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DCs offset health care provider shortages in medically underserved areas.
By Rebecca Jones
More often than not, when a bone is broken in Pulaski County, Ill., it’s Dewey Dixon, DC, who gets the call for help. Dr. Dixon, 49, grew up here, and he’s been practicing in this rural part of the state his entire career. Folks know him and trust him.
Besides, who else would they call? There’s not a single medical doctor in the whole county, and while there is a physician’s assistant in Mounds, the county’s largest town, that office is staffed only four hours a week. “The nearest WalMart is 25 miles away, and there’s not a stoplight in the county,” says Dr. Dixon. “So when we talk rural, Mayberry doesn’t have squat on us.”
Dr. Dixon doesn’t actually set bones, of course. But he takes X-rays, does exams, and knows whom to refer his patients to, and how to get them immediate care. “I could get on the phone today and call an orthopedic guy and say, ‘This is what I’ve got.’ They know if I tell them it’s a particular fracture, that’s what it is. And it will be treated tonight. I have some colleagues in the city who complain it’s always a hassle to get an MRI for a patient. But my agreement is, I’ll get it within 24 hours. I’ve developed great relationships with a variety of medical doctors and surgeons.”
Dr. Dixon is among many chiropractors practicing in medically underserved areas who often find themselves in the role of primary care provider. Their practices encompass far more than traditional musculoskeletal work. In many ways, they are on the front lines of the nation’s health care crisis, providing basic treatment to people who might not otherwise have access to health care professionals. “I actually took an emergency medical technician course while in chiropractic college, and started taking paramedic courses, as well, because I knew I would be called on to do what isn’t classic chiropractic,” says Dr. Dixon.
Government Incentives for DCs?
Nationwide, an estimated 65 million people live in places where there aren’t enough primary care providers. About two-thirds live in small towns and rural areas outside large cities. But about a third live in pockets of poverty within metropolitan areas. These populations have difficulty getting access to health care because of their lack of insurance and inability to pay enough to attract providers.
It’s a situation that is both challenging and rewarding for chiropractors who choose to practice in such areas. Often, DCs are uniquely positioned to help. Yet despite evidence of high patient satisfaction with chiropractic care, the increasing adoption of evidence-based treatment practices by most DCs and their wide acceptance by the medical community, hurdles remain.
The National Health Service Corps (NHSC), which recruits health professionals—including medical doctors, dentists, physician and nurse assistants, dental hygienists and social workers—to practice in medically underserved areas in exchange for significant help in repaying their school loans, remains closed to chiropractors. This is despite a three-year demonstration project, during which chiropractors were eligible for NHSC slots.
“The report on that is pending, and has been overdue for a year now,” says David O’Bryon, executive director of the Association of Chiropractic Colleges, which has been closely following the issue. “Like medical students, our students can end up with debts of $100,000 or more, and this would be a way for them to be able to pay off their loans. But the issue that becomes apparent here is that the NHSC program has never been fully funded by Congress, so it’s highly competitive.”
John Falardeau, vice president of government relations for ACA, has been working with members of Congress to try to create similar avenues for loan repayment that would be open to chiropractors. One bill that would do just that, the Frontline Providers Act, sponsored by Rep. Bruce Braley (D-Iowa), is part of the package of health care reform legislation approved in November by the House. But what will happen in the Senate is yet unknown.
“The Frontline Providers Act is very similar to the National Health Service Corps, but provides for loan repayment for groups that fall outside the NHSC’s definition of eligible health care providers,” Falardeau says. “NHSC has been very averse to including more groups, so we’ve worked with concerned legislators to open up these opportunities.”
Offsetting Provider Shortages
Meanwhile, chiropractors still flock to medically underserved areas, with or without government sweeteners to lure them there.
Kelley Pendleton, DC, a 2005 graduate of Logan College of Chiropractic and a native of Maine, never imagined herself practicing in Louisiana, the last state in the union to legalize chiropractic, in 1974, and a state with a chronic shortage of health care providers. “I came here because I was under the influence,” Dr. Pendleton says, joking. “I was engaged to a man who was from here. It was quite the transition, and not just in terms of the weather.”
Dr. Pendleton practices in Mandeville, a town of 20,000 people on the north shore of Lake Pontchartrain. While her practice, Natural Health Chiropractic, is just down the street from a hospital, she nevertheless frequently finds herself the first provider that patients turn to for health care.
“You’ll find patients that just have a stronger rapport with their chiropractor than with a medical doctor,” she says. “Maybe it’s the length of time that we see them, or the frequency, or the fact that we touch them without gloves. One patient today came in with a shoulder problem. He said, ‘My doctor will just want to take X-rays and do tests, and I just want somebody to put their hands on me and tell me what’s going on.’”
Joseph Hawkins, DC, understands. Though his BIONIC (Believe It Or Not, I Care) chiropractic practice in Palmer, Alaska, is a world away from the bayous of Louisiana, he, too, has patients for whom he is the primary care provider. A 1997 graduate of Parker College, Dr. Hawkins came to Alaska after graduation, intending to stay only a year or so. Twelve years later, he’s hooked on life in what he calls “the biggest small state in the union.”
Alaska’s vast geography shapes his practice. “I routinely get patients who work two weeks on, then two weeks off the oil fields in Prudhoe Bay,” he says. “They’ll pop into town for a week; then they’re gone for three. It can definitely affect a treatment plan.”
“They’re tough as nails, these heavy equipment operators who run their own gold mines, or fishermen who work literally day and night when the sun doesn’t go down,” he says. “They’ll do what it takes to make money. But I’ll be very frank with them about what symptoms to watch for. They need to know that, if these symptoms show up, they need to get into town and get care. I’ve articulated that a lot, more often than a typical chiropractor in Dallas would do for someone who’s not hours and hours away from medical care.”
Dr. Hawkins often refers patients to medical doctors when he diagnoses a problem that is beyond his admittedly broad scope of practice. “There are many people here who will only go to a chiropractor or alternative care provider because of their philosophy,” he says. “Some of my best patients are the ones whose arms I’ve twisted to say, ‘You need to have surgery,’ or ‘I can’t do anything for you,’ or ‘You need to go get checked.’”
Dr. Hawkins sees himself as having the opportunity to help the struggling health care system as a whole. “We chiropractors do sports exams, order lab work, share patient MRI and X-ray image files and reports, and do all sorts of things that can alleviate the stress on the health care system. I work very well with the medical doctors in the area. I refer patients to them regularly, and they refer to me. We all advocate for the team approach in Alaska because it’s a necessity.”
The Team Approach
Gerald Stevens, DC, an assistant professor at New York Chiropractic College, embraces the team approach, as well. In addition to teaching, he’s on staff at the Lighthouse Free Chiropractic Clinic, a program of the Lighthouse Free Medical Clinic on the east side of Buffalo. Founded in 2001, the clinic is in a neighborhood where 38 percent of households are below the poverty level and 20 percent get some form of public assistance. A survey showed that 70 percent of patients at the clinic had household incomes of less than $10,000 a year.
“That population, since they have no money and no regular health care, tends to have more chronic complaints,” says Dr. Stevens. “We see anything and everything, from run-of-the-mill maintenance visits to chronic conditions that require supportive care.”
The clinic is multidisciplinary, providing medical, dental and chiropractic services. There’s a part-time medical doctor on staff who frequently refers patients to the chiropractic clinic. But Dr. Stevens also serves as primary care provider for many patients simply because there often are no other doctors available.
“I’m not daunted about being a primary care provider,” he says. “I feel that with the training we have, we know enough to refer them when necessary. Just this past year, we’ve referred five people with cancers that we found.”
The greatest challenge, Dr. Stevens says, is getting patient compliance. “It’s hard to get them to come back in for more care,” he says. “They have a lot of other concerns, like food and housing. Getting them to come in and take care of themselves is difficult.”
Despite the challenges, Dr. Stevens is drawn to his work with the indigent. “I would rather make a difference in the community if I can,” he says. “These people really appreciate the services they get. They don’t have anywhere else to turn, and it’s satisfying to see them able to finally get around and do things they couldn’t do before. They really see the value of it.”
Another chiropractor who has found great professional success using the team approach is Ian Paskowski, DC, medical director of the Medical Back Pain Program at Jordan Hospital in Plymouth, Mass. As part of the hospital’s program, occupational health physicians, neurosurgeons, rheumatologists, chiropractors, pain management specialists and physical therapists openly collaborate, with the chiropractors serving as central triage for the group.
“The one thing I’ve learned is never to talk outside my level of expertise,” says Dr. Paskowski. “Never guess. If you don’t know the answer to a question, the best answer is ‘I don’t know.’ Because there’s always someone in the room who does know the answer.”
Through his collaboration with so many other health care professionals, Dr. Paskowski has learned just how much chiropractors can do to provide much-needed primary care. “Taking patient histories, doing physical exams, taking blood pressure, blood sugar levels—so much can be picked up on and understood by doing the basic things correctly,” he says. “Too often, we want to skip ahead to expensive tests and procedures, but the things you learn in chiropractic school about exams and patient interactions need to be done thoroughly and with excellence. Just with these, we can do a lot of good and improve health care.”
“It’s not brain surgery,” he says. “It’s just doing a good job at what we do.”
ACA News Extra...
To read more about DCs providing care in medically underserved areas, see:
- Hawk C, Nyiendo J, Lawrence D, Killinger L. The role of chiropractors in delivery of interdisciplinary health care in rural areas. J Manipulative Physiol Ther 1996 Feb; 19(2):82-91.
- Lawrence, DJ. An overview of rural health. J Manipulative Physiol Ther 1996 Feb;19(2):75-81.
Published in the February 2010 issue of ACA News.