Whether referrals are part of the practice of straight chiropractic is another controversial issue. The generally understood position of the “straight movement” is that we do not refer. This, of course, raises the ire of many critics of straight chiropractic, especially those within the profession at large. It also gives them an opportunity to point the finger of scorn at us and say to government and society “See, there is one more example of their irresponsibility.” The issue, more than likely, causes some concern even among straight chiropractors. While not admitting it, some do make referrals. Others admit it and fear that they are being condemned by their fellow straights.
Unfortunately, in chiropractic many questions have no easy answers and this is one of them. But there are answers. The first issue to resolve involves determining what constitutes a referral. To do that, we must define our terms. Often a debater’s technique is to play the semantics game. The straight chiropractic opponent may say there is no difference between such terms as diagnosis and analysis, manipulation and adjustment, and disease and subluxation. The term “referral” is another word that fits into this category. The straight chiropractic antagonist would very much like the response to “Do you refer?” to be “yes” or “no.” The chiropractor who attempts to answer either in the affirmative or negative is in as much trouble as the man required to answer the question “Do you still beat your wife?” with a yes or no answer. If the realm of chiropractic principles could be reduced to yes or no answers, we would not need four academic years to teach it. So the response must be, “What do you mean by a referral?”
Webster defines the word as “(2) To send or direct (to some person or place) as for treatment, aid, decision, etc.” To you, to refer may mean to tell an out-of-state relative or patient the name of a chiropractor in her town. To the opposition this also constitutes referral. However, to him referral may also mean making the determination that a disease or condition needs more than just chiropractic “treatment” and then directing the patient to the appropriate health care provider. He usually, but not always, expects follow-up reports and/or consultations with the other provider. The mixer believes the recognition and determination that a patient needs another specific health care practitioner (orthopedist, internist, dermatologist, podiatrist, opthamologist, etc.) is within his area of expertise. The straight would not agree. He believes that the patient, the family physician, (M.D.) or another qualified professional should make that judgment. The straight chiropractor does not assume that responsibility, and so informs the patient of that fact from the start. He continually reinforces his objective and responsibility while the patient is under his care.
A wise man once said that there is no right answer to a wrong question. “Do you refer?” is a question that must be clarified. If a patient asks me for the name of a good auto mechanic and I give them the name of my service station, does that constitute a referral? If a patient asks where the nearest 7-11 is located and I give them the name of one or two that are equally close, is that a referral? By a broad interpretation of the word it could be so construed.
The following are two very different hypothetical scenarios; both could be considered referrals.
A patient may say “I have something wrong with my foot, I think I need a podiatrist. Do you know one?” A straight chiropractor may answer, “Yes, Dr. Smith up the street, I am told, is a fine podiatrist. He is a nice enough fellow and he comes in this office to have his spine checked regularly. However, there is also a different concept. A mixer would say in response to the same question, “Let me examine your foot.” He would then make a diagnosis or determine whether the foot problem is best treated by a podiatrist, dermatologist, or perhaps himself, if, in fact, the foot needed any care. Thus, we have two different responses to the same question, determined by the chiropractor’s objective. Apparently we need a different term to describe what each of the two chiropractors did. For the sake of the rest of the article, let us call the first scenario above a “referral” and the second (involving differential diagnosis) a “Referral.” You can be sure that when a straight chiropractic opponent poses this question, he means “Refer.”
As we answer this question, we need to consider it from a practical standpoint. Most of us will never be in a position of debate so we need practical answers.
A straight chiropractor who has adequately educated the patient should never be placed in a position to have to Refer to another health care provider. If the patient understands the chiropractic objective and the chiropractor is practicing that objective, the situation should never arise. The patient may indeed need specific care by another trained professional but he would not ask his chiropractor to Refer him to a particular health care provider. He would realize that that is not in the area of his chiropractor’s expertise. The straight chiropractor should be correcting subluxations exclusively, something that no other health care provider can provide. If a patient asks whether he or she should see a physician, orthopedist, neurologist, internist, etc., then the chiropractor has probably failed somewhere in educating that patient as to his role in the patients’ health care. If the patient has decided to see one of the above and asks for a name from you, it would not be a Referral anymore than giving them the name of an auto mechanic, by Webster’s definition. You did not “send or direct” them for “treatment.” He decided on his own to go. It is, however, my opinion that, in the case of health care providers, it is unwise to give out any names. The best and safest response is to advise them to see their family physician for a recommendation. This prevents any confusion regarding the chiropractic objective. If more patients ask you for the names of other professionals within the health field than they do for auto mechanics, there is a good possibility that you are not making your objective as clear as you should. This may be stretching it, but I think you get the point.
The question of a chiropractor noticing an obvious deviation from the average in examining a patient’s spine can be raised. It is, of course, the responsibility of the D.C. to make known to the patient his “unusual finding.” If the patient wants to know what to do about it, then his options should be explained to him. But then, every patient coming in with a symptom, should have his four options explained to him prior to beginning care. If you do not know what these options are or how to explain those options, write the Foundation and we will send you information on how we think they should be explained.v5n6