Cherkin DC, MacCornack FA
We compare health maintenance organization enrollees’ evaluations of the care they received from family physicians and chiropractors for low back pain. Patients of chiropractors were three times as likely as patients of family physicians to report that they were very satisfied with the care they received for low back pain (66% versus 22%, respectively). Compared with patients of family physicians, patients of chiropractors were much more likely to have been satisfied with the amount of information they were given, to have perceived that their provider was concerned about them, and to have felt that their provider was comfortable and confident dealing with their problem. Although the more positive evaluations of chiropractors may be related to differences in the patient populations served by the two providers or to benefits of spinal manipulation, it is suggested that a potentially more potent force–the therapeutic effect of the patient and provider interaction itself–may explain the observed differences.
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Persons who sought care for low back pain from chiropractors rated the care they received much more highly than persons who sought care from family physicians. Patients of chiropractors were more likely than patients of family physicians to have been satisfied with the information they were given about their problem, to have perceived that their provider was concerned about them during and after the visit, and to have felt that their provider was comfortable and confident in managing low back pain. Patients of chiropractors were also more likely to report that they would return to the same provider for care and were less likely to report that there were things the provider did not do for them that would have helped. Patients ofchiropractors also reported far fewer days oflimited activity due to their back pain.
The only other published study comparing allopathic and chiropractic care for back problems reported similar results. In their study of workers’ compensation cases, Kane and co-workers reported that patients who received care for back or spinal problems from chiropractors felt more welcome and were more satisfied with the provider’s explanation of their problem and treatment than were patients of allopathic physicians. No differences were found in functional improvement. 
There are a number of possible explanations for the differences observed in this study. One is that the family physicians and chiropractors saw different types of patients. From Table 2, we know that although the two patient groups were similar in terms of age and sex, they differed in terms of health status and number of previous episodes of back pain. Controlling for these differences, however, did not materially affect the results. It is not known whether there were differences in socioeconomic status between the two patient populations studied. While one of the earliest reports of chiropractors indicated that they attracted persons from the lower socioeconomic strata,  a more recent and nationally representative survey found the likelihood ofvisiting a chiropractor was not clearly related to either income or educational level. 
We do not know why individual patients selected a particular provider or whether patients had different expectations about the ability of each type of provider to help them. We presume that enrollees who chose to see chiropractors did so because of an expectation that their needs were more likely to be met by a chiropractor than by a family physician. But what about enrollees who chose to see a family physician even though their insurance covered chiropractic services? One would expect the 54 enrollees in this group to have been more satisfied with their care from family physicians than were enrollees whose only option in terms of insurance coverage was to see a family physician. In fact, we found the responses of the enrollees in these two groups to be virtually identical. This suggests that the more favorable views about chiropractors do not merely reflect the benefits of being able to select the type of provider that one expects to be the most helpful.
Practice setting differences, with the family physicians being on salary within a single HMO and the chiropractors in fee-for-service practices, could also have influenced the findings. A fee-for-service practice provides different incentives than a salaried practice in an HMO for scheduling return visits, ordering tests, referring patients to specialists, and possibly for length of visit. In addition, therapeutic options such as physical therapy may be more readily available within an HMO system than they are in most fee-for-service practices. Nevertheless, family physicians in fee-for-service practice and in HMOs have been shown to have generally similar beliefs and behaviors related to the management of low back pain.4 Hence, it is unlikely that practice setting differences alone are responsible for the large differences that were observed between family physicians and chiropractors.
The differences in patients’ evaluations of their care from family physicians and chiropractors may have resulted from differences in the providers themselves. Differences between the types of persons who ultimately enter chiropractic and medicine are evident even before they begin training. Compared with other health professionals, chiropractors are more likely to have chosen their profession after having witnessed a miraculous success achieved by a member of their profession  and to have chosen their profession as a second career.  Chiropractors are also more likely than physicians to resemble their patients socioeconomically and are less oriented toward financial success than are physicians. 
Probably the most profound difference between chiropractors and family physicians is their training and consequent beliefs, attitudes, and behaviors concerning the management of low back pain. Chiropractic training focuses on the spine and emphasizes a particular therapeutic technique-spinal manipulation-while family physician training covers the entire spectrum of clinical topics and does not emphasize the paramount importance of a particular therapy, even for back pain. Chiropractors generally believe that most back pain is caused by anatomic derangements in the spine, such as vertebral subluxations, that can be identified on a spinal radiograph and effectively treated using spinal manipulation. In contrast, family physicians believe that most back pain is caused by muscle strain, that spinal radiographs are rarely useful, that appropriate therapy does not depend on a precise diagnosis, and that patients will get better without professional help.  These differences may explain why family physicians are more likely than chiropractors to feel frustrated by back pain patients, less likely to think they can help prevent future episodes of back pain, and less confident that their back pain patients are satisfied with their care.  The results of this study suggest that patients may be more satisfied with the confident and definite approach ofchiropractors than with the less certain and more scientific approach of family physicians. Other factors, such as possibly longer visits with chiropractors than with family physicians, could also explain differences in patient satisfaction.
There are many differences between family physicians and chiropractors that could explain the observed differences in patient satisfaction, and it is not possible from this study to determine with certainty which might be the most important. The most clinically relevant question for patients and physicians, however, is whether patients’ more positive evaluations of chiropractors result from specific benefits of spinal manipulation or from other aspects of the interaction between patient and provider. Although studies of spinal manipulation for back pain have generally found that it provides more immediate relief of back pain than other methods with which it has been compared, [10, 11] other differences between the chiropractic and medical approach to low back pain could conceivably have a more potent effect on patient outcomes.
Coulehan claims that an interaction with a patient may have either a “beneficial (positive placebo) or harmful (negative placebo) influence on the patients’ condition,” and that “in many cases inadequacy of the medical process for musculoskeletal pain causes continuation of symptoms which then might be relieved through certain positive features of the chiropractic process.” He suggests that chiropractors may be better able than allopathic physicians to promote patient acceptance and validation, fulfill expectations, provide explanations, and engage patients’ commitment because chiropractors strongly believe their therapy will help and they are less constrained by “scientific” models ofdisease.  Recent studies have shown the importance of the patientprovider interaction on the outcomes of care. For example, in a study of the outcomes of new episodes of common nonrespiratory tract symptoms, Bass found that the only element in the process of care that was related to early resolution of a patient’s symptom was agreement between physician and patient about the nature of the problem.”  In a randomized study of patients with symptoms but no abnormal physical signs and in whom no definite diagnosis was made, Thomas reported that patients given a firm diagnosis and assurance that they would be better in a few days were more satisfied and were more likely to get better than patients whose physician expressed uncertainty about the diagnosis and the likelihood that the therapy would be effective.  Other studies of the therapeutic aspects of the clinical encounter have been summarized by Novack. 
The science of medicine may not provide physicians with tools that are generally effective for managing back pain. Although particular therapies, such as spinal manipulation, may in fact be effective for some patients, there is reason to think that other aspects of the patient-provider interaction may have a greater influence on the outcome of care. Greater consideration should be given to the potential for the art of medicine to provide low back pain patients with effective therapy.
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