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Federation of ChiropracticLicensing Boards

May 2002

Diagnosis - Who Needs It?James Winterstein, D.C., D.A.C.B.R.

President National University of Health Sciences

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Diagnosis -

“To distinguish, toDiscern, to learn to know, to Perceive.”

Gnosis - “relating to knowledge, Investigation - a higher knowledgecognitive, intellectual”

,

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Dia - “through, as in running through -thorough.

Perhaps more literally, “thorough knowledge.”

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Diagnose - to have or develop athorough knowledge - as it is applied in the healing arts - ofthe state of health of the patient.

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Confusion in Chiropractic - fromwhere did it come?

1907 Shegataro Morikubo vs. the state of Wisconsin - practice of medicine without a license - LawyerThomas Morris - working for B.J. Palmer took the position thatchiropractic was separate and distinct.

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Chiropractic was unlike medicine

1.Did not diagnose2. Did not treat3. Adjusted - did not manipulate4. Chiropractor is concerned withimpulses emanating from the brainwhich is the builder of the body.

Case was won.

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Diagnosis in Chiropractic -

Historically - confusion perpetuated by B.J. Palmer who stated “chiro-practors do not diagnose disease.”Further, he stated, “from now onlet us use the term ‘analyze’instead of diagnose in connectionwith disease.” (The Science of Chiropractic Vol. I page 171)

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By 1908, B.J. Palmer began touse the term “chiropracticphilosophy,” within which was thepremise that chiropractors do notdiagnose and chiropractors do nottreat.

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By comparison, John Fitz Alan Howard, D.C. wrote the following:

“In correct diagnosis lies the nucleusof success in the healing art. Tobegin with, our diagnosis must bethorough and painstaking. No pointis of too little importance to beconsidered....to much emphasis cannot be laid on this point.”

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Thus began a battle within the profession that has been waged for 92 years.

To diagnose or not to diagnose -that is the question.

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In more recent times the samelegal tactic has been employedfrom time to time but usuallywithout positive outcome - exceptfor one case in Michigan in 2000.The court held the DC was notresponsible for diagnosis becausethe state law does not require it.

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During my terms of office in theCouncil on Chiropractic EducationSome institutional presidents triedto make a distinction between “diagnosis” and “medical diagnosis,”claiming that chiropractors are notcompetent to make a “medicaldiagnosis,” thus this “kind of diagnosis” should not be taught

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In reality, the patient does notdifferentiate one “kind of diagnosis” from another. The purpose of thiskind of knowledge is to find outwhat is wrong with the patient sothat proper care can be administered.

The argument is specious.

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Physician vs. technician

What are the characteristics thatdifferentiate the two?

1.Education - undergraduate plusfour years of professional educationplus a residency for the physician -something considerably less for thetechnician

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Physician vs. technician

Scope of license - broad for the physician - narrow for the technician

Right to diagnose - required forthe physician - prohibited for the technician except under the direc-tion of the physician. This aboveall else is the KEY.

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Physician vs. technician

Right to determine treatmentprotocol: The responsibility of thephysician - prohibited by the technician except as prescribedby the physician.

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What is the point?

We want the title and prestige ofbeing doctors - these do not comewith................

“technician responsibilities”

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What is required by state statute?

With less than a half dozen excep-tions, state statutes require chiropractors to diagnose and usethe terms “therapeutic and or treatment.”

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What is required by CCE?

“The clinical training program mustensure that students develop theattitudes, knowledge and skillsrequired to collect appropriate patientassessment data, determine a diagnosis and establish an appropriate plan of chiropracticmanagement etc.”

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What is required by the third partypayer system?

No reimbursement without anacceptable diagnosis.

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What is required by ourmalpractice carriers?

Still the most common reason forlosses in malpractice cases arethe result of failure to diagnose.

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What is the established standardof care within the other health care first professions (allopathy, oste-opathy, optometry, podiatry, dentistry?

A patient diagnosis is required prior to commencement of careof any kind.

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What is required in our new roleas doctors within the DoD andVeterans Affairs?

Diagnosis is a mandate forpatient care

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DOD case - soldier - hip pain

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DIAGNOSIS - not subluxation, not posterior ilium, not pelvic tilt, not a weak sartorius - thediagnosis was:

Malignant fibrohistiocytoma

Diagnosis is the KEY to proper care

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Fortunately, the DC involvedwas thoroughly capable of proper examination, and laboratoryprocedures which led to thecorrect diagnosis, and proper pro-tection of the patient.

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By comparison consider thefollowing “mission” of a group ofso called “straight chiropractors” whothink diagnosis is not necessary.This group calls themselves COPS which, they say means Chiropractors On Purpose Serving -unfortunately is not just their lackof knowledge of English that matters.

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“Our Mission

I am a chiropractor. My goal andambition in life is to reach each andevery person I can. There aremillions of people dying. Each andevery person that has nerve inter-ference is dying. I have no time totreat symptoms because I am too

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busy removing nerve interferenceand increasing life. Symptoms arethere for a reason. Not everyone isready for what I have to offer. That’sok, because for every one personthat leaves, two more people willtake their place. I will do whateverI need to do to get to every sickand dying person that I can. I don’t

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like it when children’s wishes are thattheir mother or father would getbetter or that their little brother orsister could breathe again on theirown. I have the answer. When Ilay my hands upon every person andmake the adjustment, the lifechannels open and God’s messagecan be expressed at 100%.

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I will do whatever it takes to reachevery person I can and I will changethe world, one spine at a time.”

This from a chiropractic group thatis claiming to be “one of the most talked about and envied chiropractic groups, not only in the state, butacross the country.”

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What is actually happening inthe profession?

1. The majority of chiropracticphysicians recognize the responsi-bility and carry out appropriatediagnostic procedures.

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2.There is a significant minoritywithin the profession which takesthe position that diagnosis is nota chiropractic responsibility, noris it relevant, because chiropractorsdo not treat disease. This elementhas consistently resisted CCE requirements for diagnosis as a partof the academic process.

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The claim is made, by this minority,that there is no need to diagnosedisease because the chiropractoris not interested in treating humansfor any disease. His/her onlyconcern is for recognition andremoval of vertebral subluxationswhich, in their belief system, detract from human health.

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This premise is contrary to everypreviously outlined legal, educational, accreditation, and generally acceptedhealth care process. It stems froma 1907 legal case in Wisconsin,upon which B.J. Palmer based hisconcepts of “chiropractic philosophy.”

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Failure to diagnose removes thekey ingredient which distinguishesthe physician from the technician.

This leaves the profession with an internal dichotomy - those whodiagnose and those who do not -those who are physicians andthose who are not.

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Our internal dichotomy truly is notin any way related to how we choose to treat a patient - the possibilities aremany. It relates specifically to theaspect of responsibility and accountability for the welfare of thepatient - something that falls on theshoulders of the physician rather thanthe technician.

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The fact that some in our professionbelieve that a diagnosis is notrelevant to good health, (as they say,there is no need to name a diseasebecause innate intelligence knowsfar better than any intellect the physician might bring to bear), doesnot change the cultural, societal expectation that a cause for thepresenting complaint will be found

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It does not change the legal, oreducational, or practice requirementsplaced upon those who have been licensed as doctors.

All doctors, even those limited by anatomy (which chiropractors are not)are required to make a diagnosis - can we expect to be theexceptions?

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Diagnosis - Who needs it?

The patient needs it - The law requiresit - malpractice carriers require itsociety expects it - it providesprotection for the patient - Can therereally be any further question?

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A copy of this presentation can be obtained by e-mail from:jwinterstein@nuhs.edu, orby regular mail from:

James Winterstein D.C.200 E. Roosevelt Rd.Lombard, Illinois 60148