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The NHSCS Rejects Part of Choosing Wisely

 Concerns on behalf of all NH DCs that led to a position opposing the X-ray
portion of the controversial Choosing Wisely

Choosing Wisely
Essentially, the Choosing Wisely initiative was a well-intended and widely lauded effort by a
variety of health professional associations to improve patient-doctor communications, ideally
resulting in improved patient care. The Choosing Wisely initiative was supported by the
American Chiropractic Association in 2017.

By the fall of 2017, Chiropractic associations, Chiropractic colleges and plenty of individual DCs
were startled by and extremely concerned about wording in Choosing Wisely regarding the use
of plain film radiography, specifically:
“In the absence of ‘red flags,’ do not obtain spinal imaging (X-rays) for patients with acute low back
pain during the six weeks after onset of pain” and “Do not perform repeat spinal imaging to
monitor patients’ progress.”

On May 3rd, 2018 the NHSCS Board of Directors unanimously supported
a resolution (attached), which rejected the ACA’s endorsement of Choosing Wisely (as it relates
to Chiropractic spinal imaging) and forwarded it to the leadership of the American Chiropractic
Association.

Here is the resolution.

New Hampshire State Chiropractic Society

BOARD OF DIRECTORS’ RESOLUTION #1-2018
May 3, 2018
Certificate of Resolution Supporting the Chiropractor’s Right to Clinical Decision-Making Regarding Radiology

WHEREAS , the New Hampshire State Chiropractic Society (NHSCS) embraces
Conservative Care First as a verified public health policy strategy for safe and
cost-effective health care for all NH Citizens;

WHEREAS , the NHSCS represents the interests of NH licensed doctors of chiropractic
and pursues its purpose by informing, educating, and advocating on behalf of all doctors
of chiropractic and their patients;

WHEREAS , the NHSCS recognizes its responsibility not to set policy, but to protect
and perpetuate the rights of individual chiropractors to choose the clinical procedures
within the chiropractic standard of care and practice, that he or she believes best
address the patient’s complaint and/or diagnosis;

WHEREAS , the New Hampshire Chiropractic Practice Act, Section 316-A:1
defines the scope of practice of chiropractic to include, among other things, “the use of
x-ray and other analytical instruments generally used in the practice of chiropractic. ”
(emphasis added);

WHEREAS , radiology is a scientifically proven component of the chiropractor’s clinical
practice, as the role of diagnostic radiology is clinically useful in evaluating multiple
aspects of human spinal anatomy, biomechanics, postural faults, misalignments,
vertebral subluxation complex, and other pathologies;

WHEREAS , the NHSCS recognizes that clinical practice guidelines do not, cannot, and
should not represent a “set-in-stone” prescription of care, as they do not take into
account such critical factors as the judgment of the chiropractor and the individual
circumstances and values of the patient;

WHEREAS , the NHSCS is aware of recent publications from the American Board of
Internal Medicine (ABIM) Foundation, as part of the ABIM Foundation Choosing
Wisely® campaign and the American Chiropractic Association (ACA) endorsement
regarding the appropriateness of radiological spinal imaging for patients with low-back
pain during the six weeks after onset in the absence of red flags. The NHSCS Board of
Directors fundamentally rejects the statements in this document that state: “Do not
obtain spinal imaging for patients with acute low-back pain during the six (6) weeks after
onset in the absence of red flags” as well as “Do not perform repeat imaging to monitor
patient’s progress” as they are in opposition to reason and to usual and customary
Chiropractic practice. They are also contrary to the Practicing Chiropractors’ Committee
for Radiology Protocols (PCCRP) Guidelines as accepted by the National Guideline
Clearinghouse.

WHEREAS , the NHSCS recognizes that entities such as insurance companies and their
claims reviewers have used this publication to deny the use of radiographic studies to
patients and deny reimbursement for such studies to chiropractors;

WHEREAS , the NHSCS recognizes X-rays should be taken as clinically indicated, as a
matter of public health, and based upon a thorough clinical evaluation within the lawful
scope of chiropractic in New Hampshire; and NOW, THEREFORE, BE IT RESOLVED,
by the NHSCS, that the NHSCS re-affirms that it fundamentally rejects the American
Chiropractic Association (ACA) endorsement of the Choosing Wisely campaign as it
relates to spinal imaging within a chiropractic setting.

Unanimously approved by official vote of the NHSCS Board of
Directors on May 3, 2018