A more serious tone this week. I was prompted by the excellent effort last week by Loretta Marron which made both the mainstream ( http://bit.ly/eW8l6J ) and medical press. For those caught napping Loretta submitted a letter to the Health Minister Nicola Roxon demanding that RMIT University close their paediatric chiropractic clinic as it perpetuates the myth that there is a reason for chiropractors to even be touching children and babies. For me it also raised the question of what sort of more general child health advice might be given out to parents at such a clinic.

As part of the transition to the new Australian Health Practitioner Regulatory Agency (AHPRA) the regulated professions have been asked to sign up to Codes of Conduct proposed by the new Boards which have been created. A split appears to be looming between the Chiropractic Board of Australia (CBA) and a number of the major professional organizations over the Code of Conduct for registered chiropractors.

The CBA website shows the Code of Conduct, and they have also taken the step of publishing the submissions by organizations and individuals which informed its development. The Code and submissions can be found at http://www.chiropracticboard.gov.au/Codes-and-Guidelines.aspx

Whilst there are the obvious typo corrections and suggestions for re-wording the bureaucratic language of the Code, there are also some indications in the submissions of deep division between the CBA and the major chiropractic professional organizations, particularly in the areas of public health, informed financial consent and the use of x-rays.

With regards to public health issues, there appears to be reluctance on the part of the Chiropractic Association of Australia (National) (CAAN) and its state bodies to embrace the fairly uncontroversial proposition that health professionals of any stripe have public health responsibilities with regard to the spread of communicable diseases. The CAA Victorian Branch submission specifically disclaims such a responsibility
‘We note a statement in section 1.2, 3rd paragraph that chiropractors have a role to not only promote health but to protect the health of the community. We would seek some clarification from the CBA as to how it understands that Chiropractors could protect the community’s health.

The SA branch of CAA (CAASA) submission recommends removing a clause about chiropractors ‘understanding the principles of immunisation against communicable diseases’ because
‘Understanding the principles of a singled out particular public health procedure is inappropriate and certainly incomplete. There are many other public health procedures, eg hand washing or equipment cleaning that are not listed; it is incomplete to single one out.’

The NSW Branch agrees
‘CAANSW questions why chiropractors need to understand the principles of immunization. This is not within the scope of chiropractic.’

The Gonstead Chiropractic Society is more forthright
‘Immunisation has nothing to do with Chiropractic and should not be included in this document. Chiropractors as part of their education are taught about communicable diseases and immune function, they also learn about spinal biomechanics. I see no specific reference to spinal biomechanics in this document yet it has far greater relevance to the practice of Chiropractic than immunisation.
This clause does not belong in this document and must be removed. Reference to this topic was made in the first draft and it is still inappropriate.’
The final CAAN submission contains overtones of some of the misrepresentations that the anti-vaccine movement is fond of promoting. Judge for yourself..
Immunisation is not a central aspect of chiropractic practice. Vaccination does not guarantee immunisation.

Mandating an “understanding” of the “principles of immunisation against communicable diseases” is a simplistic requirement that will be considered by most of the chiropractic profession as a direct insult towards the right of free will and informed choice.
In light of recent safety concerns, hospitalisations and deaths from influenza vaccination a government regulatory body may wish to consider the wisdom of this subsection.
The issue of vaccination requires consideration of complicated variables, including the virulence of the disease in question, the evidence (or lack thereof) of safety and efficacy of the vaccine in question, the individual health status of the patient and the environmental/geomedical context in which the vaccine is being considered.

It may be worth pointing out that while immunisation is not a central aspect of optometry, osteopathy, physiotherapy or podiatry, these Boards have included the exact same phrases in their respective Codes of Conduct without this degree of controversy from a peak professional body. Professionals in these disciplines are presumably content to accept that public health experts know that they are talking about when they make their recommendations. The submission from the Chiropractic and Osteopathic College of Australasia (COCA) is the lone submission from a peak body which supports the Code in this respect, and indeed calls for it to be more explicit in stating that mass vaccination is a well-established public health tool.
‘The College can only restate its view, that the Board include in its code of conduct, reference to the need for chiropractors to set aside any anti-vaccination beliefs they have, in favour of the promotion of health and disease prevention through vaccination and to be immunised against relevant communicable diseases.’

To summarize, the Board is trying to get chiropractors to accept that they should be immunized to promote herd immunity and as part of their ethical commitment to their profession’s public health responsibilities. The CAA and its derivatives as well as the Gonstead faction (splitters) vehemently disagree that any such duty of care exists, or that they should even be immunized at all, let alone compulsorily, as is the case for many hospital workers such as ICU staff.

A second issue of major contention is the requirement under the Code of Conduct for informed financial consent to be obtained for pre-paid courses of treatment. A particular bone of contention is that the Code advises that
‘that agreements should not extend beyond 3 months or 12 visits whichever is the greatest, unless there is clear and appropriate clinical justification to support a renewed period of agreement and care.’

It seems not unreasonable to justify ongoing treatment beyond 3 months, if the fees are to be pre-paid, regardless of the condition being treated simply because it is hard to predict virtually any health outcome that far into the future, and consumers should be protected from honest errors of prognosis on the part of the health practitioner. If 6 months of treatment have been prepaid and the condition has resolved after 3 months, there should be a mechanism by which the payment could be reviewed, instead of the practitioners just keeping the money. In prolonged rehabilitation from severe injury, for example, insurers will routinely require reassessment against stated treatment goals to be done every few months to ensure that the prognosis is on target, and to make adjustments when circumstances change. The COCA submission is the only one of the major submissions which seems to explicitly acknowledge this, making the recommendation that a validated outcome measure of some type should be included as part of such treatment courses. The CAAN submission recommends that the entire section of the Code (3.6) which deals with informed financial consent be dropped, because

‘CAAN is unaware of ANY peer-reviewed evidence to suggest that care plans and financial arrangements between practitioners and their clients should not exceed 3 months.Without a compelling, evidence-informed reason to limit the time frames for financial arrangements as suggested in section 3.6 g), CAAN is concerned that CBA may limit access to, as long as those arrangements are conducted in line with the above sections of the draft Code of Conduct.
CAAN recommends the removal of section 3.6 from the Code of Conduct.’

They could perhaps consider the moral, legal and ethical reasons to limit such arrangements instead of disingenuously demanding clinical reasons to alter such widespread business practices. They want the respectability and gravitas that science provides without having to adjust their view of reality when it conflicts with the findings of science. Business ethics and consumer protection are not inherently scientific fields, but a combination of moral, legal and economic considerations. I would be fascinated to see the ACCC’s attitude to such an arrangement.

Chiropractors have used x-rays as part of their clinical assessment for decades, including asymptomatic monitoring of healthy individuals. The Code of Conduct includes an Appendix specifically addressing the appropriate use of ionizing radiation as part of chiropractic practice. It refers to two existing guidelines on chiropractic uses of ionizing radiation and the CBA has also felt the need to specifically affirm in addition to the quoted guidelines that any exposure to ionizing radiation must be justifiable clinically and must be judged to be of greater benefit to the individual than the small but definite increased risk of cancer produced by such exposure. The COCA submission goes further, specifically recommending that the Code advise that
Routine X-ray screening of consumers including the routine evaluation or re-evaluation of biomechanical/postural disorders, other than for progressive scoliosis or other exceptional circumstances, is not supported by the scientific literature and may be inappropriate.
COCA also recommend that the Code restricts use of x-rays in children to
‘conditions such as fracture, dislocation, bone pathology, unresolved skeletal/spinal pain, scoliosis and to exclude or confirm a clinical suspicion of conditions which may be a contra-indication to proposed care.
This is because of the higher risk to growing bodies of ionising radiation exposure. None of the other submissions drew attention to this specific requirement for children, which is not mentioned in the Code, even though it does devote a section to the needs of children (Section 3.7) Submissions from CAANSW, Gonstead Chiropractic Society and CAAN appear to see no special reason why children should be treated any differently to other patients, despite COCA warning that treatments, assessments and examination procedures for children require far more extensive training and experience than provided in some undergraduate chiropractic teaching institutions.

The diversity of opinion within the chiropractic profession, and particularly between the CBA and the CAA appears more than trivial. At stake is the potential inclusion within AHPRA of one profession with a dramatically different and even opposing Code of Conduct to the others. I have discussed only the three most obvious and substantive issues at play, but there are others as well where the CBA and the professional organizations appear to be poles apart (the role of scientific evidence in the chiropractic profession, and public spinal screening being other examples.) It will make for an interesting and no doubt challenging few months as the chiropractic profession attempts to unite behind a Code of Conduct which accords even in general terms with the other AHPRA Boards. The Annual Report of the CAA, available online at http://caaannualreport.realviewtechnologies.com/ does not inspire confidence, as the President of CAA Simon Floreani calls those who oppose the CAA on vaccination ‘geese’ and warns in vaguely menacing terms that they are somehow in league against the CAA and chiropractors generally. It is also of interest to skeptics that the President of the CAA feels that chiropractors are better positioned politically now than they have been in 20 years. Sounds to me like there are some major offensives coming for which we will need to be motivated.