Chiropractors–GPs told to team up

CHIROPRACTORS and GPs should bridge their professional schism and take a team approach to treating their patients to optimise treatment, according to experts.

A study published online today by the MJA on the clinical practices of chiropractors found chiropractors referred patients to a GP in only 3% of consultations and patients had been referred to a chiropractor by a GP in 4% of consultations. (1)

The Chiropractic Observation and Analysis Study (COAST), based on chiropractors in Victoria, was the first of its kind in the world.

Data collected between 2010 and 2012 on 4464 chiropractor–patient encounters from 52 chiropractors showed 60% of appointments were for musculoskeletal conditions, mostly for back problems.

The research showed patients were commonly treated for “maintenance and wellness” or check-ups, which constituted 39 of every 100 chiropractor-patient encounters. The most common treatments were spinal manipulation and soft tissue therapy.

Most (71%) encounters involved patients aged 25–64 years while 1% of encounters were with infants aged under 1 year.

Professor Marc Cohen, of the School of Health Sciences at RMIT University, said the lack of cross-referrals and communication between GPs and chiropractors identified in the research represented a professional schism that few practitioners seemed willing to cross.

“This schism may also indicate that patients are compartmentalising their treatment plans and not discussing their treatments with their different practitioners”, he said. “This may lead to suboptimal care and reduce the effectiveness of the therapeutic relationship.”

Professor Cohen said a lack of understanding across the many different health disciplines, along with real or perceived competition between them, hindered interdisciplinary communication.

He said patients were likely to benefit from a coordinated care approach where they felt free to discuss all their treatments with their practitioners, and their treating practitioners collaborated to provide the safest and most appropriate care.

Professor Peter Brooks, director of the Australian Health Workforce Institute at the University of Melbourne and chair of the Australian Acute Musculoskeletal Pain Guidelines Group, said chiropractors should be part of the primary care team but all members of the team should espouse and practise evidence-based care.

“At least an exchange of information between [GPs and chiropractors] would assist treatment and diagnosis”, he said.

The study authors said most people who saw a chiropractor and other complementary and alternative practitioners also consulted a medical practitioner. They suggested further research “to maximise the patient benefit that can be gained through a team approach to primary care”.

Dr Liz Marles, president of the Royal Australian College of General Practitioners, said it was important for GPs to know if their patients were receiving chiropractic treatment to ensure treatment plans were not conflicting.

“It is of utmost importance that chiropractors keep GPs informed and report back on any findings and treatment plans”, she said.

Andrew McNamara, CEO of the Chiropractors’ Association of Australia, said his organisation encouraged chiropractors to refer to a GP when it was in the best interests of the patient.

“Patients with musculoskeletal conditions will benefit from managed or integrative care, particularly where the patient wants a drug-free approach or wants to consider all options before surgery.”

Professor Cohen, who is past president of the Australian Integrative Medicine Association, said the snapshot of chiropractic practice provided by the study was useful to GPs.

“Knowing that many of their patients are seeing chiropractors may prompt GPs to open discussions about chiropractic care and communicate with chiropractors about reinforcing evidence-based lifestyle recommendations”, he said.

Professor Brooks said it was a good thing that chiropractors were mostly confining their work to musculoskeletal problems.

“Mind you, a lot of back pain will get better whatever we do”, he said.

Professors Brooks and Cohen said further research was needed to determine the patient outcomes from chiropractic services.

The MJA research authors said it was important to have reliable, up-to-date information about what is actually happening in chiropractic clinical practice, with about 4400 registered chiropractors practising in Australia.

1. MJA 2013; Online 11 November