While doctors of chiropractic (DCs) focus primarily on the evaluation, diagnosis and treatment of musculoskeletal disorders, a leading cause of disability,1 they are also aware of the many other public health crises affecting the nation’s people, such as heart disease, diabetes, stroke and even concussion, and can counsel patients on them. A typical chiropractic college curriculum focuses on health promotion and disease prevention and requires students to take courses to learn the basics of nutrition, public health, and health and wellness during their doctorate-level education.
As first-contact, physician-level providers, DCs should prioritize continuing education in wellness since this will give them a greater role in mitigating America’s public health crises and position chiropractic as the nation’s primary complementary and integrative health care profession.
What Is Wellness?
“Wellness is total, proactive body, mind and spiritual health,” says Jay Greenstein, DC, a chiropractic sports physician. “It is something you work toward; you acquire it.”
Will Evans, DC, PhD, head of the Food Science, Nutrition and Health Promotion Department of Mississippi State University, adds, “It is ongoing and lifestyle-related. It is not a supplement, although that can be a part of it, and it is not an adjustment, although that can be a part of it as well.”
DCs understand the importance of living a healthy, fulfilled life,” says Dr. Greenstein. “Therefore, chiropractic is a mechanism to help achieve patients’ best selves, so that they can flourish,” he says. He points out that DCs spend a lot of time with their patients, giving them a greater ability to build strong relationships and more opportunities to have conversations about how to be healthy and how to truly be well.
Dr. Evans agrees, adding that because DCs see people on a more routine basis than do MDs, they have an advantage in talking to and educating patients about wellness.
Participants in a 2010 study reported receiving health promotion advice from their chiropractor only 30 percent of the time, less than general medical doctors.2 When DCs provided advice, 88 percent of patients indicated they complied.
An Opportunity in Wellness
DCs are in a position to achieve the many goals of the Surgeon General’s 2011 National Prevention Strategy. “The National Prevention Strategy will move us from a system of sick care to one based on wellness and prevention. Poor diet, physical inactivity, tobacco use and alcohol misuse are just some of the challenges we face,” says former Surgeon General Regina Benjamin, MD.3
Dr. Evans argues that not choosing a “wellness lifestyle” is killing more people than any single factor when it comes to premature, preventable death.
David Radford, DC, a chiropractic physician with the Spine & Orthopedic Institute at St. Vincent Charity Medical Center, finds that, “Modern medicine has largely failed our needs.” He continues, “Chronic illness is being ignored; more than a third of us are obese, one out of five of us are diabetic, and half of us are pre-diabetic.” (See “The Obesity Epidemic,” April 2012 ACA News, at http://bit.ly/1MxWyTc and “Wellness: Discussing Obesity with Patients” on Page 18 of this issue.)
Dr. Evans, who worked in private practice for more than 17 years, finds that most practicing DCs aren’t putting enough emphasis on health and wellness in their clinics. “DCs are okay with recommending exercise as part of chiropractic care and telling a patient to get preventive chiropractic adjustments, but they are really not comfortable with discussing tobacco cessation and dietary change, outside of supplement use in most cases,” Dr. Evans explains.
Dr. Evans, who has applied health promotion in his own practice, has earned additional degrees in the subject – both a master’s degree and a PhD in public health education and promotion – to expand on the basics learned in chiropractic college. “Many of the chiropractic programs still do not place a lot of value on evidence-based health promotion and wellness,” he says. He believes chiropractors should take advantage of the many postgraduate opportunities available to them and continue their education in health promotion and wellness.
Continue Your Education
To gain maximum knowledge in various wellness-related fields, like nutrition, DCs may seek further education, such as earning diplomate status from the Chiropractic Board of Clinical Nutrition or by pursuing certification as a clinical nutritionist. (See “Nutrition: A Necessary Component of Chiropractic,” May 2015 ACA News, at http://bit.ly/1TOk7Pw.)
The ACA Council on Diagnosis and Internal Disorders provides DCs with an educational opportunity in which they can become trained in modern medical diagnosis, functional medicine and natural therapeutics. Chiropractic physicians with the Diplomate of the American Board of Chiropractic Internists (DABCI) postdoctoral certification routinely employ methods such as blood laboratory studies, urinalyses, electrocardiograms, vascular Doppler ultrasound, spirometry, DEXA bone density testing, salivary assay hormonal and neurotransmitter tests, IgG food allergy testing and many other diagnostic tools into their practices. The DABCI also promotes the use of nutrition, dietetics, exercise, and vitamin and mineral supplementation.4
DCs may also choose to become certified wellness practitioners (CWPs) through the National Wellness Institute (NWI). The CWP “designation symbolizes an individual’s strong academic preparation, professional competency in wellness programming and commitment to continuing education, scholarship and professional development,” according to the NWI website.5
Dr. Evans, a certified wellness practitioner through NWI, explains that in this program, “you have to prove you have training in key areas of wellness and health promotion, such as in a traditional educational format like a BS, MS or PhD degree, and that you can implement programs with accepted means of planning and evaluation.” The program has little to do with clinical practice, he advises. The program may not be an ideal option for those not already regularly incorporating wellness into their practices, as five years of professional wellness experience and professional engagement in the field of wellness are two of the requirements for applicants.5
To remedy the lack of clinical application in the program, Dr. Evans, Cheryl Hawk, DC, PhD, and Mike Perko, PhD, led the development of NWI’s Wellness in Clinical Practice (WCP) Professional Certificate Program, which requires a certain level of clinical knowledge and has been popular among physicians. The certificate program provides participants with tools to integrate the principles of evidence-based health behavior, wellness, coaching, health promotion and disease prevention into their clinical practice, and consists of 40 hours of self-paced online training.6
“The certificate program builds on six dimensions of wellness,” Dr. Evans says. “It takes into account everything from personal knowledge to health and wellness aspects of the worksite, spiritual life and social interactions. It is a strong ecological model of health promotion in action.”
Certification from the Institute for Functional Medicine (IFM) offers DCs another option. Dr. Evans cites the expansion of the Cleveland Clinic’s Center for Functional Medicine, in the last few years, as a symbol of the public’s dire need for functional medicine and a sign of opportunity for the chiropractic community. “While some DCs incorporate functional nutrition or functional medicine, most do not,” he says. “We are often treating patients’ backs and ignoring the wellness needs of the patient, which doesn’t make sense.” He explains that chronic disease is often comorbid with spinal disease. “Why would we address one and not the other?” he asks. Functional medicine addresses the whole body as a fully integrated system and not just an isolated set of symptoms,7 according to the IFM website.
Choosing a Specialty
DCs may feel more confident discussing a certain aspect of health and wellness with their patients if they continue to inform themselves of the latest research regarding a specific public health issue.
Dr. Greenstein’s particular focus is on athletes and the concussion epidemic. “Educating patients on the prevention of concussions [while participating in] football [and other sports] can add to the health and wellness of a patient,” he says. “Chiropractic is the perfect profession to help instruct and educate patients and athletes alike on health and wellness prevention strategies.”
Dr. Greenstein often educates his local community on concussions by talking to coaches or parents of high school student athletes about how to recognize and prevent them. In addition, he uses PubMed and the Turning Research Into Practice (TRIP) database to stay abreast of the latest research regarding athletes and concussions.
“Wellness is a great opportunity to draw a positive impact,” he says. “An even greater impact requires education. Are you interested in nutrition, sports or women’s health?” Dr. Greenstein believes that whatever a DC’s passion, it’s important to implement evidence-based research about that passion into their practice. Continuously educating yourself on a topic, or topics, will make you a better physician and will help to put your patients on the road to optimal health.
The Benefits of Pursuing Wellness
“Any time you focus on legitimate wellness and health promotion in your community, you are going to get noticed,” says Dr. Evans. If a patient is getting preventive advice from a DC, and if the patient mentions this advice to their MD, then chiropractic is going to be seen in a positive light in the medical community, he stresses.
Supplementary credentials and continuing education will only help. “When a local MD in my community found out that I had a master’s degree in health promotion and was talking to the patients we had in common about tobacco use, exercise and diet, he eventually became a patient himself,” roles with the American Heart Association, the health committee for his local Chamber of Commerce and his state’s smoke-free task force have also added legitimacy to his practice since they show his advocacy for a healthier environment. Dr. Evans says. His past leadership roles with the American Heart Association, the health committee for his local Chamber of Commerce and his state’s smoke-free task force have also added legitimacy to his practice since they show his advocacy for a healthier environment.
Dr. Radford, who earned his master of science in clinical practice, is often asked to consult on patients with atypical presentations in the Spine & Orthopedic Institute. He sees mostly patients with spine disorders, but he is building a referral practice of chronically ill patients. “It all started when I took a functional medicine approach,” he says. “I look at the whole person: body, mind and spirit. I routinely see patients who are being referred for consideration of spine surgery only to find they are poorly managed diabetics with peripheral neuropathies, not radiculopathy.”
In knowing that 88 percent of patients comply with wellness advice received from chiropractors, all DCs should further their education in wellness. This education will make you a better provider and your patients healthier, and it enhances the chiropractic profession’s credibility, especially in the eyes of the medical profession.
1) US Burden of Disease Collaborators. The State of US Health, 1990-2010 Burden of Diseases, Injuries and Risk Factors. JAMA. 2013;310(6):591-606. doi:10.1001/jama.2013.13805. Available at:http://jama.jamanetwork.com/article.aspx?articleid=1710486.
2) Ndetan H, Evans MW Jr, Bae S, Felini M, Rupert R, Singh KP. The health care provider’s role and patient compliance to health promotion advice from the user’s perspective: analysis of the 2006 National Health Interview Survey data. J Manipulative Physiol Ther. 2010 Jul-Aug;33(6):413-8. doi: 10.1016/j.jmpt.2010.06.009. Available at: www.ncbi.nlm.nih.gov/pubmed/20732577.
HEALTH Promotion + WELLNESS
WILL EVANS, DC, PHD, AND CHERYL HAWK, DC, PHD, co-wrote the book “Health Promotion and Wellness: An Evidence-Based Guide to Clinical Preventive Services,” designed to provide health care providers with both the theoretical knowledge and practical skills they need to render high-quality clinical preventive services. Providers can find screening, prevention, health promotion and advising information and resources that will complement their routine care of their patients, as well as instructions for how to appropriately use CPT codes for billing preventive services.
Counseling Patients on TOBACCO + ALCOHOL Addiction
ACCORDING TO THE NATIONAL BOARD OF CHIROPRACTIC EXAMINERS, chiropractic physicians are consulting patients about smoking cessation on only a weekly basis.1 Smoking is the single largest preventable cause of death and disease in the United States.2 In addition, a job analysis found that only 13 percent of DCs felt comfortable giving advice on alcohol use.3 ACA News has covered both important public health crises in recent issues. DCs can learn about speaking to patients about smoking cessation by reading “Cigarette Cessation: Tobacco’s Public Health Crisis” in December 2015 ACA News, at http://bit.ly/1QX3dN3. In addition, DCs can refer to the “Alcohol Abuse: Public Health Crisis” article in March 2016 ACA News, at http://bit.ly/1S6KdK6, for a guide on how to help your patients who are abusing alcohol.