The purpose of this study was not to establish whether chiropractic training prepares the chiropractor to be a primary care physician, neuromusculoskeletal specialist or subluxation based provider. The role of the chiropractor in healthcare has been eloquently debated in several articles [1
]. Our interest was to provide preliminary data in the process of determining if chiropractic training provides the chiropractor the ability to recognize undiagnosed LTC which is a fundamental requirement of all physicians. The 576 surveys validated for our study represent 11442
years in practice and a reported 3861 patients with an undiagnosed LTC. Based on this data the typical chiropractor could expect to have 1 patient with an undiagnosed LTC to present in their office every 2.5 practice years using Poisson Regression analysis. Respondents identified over 50 different conditions that fit the operational definition of “life threatening”. Considering the total number and wide variety of diagnoses reported the authors feel there is preliminary evidence to support the position that chiropractic training provides an educational base to the chiropractor to be able to recognize undiagnosed LTC when they present in their office.
The concern relating to missed or delayed diagnosis is common throughout the healthcare professions. Between 2007 and 2009 the NCMIC Insurance Company reported 7.5% of claims made against their insured chiropractors were related to missed diagnosis or delayed referral based on personal communications with Keith P. Henaman, Assistant Vice President of Claims. Within the medical community the most common malpractice lawsuits were related to missed diagnosis, failure to diagnose or delayed diagnosis [19
] representing 34% of primary care cases according to Phillips et al. [20
]. Interestingly the most common missed diagnoses in medical practice are similar to the most common presentations of LTC in chiropractor’s offices. These include carcinoma, myocardial infarct, stroke and abdominal aneurysm [20
]. This is not to suggest chiropractors are diagnosing conditions missed in the medical doctor’s office but that these type conditions are common, easy to misdiagnose and can have deadly consequences. As one author noted the gold standard of diagnosis, the clinical autopsy, would not have been necessary in 12% of cases if the proper diagnosis had been made and the proper treatment given [23
A very important component of our study was to identify the most common conditions chiropractors reported encountering. In rank order they include carcinoma, abdominal aneurysm, deep vein thrombosis, stroke, myocardial infarction and subdural hematoma. There was a large group of other conditions commonly reported which included severe hypertension, other cardiovascular disease, infection, diabetes, meningitis, cervical fracture and appendicitis. It is interesting to note that many of the most commonly reported presenting conditions often share one of two characteristics. The first is that many patients present with conditions that may manifest themselves as neuromusculoskeletal in origin thereby causing them to choose a chiropractor as the physician of choice. These conditions could include myocardial infarction manifesting as thoracic tightness, carcinoma resulting in perceived muscle/bone pain, deep vein thrombosis resulting in leg pain and stroke or subdural hematoma resulting in headache or extremity weakness. Secondly many of the conditions reported could appear to be discovered incidental to radiographic examination such as abdominal aneurysm and carcinoma.
In addition to the number of LTC reported and the varied diagnoses, several findings of interest were discovered when analyzing relationships (Table ). The reader is cautioned that the reasons for these differences may be due to the inherent bias of the survey instrument and should be interpreted as no more than points of interest requiring additional study.
1. Although the chiropractic profession continues to battle over philosophical questions, this study provided preliminary evidence that the reported ability to recognize LTC was equal among schools when divided into liberal, mixed and conservative categories. Additionally there was no significant differences in those doctors that categorized themselves as “subluxation based” compared to those that did not.
2. Rural practices appeared to experience an increase in reported recognition of patients with LTC compared to other practice environments.
3. A doctor in multi-DC practice reported recognizing more LTC than a doctor in solo practice.
4. Doctors with a blend of recent education and experience (6 to 15
year’s experience) reported recognizing LTC at a greater rate than more recent graduates or those in practice over 15
5. Male DC’s reported recognizing LTC at a more frequent rate than female DC’s.
This paper had several limitations which are common to survey instruments. Recall bias may have resulted in over reporting or under reporting of LTC.
The presence of LTC was determined by the survey takers themselves and did not require confirmation by any outside source. It is possible that what a responder thought was a LTC may have been misdiagnosed or not truly life threatening and as a result weakened our findings. It should be noted a total of 37 conditions were removed from data analysis because in the opinion of the authors they did not meet the operational definition of life threatening. Two examples of conditions removed included subluxation and mononucleosis. The response rate for this survey was lower than desired. The findings in a study by Russell et al. indicated that the response rates for postal surveys of chiropractors range from 7.0% to 91.4% with an a mean of 52.7% [24
]. It should be noted many surveys reported in the Russell et al. study were of specific populations of chiropractors which generally provide higher response rates, while surveys which include all chiropractors generally have lower response rates [25
Lastly this survey did not attempt to determine “missed” diagnoses on the part of the chiropractor as that was not the purpose of the paper. The authors acknowledge that diagnoses may have been missed which would have increased the frequency of these conditions.