College of Chiropractor's of Ontario - October 2001 Chiropractice Newsletter Excerpts

The following excerpts are from a recent newsletter from Allan Gotlib, former president of the College of Chiropractors of Ontario. This was circulated to licensed chiropractors.

You can read it all in .pdf format

By Dr. Allan Gotlib
Vice President

In the CCO 2000 Annual Report (which by the way is still not on their own web site), I spoke as president of how "acting beyond the scope of practice" without the patient being fully informed has continued to cloud professional growth and brought pressure to the concepts of public safety and protection.

While the public recognizes the diversity in our profession, they want assurances that the chiropractic care we deliver is both competent and ethical, and frankly, so do I.

Letter to Ms. Jo-Ann Willson

Dear Ms. Willson:

I would like to formalize my gratitude and appreciation for your extensive response to my query of eligibility of chiropractic to order diagnostic tests in the hospital setting.

The report has pulled together and summarized many of the questions about document and legislative references, which I had. It offers more clarity for our organization to now move forward and develop our own internal directives for handling this issue.

As per our telephone conversation, I too, would be pleased if you would share this information with the Ministry of Health and Long-Term Care, College of Physicians and Surgeons, and the College of Medical Radiation Technologists of Ontario. I agree that across the varying legislative bodies and within their own directives exist many inconsistencies. It is my hope that by sharing this formal inquiry with the varying governing bodies that future due attention will be drawn to this issue as deserved.

In the memorandum enclosed with this newsletter, you will see that we are consulting with the profession, the public and other stakeholders on two standards for the purpose of further protecting this public interest. The proposed standards of practice are designed to raise the level of enforceability. They emphasize and reinforce the importance of chiropractors operating within the scope of practice of this profesion.

Our scope of practice statement is not a license. It is a description setting out an explanation to the public about what we commonly do and what they may expect when attending a chiropractor. What is licensed are the controlled acts. The area in-between a monopoly (the old system) and the licensed controlled acts (new syste), where all health professionals practice their profession, must be set out in policies, guidelines, and standards of practice. Each self-governing profession must determine those policies, guidelines and standards within their statutory mandate and then articulate them to the profession and the public.

However, many of the services in this in-between area may be provided in the public domain by unregulated professionals or even non-professional practitioners. This system error, common to all regulated health professionals in Ontario, has created confusion for patients and regulated health professionals. Regulated professionals may provide services that are not usual and customary for their particular profession, yet the public assumes they are receiving competent, ethical services from a regulated professional.

This provision of health services falls within the public domain if it does not involve a controlled act. Even when a practitioner has his/her certificate of registration revoked, he /she is still able to provide health services to the public services that are in the public domain. This is particularly frustrating to regulatory boards and to those patients who have engaged in the disciplinary process.

When we are not clear with our patients and the public at large, there is confusion and complaints emerge from patients, the public or other health care professionals.

The issue of informed consent is well settled in our existing requirements set out in the professional misconduct regulation, many of our standards of practice, policies and guidelines as well as in case law.

To insure consent is fully informed and voluntarily given, chiropractors must clearly explain the following to their patients:

a service being provided is in your capacity as a chiropractor and conforms to the current standards of practice of chiropractic; or
a service being provided is in your capacity as a chiropractor but does not conform to the usual and customary standards of practice of the profession of chiropractic and the patient may not have the benefit of malpractice liability protection in the event of an adverse outcome. In this scenario, the chiropractor may receive the patient's consent to undertake a short therapeutic trial of treatment for a particular condition currently not well-supported in the scientific literature with clear, convincing and cogent evidence, but supported by experts in clinical opinion or case studies in peer-reviewed scholarly chiropractic literature;
a service being provided is not in your capacity as a chiropractor but simply as a practitioner operating in the public domain, does not conform to the standards of practice of the profession of chiropractic, and the patient may not have the benefit of malpractice liability protection in the event of adverse outcome. In this scenario, services that are not controlled acts, such as iridology or ear candling, could be provided if the member has appropriate training and expertise.

Current data suggest that approximately 95 percent of patients interactions relate to the treatment of conditions commonly referred to as neuro-musculoskeletal, while only 5 percent relate to non-neuromusculoskeletal conditions.

Confusion arises when patients with serious conditions, such as allergies, cancer or AIDS, believe they are being treated for those particular conditions when, in fact, the treatment focuses on concurrent secondary neuro-musculoskeletal problems. There is a clear distinction in treating a patient for a condition as opposed to treating a patient with a condition.

The treatment by chiropractors of various pain syndromes (headache, neck pain, back pain) is now well established in the scientific literature. However, the treatment of pediatric conditions, such as colic, enuresis, asthma, otitis media, attention deficit hyperactivity disorder, commonly referred to as non-neuro-musculoskeletal, has yet to be based on unequivocal cogent evidence beyond the expert clinical opinion or case report levels. Also, characterizing some of these conditions as non-neuro-musculoskeletal as opposed to neuro-musculoskeletal is in dispute. These academic arguments are not relevant to the patient - what is relevant is safety and competent, ethical chiropractic care.

Clearly, the scope of practice statement does not restrict or limit us to only musculoskeletal conditions. The purpose of the Regulated Health Professions Act (RHPA), was to provide for the evolution in the role that all regulated professionals, including chiropractors, play in the health care system.

However, in the same breath, the public must be assured about public safety and ethical competent care. How can we address this issue in language that meets the needs of the profession, the public and all other stakeholders while allowing our evolutionary role to benefit the health care system?

The Health Professions Regulatory Advisory Council (HPRAC), an advisory body to the Minister of Health and Long-Term Care, is addressing some of the challenge relating to the regulation of health care professionals who provide services in the public domain.

The CCO looks forward to offering input into recommendations relating to the difficult issues surrounding health care services that do not fit neatly into current controlled act/public domain model of the RHPA. In the interim, I invite the entire profession to provide feedback to Council in formulating standards of practice that address the needs of the public and other stakeholders in addressing chiropractors who act beyond the scope of chiropractic practice. The public and other health professionals are also stakeholders and we will be seeking their input as well. The final language must have provisions that will accomodate the evolution of the profession and allow for new research and knowledge to be transferred into the clinical setting.

You should review the documents through the eyes of the public - what does the public need to need to know in forms of efficacy and safety! We need to be absolutely clear with the patient.

Imposing your personal veiws is not acceptable. It is not about you, it is about the patient. Patients expect safe and effective treatment and their views may not be congruent with what you want. It is not your choice, it is the patient's choice and you should respect that choice.

There are 2,800 chiropractors in this jurisdiction. We must all interact and collaborate with the Ministry of Health and Long-Term Care, the health care system and the other health professions to the benefit of the jointly shared consumers of our services. Chiropractors can no longer remain isolated or marginalized. We must take up our duties in support of the core businesses of our Ministry of Health related to public health, health promotion and wellness, health policy and integrated health care programs.

Chiropractors must be in concert with the Ministry committments and strategies.

You should not be defensive about this accountability measure. You should view this as providing a more professional service in the best interest of your consumer. You are not the only one providing services to the patient, whether they are acute care services, chronic care, wellness care or preventative care. All regulated practitioners provide these - we must collaborate and make the sytem work better.

It is up to our profession to set standards of practice that provide for competent and ethical care and at the same time assure public safety and protection.

read the proposed standards carefully;
before giving us a defensive response, think about what is best for the patients;
consult with colleagues and other health professionals;
give some consideration to the diversity within our profession; and
give us your views in a manner helpful to the CCO, your patients and Ontario's health care system.

The fax lines are open.

CCO would like to take the opportunity to set the record straight on a number of issues that have arisen and may be causing concerns to some members:

CCO is not out to get subluxation-based chiropractors

Subluxation-based or evidenced-based, limited care or full-spectrum care, the CCO could not care less, as long as members comply with all CCO standards of practice, policies and guidelines. A range of practitioners serve on CCO Council and committees, and participate as examiners and peer assessors.

CCO does not like treatments plans (i.e., putting patients on long-term care).

Long term treatment plans may be reasonable when based on therapeutic necessity, appropriate record keeping; chiropractic examination and assessment; x-rays where necessary; progress evaluation indicating the necessity assessment and further care; and age and condition of the patient.

CCO is against block fees

Charging a patient a block fee is permissible if the patient is given the opportunity of paying for each service as it is provided; a unit cost per service is specified; and the member agrees to refund to the patient the unspent portion of the block fee, calculated by reference to the number of services provided multiplied by the unit cost per service. The patient must be fully informed! (see R-008: Professional Misconduct s. 25)

CCO does not like specialties (e.g. pediatrics)

CCO is a member of the Canadian Federation of Chiropractic Regulatory Boards and fully supports specialties. Efforts are underway at tha national level to recognize various specialties across the country instead of on a province-by-province basis. This is particularly important given the mobility of chiropractors under the Agreement on Internal Trade.

(I don't think that Dr. Gotlib has read his own web site that says that the CCO does not regulate, but does approve of only 3 specialties. Pediatrics is NOT one of them.

Here are comments about pediatrics from the CANOE.CA web site.)

Executive

                           Dr. Keith Thomson, Chair

                           Dr. Allan Gotlib, Vice Chair

                           Ms Regina Willmann, Treasurer

                           Ms Gail Diamond

                           Mr. Calvin MacPherson

                           Dr. Drew Potter

                           Dr. Donald Viggiani

                        Complaints 

                           Dr. Keith Thomson, Chair

                           Dr. Elizabeth Anderson-Peacock, non-Council member

                           Dr. Gilles Lamarche

                           Ms Regina Willmann

                           Ms Ruth Mabee, alternate

                        Discipline

                           Dr. Lynda Montgomery, Chair

                           Dr. Richard Bray, non-Council member

                           Dr. Douglas Brown, non-Council member

                           Ms Gail Diamond

                           Ms Helen Foster 

                           Dr. Jacques Laquerre

                           Ms Ruth Mabee, alternate

                           Ms Jane Ann McLachlan, alternate

                        Fitness to Practice

                           Dr. Brian Schut, Chair

                           Ms Clarissa D'Cunha

                           Dr. Drew Potter

                        Patient Relations

                           Dr. Gilles Lamarche, Chair

                           Ms Gail Diamond

                           Ms Helen Foster

                           Dr. Brian Kleinberg, non-Council member

                           Dr. Janit Porter, non-Council member

                        Quality Assurance

                           Dr. Donald Viggiani, Chair

                           Ms Gail Diamond

                           Dr. Jacques Laquerre

                           Dr. Jeffrey Lustig, non-Council member

                           Ms Regina Willmann

                        Registration

                           Mr. Calvin MacPherson, Chair

                           Dr. David Leprich

                           Dr. Lynda Montgomery

                        non-Statutory Committee

                        Advertising

                           Dr. Drew Potter, Chair

                           Dr. Peter Amlinger, non-Council member

                           Ms Helen Foster

                           Dr. David Leprich