is this right, Chris?" Absolutely not Jason, for my patient's sake and especially those who had a late-stage cancer. Example, Friday, new patient admitted for symptoms diagnosed by her Family Physician as asthma. Recognizing that the symptoms were rather excessive for only asthma, the proper diagnostic workup revealed she actually had Streptomyces workup from the appropriate testing (local lab, etc.) Did this come from "subluxations" and "nerve flow" as John seems to think DC's can only do? Or did this come from a "lack of diagnostic tests and differential diagnosis labels" as Jason states? (Yes, on the part of the Family PCP.) Or maybe I should not "aspire to diagnose conditions outside of the movement system" as John states and continue to treat her for functional deficits of asthma. Absolutely not...I should diagnose her, and soon, so she can seek the necessary care from a Specialist since this specific diagnosis is outside my scope of treating.

Jason, you state "I am a military therapist and have imaging and limited prescription rights. I have not found a great use for those privileges in most cases, though they are critical for direct access. I have found in the medical system a lack of understanding of pain and poor managment of chronic musculoskeletal pain syndromes, as Jon Newman mentions. I have not found a lack of diagnostic tests and differential diagnosis labels." If that is all DPT does, I would agree. My opinion is that the DPT is far better than that, and if to successfully gain Direct Access in the civilian environment, it WILL be much more than that if true Open Direct Access. Every Tom, Dick, and Harry will come in your office and being able to utilize every avenue you have available to assist in the proper diagnosis will only make one a better diagnostician. I do not imply that I am only a diagnostic doctor, however that IS how I was trained with the emphasis on neuro-musculo-skeletal. Therefore, those endless classroom hours on dermatology, internal, micro, pathology, genetic, etc. were critical to round out the educational preparation for diagnosing.

If PT is to continue to seek Open Direct Access, then to be successful, we will need to demonstrate that we meet the Standard of Care for that responsibility prior to being accepted by the public at large, I think.

John, as you have so eloquently stated, what you hear from your disgruntled patients pales to what we hear from ours about the medical model. We all have our skeletons, unfortunately we do seem to have our large share in chiro. "We're just trying to make the whole system better." Again, not speaking for Michael, I am headed for the DPT becaue of the exact comments you make. But isn't it ironic how that the new "manual therapy" boom in PT is so progressive, utilizing the very same method of treatment which originally DO and recent hundred years the DC uses, and quite well, to be so effective in patient care? I am not sure that I have not met a DPT who was not first influenced by one or the other originally. It is unfortunate for the treatment method (maipulation) to only recently have received the accolades it deserves by a group of hard working determined researchers. All of us who utilize the manipulation in our practices are indebted to folks like Wainner, Flynn, Childs, etc. who have finally provided the necessary "pudding" showing just how effective the manip really is. I should not matter if you are a DC, DPT, PT, DO, MD - if you manip and do it EBP as your "profession that's grounded in science," you should be applauded for your progressive thinking. But if you perform ANY procedure based upon "fanciful theories about "subluxations" and "nerve flow," (whether it is manip, decompression, laser therapy, US, etc) then I think ALL of one's practices will definitely be criticized, questioned and judged as to its validity as Jason exemplifies so well.

Back to diagnosing. Lets not forget that even as a PT, we use the ICD code book and utilize patho-anatomical diagnoses, with few exceptions like gait imbalance, muscle fatigue, postural changes, etc. Do we, as PT's, not use degenerative changes, or sprain/strain, or hip replacement diagnoses? Absolutely we do.

In like manner, are we to treat Streptomyces with manips or functional care? No - but since we can diagnose, the patient is now receiving appropriate medically necessary sulfamethoxazole/trimethoprim, rather than an inhaler for her "asthma." You see, if we are to be Open Direct Access, then we will be expected to step up to the plate and take our job seriously and professionally...and do so according to the accepted Standard of Care required of us as Portal of Entry provider....if we are to be respected by the field of docs we so "have a tremendous amount of respect for..."

Chris

Chris

[Jason Silvernail]

Chris-
Thanks for your post. In no way was my post meant to criticize the DC education or your practice. I find PTs and DCs I've worked with to be every bit as intelligent and hardworking as medical physicians.

I think that while we fundamentally disagree on the diagnosis issue, we agree on most other things.

I do not think the APTA's current vision, nor clinical reality, supports the paradigm of "diagnose it all - then treat only MSK" as I gather from your posts. I do think both clinical reality, long history in the US military and Commonwealth countries, and the APTAs vision supports the "open direct access, unlimited MSK treatment, screening and referral as needed" paradigm that I mentioned.

I think it's impressive for you as a practioner to use diagnostic tools to fully medically diagnose a patient without the benefit of medical school, clinical training and hospital rotations that a medical doctor has. It is my understanding that Chiropractic school does not have the clinical internships or a residency program in hospitals managing sick patients and using these diagnostic tests and clinical reasoning under supervision. If the MDs and DOs seem to think it takes 4 yrs med school and 3 yrs residency (family medicine) to do these things, I wonder what your assessment is of your training in comparison to theirs. Based on time in training alone, it seems you got a much better deal, don't you think? Especially since no MD or DO straight out of med school is considered to be qualifed to practice without at least an internship, and almost always a residency.

I wonder how common this diagnostic confidence is among your colleagues. I also wonder regarding consequences of missed diagnosis, especially when working up a condition that is outside the MSK/movement system area (which is what I believe both DCs and PTs are primarily trained in).

Thanks for the courteous and informative exchange on a hot button issue between two professions with a history such as ours.

J

[Carina Lowry]

Chris,

Thank you for the clarification. To me, you are making medical diagnoses and are managing them as such instead of referring back to an MD or DO. Maybe I am just unaware of the extensive education that chiro receives to be able to medically diagnose and manage medications to treat medical diagnoses.

I was just wondering a few poignant questions:

1. I am not asking you to pump your school, however how do you think your schooling as a DC compares nationwide? Do you feel all chiros are able to make medical diagnoses like this? Do you feel that your schools are standardized throughout the country to prepare you for medical diagnosing?

2. Did you also receive extensive training in pharmacological management to be able to manage all of a patient's medications? Do you think this is standard across the DC profession as well?

3. Do the DC schools have a governing body overseeing the curriculum of their programs to prepare DC's to be medical managers?

4. Does the practice act of each state vary as far as DC and practice of medicine? I know that in Minnesota, there is a very clear distinction that a DC cannot make a medical diagnosis. Is the DC profession working to change this to allow unrestricted medical diagnosing for all DC's?

I am not disputing your points that entry level providers should be able to identify and differentially diagnose. However, I am not sure if anyone should be managing the medications and medical diagnoses other that a medical doctor--MD or DO. This should be the standard for referring out.

Carina

[Michael Schneider]

John, Chris, and Carina,

I think this dialogue about the role of diagnosis is very important and certainly a healthy discussion. Let me chime in on a few points made by all:

1. There is a clear difference between the amount of diagnosis coursework taught in DC vs. DPT curricula. This is a fact...not an opinion or criticism. All of the chiro colleges teach a wide variety of differential diagnosis in their curricula, as mandated by the Commission on Chiropractic Education (CCE). CCE is the chiro equivalent of CAPTE. Unlike PT curricula, which I understand to vary substantially from school to school, chiro colleges must adhere very strictly to the diagnosis courses as mandated by CCE.

2. Regardless of the fact that all chiro colleges mandate a full diagnosis coursework, the two corrollary questions that arise are: (a) Is all that coursework really necessary? and (b) Do all DCs upon graduation possess excellent differential diagnostic skills?

My answer to (a) is "probably not". I think that the ability to perform full diagnosis (which I believe I possess) is a nice attribute to possess, but it is not absolutely necessary for the version of MSK care that DPTs desire as their specialty.

I too, like Chris, routinely make a "medical diagnosis", but I would not care too much if MDs really did their job properly and I never had to do it again in my life. But the reality is such that all of us, DCs and DPTs alike, will see a number of patients off the street who think they have a MSK lesion when in fact they do not. John Mennell during his lifetime used to quote the statistic that about 20% of the patients he saw in a strictly MSK specialty practice had internal disease that was mistakenly diagnosed as MSK disease.

Should the DPT program offer a full array of medical differential diagnosis? No, in my opinion. Should it be more extensive than the present coursework. Probably yes. There needs to be some compromise on how much diagnosis is "enough"..how much is "too little"...and when "overkill" is happening. I suspect that chiro schools are overkilling the situation.

3. Are all DCs excellent diagnosticians? Absolutely not! The vast majority of DCs (in my opinion) are fair to mediocre at differential diagnosis. Chris and I probably represent outliers in our profession, but we are examples of how the system works properly.

The biggest missing link in chiro education is the lack of any meaningful residency or internship. Carina is correct to point out this deficiency. It really makes the DC inferior to the MD or DO, with respect to real experience with illnesses in the clinic while having a diagnostic mentor teaching you the ropes.

4. The issue of variation between states...wow...you are right on with that comment Carina. Each of the 50 states has different practice acts with respect to chiropractic, with Illinois at one end of the spectrum allowing DCs to basically act like MDs doing full differential diagnosis. There is no consistency between states, and this is a huge problem for the general public who are confused about the scope of chiro practice.

5. Carina also asks if we have Pharm training...only a cursory knowledge with one course in chiro school. I think it is fair to say that the majority of DCs have not recieved any formal training in pharmacology. But we don't prescribe..nor do we advise patients about their medications directly.

6. Lastly, John mentions the fact that most DCs are percieved as quacks. Well, I can not argue completely with that comment because there certainly are a lot of quacky chiros. Yet I have seen many PTs take the John Barnes myofascial release and Upledger Institute craniosacral therapy courses (just to name a couple) and they seem rather quacky to me as well.

I think the point of distinction here is that in the chiropractic profession we clearly tend to attract more "fringe" folks to our colleges, which are completely tuition dependent and accept basically "all comers", and therefore we wind up having a larger percentage of "quacks" in practice. I would expect that the PT school do not attract as many fringe folks, would screen them out during the application process, and thereby wind up with less "quacks" in practice.

Naturally it is harder to rid your profession of quacks once they have a license, than to screen them out before they ever get a license. But I must lower my head and admit that the chiropractic profession has way too many quacks who give us a collective bad name. Yet I would urge the PT profession to consider that these quacks still represent a minority, and the majority of DCs are decent folks trying their best to help sick patients get well. Quacks in any profession are not representative of the profession itself.

--------------------------

In summary, I think that the DPTs should look at the chiro curricululm and our present situation in private practice as a good example of what happens when you try to become an alternative physician. Learn from our successes and learn from our mistakes. My suggestion is not to reinvent the wheel...there should be enough diagnosis in the courseload to make the emerging DPT an excellent MSK diagnostician, rule out red flags of pathology, and also to know enough about general systems diagnosis to converse and interact with PCPs and other MDs. There is probably a need for more courses on diagnostic imaging, especially skeletal radiology, MRI, etc.

It seems to me that this is the direction the PT profession is taking, to add more diagnosis to the DPT curriculum, but to stay shy of going so far as to attempt to become full fledged physicians.... and I think it is the correct path. Just my two cents again.

Mike Schneider, DC, PhD (c.)