BC College of Chiropractors Scope of Practice Hearing,
May 31, 1999.
Oral Presentation
My name is Michael Vipond. I am the President of the BC College of Chiropractors. With me today is Don Nixdorf who is the Executive Director of the BC Chiropractic Association. Thank you very much for hearing us today.
Introduction
As you know from our earlier submissions and meetings, chiropractors in BC strongly support the scope of practice review being undertaken by the Health Professions Council. We believe the scope of practice review is an important initiative. The scope of practice review creates an opportunity for a principled review of health professional regulation in BC. We endorse the work undertaken by the Health Professions Council. However, this does not mean that we accept everything the Council has recommended in its preliminary reports. Indeed, although we are largely satisfied with the preliminary report on chiropractic, we do have some significant concerns that we would like to share with you today.
Positive recommendations acceptable to chiropractors
Our satisfaction with the preliminary report on the chiropractic scope of practice is reflected by the fact that 6 of the 8 recommendations require no further comment by us. The following recommendations are acceptable:
1 the scope of practice statement
2(a) the reserved act of diagnosis
2(b) the high velocity low amplitude reserved act which we call "adjustment"
2(d) the reserved act concerning the anal verge
3 which deals with titles
4 which deals with patient access to X-rays
Recommendations requiring modification by the HPC
In the preliminary report on the chiropractic scope of practice, chiropractors do have concerns about recommendation 2 (c) dealing with hazardous forms of energy and recommendation 4 dealing with laboratory testing.
We are grateful for the appearance at the hearing today of Dr. John Taylor and Dr. Steven Injeyan each of whom addressed these areas of concern. We hope that their submissions addressed the concerns identified in the preliminary report on these issues. We hope that their submissions will allow the panel to revise these two recommendations in a manner that will be more supportive of chiropractors ability to access the health information that diagnostic imaging and laboratory testing can generate..
Diagnostic imaging
Specifically, in relation to diagnostic imaging, there are five points we want to reinforce:
- We want to make it clear that we have not requested the use of diagnostic ultrasound. At page 21 of the preliminary report the HPC says we requested it, however, in our June 24, 1998 letter to the HPC we stated that we did not.
- In relation to the utilization of laser and electricity in treating patients we want to clarify that chiropractors do not want to use anything which is not in the public domain. We understand that the process of reviewing what is in the public domain is continuing.
- Dr. Taylor has documented the education and training of chiropractors in relation to MRI, CAT scan, and other forms of diagnostic imaging. Further, he has explained the manner in which chiropractors would utilize such technology. It is clear that chiropractors will not be administering or interpreting this diagnostic imaging unless qualified to do so. Rather, chiropractors will be ordering it and receiving reports on the outcome in circumstances where the information provided by the procedure is important to establishing a differential diagnosis and ruling out contraindications for chiropractic treatment. We submit that in the materials we have provided to date and in Dr. Taylor's presentation we have addressed sufficiently the panel's concerns about education, training, and utilization.
- The preliminary report overstates the case when it speaks of the risks involved in "unrestricted access to utilization of these hazardous forms of energy". Clearly, we are not talking about "unrestricted access" since the administration and interpretation of these diagnostic tests will be performed by qualified practitioners. If and when chiropractors become qualified to administer or interpret these new technologies, then, just as occurs with x-ray, the College of Chiropractors will be responsible for regulating its members in relation to the use of the new technologies and members will have to comply with other provincial licensing or standards requirments pertaining to the new technology.
Our submission in relation to diagnostic imaging is really quite simple. Technology allows substantially more and better information to be generated which is relevant to diagnosis. Chiropractors are primary care practitioners who are trained to use this information. Why should chiropractors and their patients in BC be handicapped because they cannot access this information readily? Surely there is a greater risk of harm to the public if access to this information is restricted unreasonably. Surely, restricted access to this information does not promote quality or efficiency or cost effectiveness. We believe it is well within the mandate of the HPC to modify this recommendation to make it clear that chiropractors and their patients should be able to access all information that can be generated from current and future forms of diagnostic imaging.
Laboratory testing
In relation to laboratory testing we trust that Dr. Injeyan's submissions have assisted the HPC by addressing a number of the panel's concerns. We appreciate that the HPC recommends that chiropractors be granted a limited range of laboratory testing. However, on the basis of the evidence presented, we submit that the HPC could modify this recommendation to make it much more positive and supportive of our request. As well, the HPC must recognize as it has in other preliminary reports that the College has the ongoing responsibility to evaluate and regulate evolving knowledge as it pertains to the chiropractic profession.
Specifically in relation to laboratory testing, we have the following four points to emphasize:
- We have shown that the range of laboratory testing requested is based upon the scope of practice of chiropractors.
- We have shown that there is a relationship between laboratory testing and diagnosis.
- We have shown that chiropractors are educated and trained in the use and interpretation of the specific laboratory tests requested. Naturally, we are limited in showing our experience with laboratory testing since we have not been allowed to access it to this point in time.
- We have shown that reasonable access to laboratory testing is not available from other sources. Indeed, we are not allowed to order it and the College of Physicians and Surgeons continues to instruct its members not to associate with chiropractors or do anything which might indicate approval of chiropractic.
We submit that the HPC does not need to be as cautious as it is in the preliminary report. The information in support of chiropractors qualifications to use information generated by laboratory testing is available and it has been presented. We urge the panel to reconsider its preliminary report and make a stronger statement in support of our position on this point. Clearly, access to laboratory testing will reduce the risk of harm to the public and will promote quality, efficiency, and cost effectiveness in the delivery of health care services.
Exclusivity of chiropractic adjustment
We would like to close our oral presentation by saying a few words about reserved acts, exclusivity vs sharing, and in particular reserved act 2(c) which deals with the high velocity, low amplitude movement of joints of the spine. We understand that the HPC is recommending that this reserved act be granted to chiropractors and that the issue of who else should be granted this reserved act will be dealt with in the context of other scope of practice reviews. We will be making profession specific submissions at the various hearings. As well, we understand the approach the HPC is taking to reserved acts and, in particular, the strong preference for increasing overlapping scopes and reducing exclusivity. However, we are very strongly of the view that the HPC analysis of this issue is flawed and we would like to take this opportunity to tell you briefly why.
When it comes to determining who can perform a reserved act, the terms of reference for the HPC can be reduced to one essential point: the onus is on the profession to show that it is qualified to perform the reserved act. To date, the HPC analysis of reserved acts is flawed because there is an absence of any identified criteria or discussion of the threshold for establishing qualification. It is not clear how the HPC is weighing the sufficiency of a profession's core competence to perform the reserved act safely.
To date, in your preliminary reports, you have recommended that each of medicine, naturopathy, and physical therapy be granted this reserved act. Yet, the spectrum of core competence in relation to reserved act 2 (c) ranges from virtually zero for medicine to an optional certificate program for graduate physiotherapists and for naturopaths, the education in the reserved act 2(c) is about 25% of the chiropractic education. The education, the training, and the commitment to daily utilization of the techniques in the practice is either non-existent in these other professions or it pales in comparison to the chiropractic programs and experience.
The question that the HPC fails to answer is "how much core competence is enough in order to entitle a profession to practice a reserved act?" It is essential to answer this question in order to fulfill your terms of reference. In our opinion, it is not sufficient for the HPC to simply say "we are satisfied that the profession has some education and training in the reserved act and we trust the College to ensure that no one practices outside their scope" since these other Colleges are saying that their members will perform the reserved act 2(c). Your mandate in the scope of practice review is to protect the public from the harm that might be caused by health professionals who practice in an area where they do not have core competence. If the current position of a profession allows that to happen then you must act to stop it. The risk of stroke or death from reserved act 2(c) is entitled to the same respect as if it came from surgery for which the HPC has no hesitation in reserving exclusively to medicine.
Yes! the legislature wants to allow greater overlap in the professions, and yes! we want to reduce barriers for interdisciplinary practice, and yes! we want to increase consumer's choice in relation to health care providers, however, this can be achieved today by existing professionals communicating more freely and readily. You must have the courage to stand up for exclusivity if it is in the public interest to do so. We have made out the case that there is a serious risk of harm in reserved act 2 (c). Further, we believe we have made out the case that only chiropractors are properly trained and educated to perform this reserved act.
You have not hesitated to express concerns for chiropractic core competence in diagnostic imaging and laboratory testing, yet you have no reservations in relation to granting reserved act 2(c) to a group of practitioners who have a broadly different experience with and understanding of this reserved act. And in doing so, there is no attempt to answer the key question "how much core competence is enough?" We urge you to take a much closer look at the preliminary reports for medicine, physical therapy, and naturopathy with a view to fulfilling your mandate to protect the public interest by limiting access to reserved acts if necessary.
Conclusion
The scope of practice review is a safety check on the government regulation of health professionals. Are health professionals doing what they should be doing? Are there unnecessary restrictions on scope of practice? Can we improve access and consumer choice by permitting more overlapping scopes of practice? The HPC review is a vehicle to recommend corrections to various scopes of practice and to limit access to reserved acts where appropriate. Chiropractors and the public have been combatting the bias of the medical profession since the inception of chiropractic. This bias has limited the ability of chiropractors to obtain necessary health information. It is in the public interest for those who choose chiropractic treatment to know that their chiropractors can access and take the benefit of all relevant health information. The HPC should be doing everything it can to reduce the barriers that preclude chiropractors from accessing current and future diagnostic imaging and laboratory testing. At the same time, we submit that we have established that only chiropractors are properly qualified to perform reserved act 2(c). Again, the public interest in safe delivery of this reserved act demands that the HPC recognize this reality.