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NUHS President James Winterstein, DC, on the Role of the Primary Care Chiropractor PDF Print E-mail
Written by John Weeks   

Other Voices: National University of Health Sciences President James Winterstein, DC, on the Role of the Primary Care Chiropractor

Summary: The Integrator story on the primary care chiropractor underscored the irony in chiropractic about kind of integrative, whole person, natural health practice. Such practices appear to be gaining favor with the public. Witness the grown of integrative medical doctor and naturopathic practices.Yet the chiropractic whole-practice specialty societies atrophy. The irony is stronger given recent publication of data on savings from the chiropractor primary care provider HMO model developed by Alternative Medicine Integration Group. James Winterstein, DC, one of his profession's most outspoken advocates for "what used to be referred to as general chiropractic practice" offers his perspectives on this change. Despite trends, this president of the multi-disciplinary National University of Health Sciences (DC, LAc, ND, massage therapy)  announces that he's "not giving up."
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James Winterstein, DC
James Winterstein, DC
, has one of the more intriguing resumes in chiropractic, or chiropractic medicine as he would put it. He has taken one of the field's oldest schools and transformed it into a multi-disciplinary institution of natural health sciences. In 2001, the now 101 year old National College of Chiropractic (NCC) became National University of Health Sciences (NUHS) and features degree programs in chiropractic, acupuncture, Oriental medicine, massage therapy and naturopathic medicine. (See relevant Integrator story.)

Winterstein is one of the chiropractors the "straights" in chiropractic most love to hate. He advocates a broad scope practice which can be similar, although without the drug rights, as that of licensed naturopathic physicians. NUHS's curriculum includes therapeutic nutrition, and some mind-body. Winterstein was trained in acupuncture when NCC was the first educational institution in the US to offer acupuncture training. (NUHS still has a continuing education program in acupuncture for chiropractors who wish to include it in their broad-scope of practice.)

National University of Health Sciences
Winterstein has also been the lead chiropractor and member of the board of Alternative Medicine Integration Group (AMI) which developed a managed care plan for HMO Illinois with chiropractors as primary care providers. (See related Integrator article here.) The plan developed by AMI, an Integrator sponsor, has led to outcomes over seven years, twice published in peer review journals, suggesting savings of 50 to 85% over utilization in among members of conventionally-managed plans. It's been hard for the straights to not claim the outcomes as part of their fold. Winterstein responds here to an Integrator article which looked closely at the small subset of chiropractors who are working to re-elevate the broad-scope practice in the profession which increasingly is only concerned with the spine.

"In response to your segment on the chiropractic physician as a primary care provider, I wish to provide some commentary from one who was engaged in what used to be referred to as a 'general chiropractic practice.' I took all patients and decided what was wrong following a proper history, examination and relevant laboratory procedures, determined whether I thought the patient would benefit from my care, would need to be co-managed, or referred and then developed the appropriate plan.

"I managed patients with simple fractures, acute and chronic musculoskeletal disorders of various kinds, the common cold and flu complaints, pharyngitis, hiccough, middle ear infections, skin conditions, peptic ulcers, pulmonary disorders, acute pneumonias and yes malignancies, as well as a host of others. In some, such as those with malignancies referral was the proper management and even then, some, while under the care of an oncologist, benefited from what I had to offer.

Developer of the DC-as-PCP HMO product
"The point is that I was  educationally prepared and certainly capable of making a diagnosis and determining the best course of clinical management and coordinating that course with others if others were to be involved (basic Institute of Medicine definition of primary care). This is how National has always taught its students as attested to by the 1910 writings of our founder, Dr. John Fitz Alan Howard, who included a broad scope approach to the educational process and the practice concepts.

"Now, with the good graces of Richard Sarnat, MD, of Alternative Medicine Integration Group (AMI), we have been able to demonstrate clinically through a 2004 study  and a 2007 publication (one with fewer pediatric cases and the second with more), that using the chiropractic physician as a primary care provider has the potential to produce major savings in health care costs – for pharmaceuticals, hospitalization and outpatient procedures. We are talking about 50% savings.

"Here is the rub. Certainly one of the major businesses in the United States today is that of the pharmaceutical industry. It is huge and involves billions upon billions of dollars annually. I suspect that our AMI model is not going anywhere quickly simply because we all know the old 'saw' about 'following the money.' Is this possible? Unfortunately it is precisely possible. Let’s add to this the diminished revenue for hospitals and the more traditionally invasive doctors and where are we? Perhaps the fact that our first article could not get published in an allopathically-oriented journal says it all. The decision-makers do not really want to save money it seems, despite all the rhetoric about it in every political campaign within the past two decades. It is numbingly ironic that one can daily listen to a litany of jargon laced commentary about health care delivery without ever hearing ONE word about the kind of outcomes we produced.

"Could we provide the number of chiropractic physicians necessary to staff such an effort? No, certainly not. But imagine that we include in these numbers the growing profession of licensed naturopathic physicians, and integrative medicine physicians and osteopaths – who we included in the last AMI study – and maybe even take full advantage of the general practice scope of acupuncture and Oriental medicine providers who have significant training in basic sciences.”

"To date, our inroads into the Veterans Administration have been minimal, but that is one arena into which I think the chiropractic primary care provider might be able to make a beginning, as suggested to me recently by Dr. Louis Sportelli, but getting a foot into that door will not be easy.

Image"I am encouraged by the number of National graduates who enter integrated practices today. I think that is a good indicator, and just yesterday, a graduate of some years who is a Diplomate of the American Board of Chiropractic Internists (DABCI) told me of being approached by her local hospital to head up a CAM department to address primarily their diabetic patients and to provide cardiac rehabilitation. These are examples that keep me centered on the concept of the chiropractic physician as a primary care provider at a time when the profession has, in my estimation, bowed to the pressure of the third party payers who have insisted that anything outside the musculoskeletal disorders is not 'within the scope of chiropractic practice,' thus de facto defining chiropractic scope of practice regardless of statutory liberties.

"Our profession should NEVER have allowed this to happen, but it has and now, as we get pushed relentlessly into an ever smaller corner, from which extrication becomes more difficult daily, there remain some, of us who insist that the chiropractic physician  has much more to offer. Ironically, it is left to an allopath – Rick Sarnat, MD - to help us see this pathway. I am not giving up. I think what we have to offer is vital – to the public as well as to the profession."
Comment: Through a certain lens, participation in third party payment is always a pact with the devil. The outcome is typically misaligned with the best interest of the patients and with the profession's own mission - though it may be aligned with the economic aggrandizement of its members. Nowhere does this pact seem so clearly and obviously damaging as in the history of the chiropractic profession.

Interestingly, Winterstein notes that insurers have not awaken to the savings of the AMI study. They seem to have little curiosity about this apparently powerful beacon in primary care, based on the abilities of the chiropractic minority of broad scope practitioners. It will be more interesting to see if the chiropractic profession, caught in something of an identity crisis, will respond.

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