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Confusing Credentials and Definitions

Why are titles so important? Dr. Narda Robinson explores the topic.

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Originally published in the April 2015 issue of Veterinary Practice News

What do the terms “chiropractor,” “nurse,” “physical therapist” and “osteopath” all have in common? Other than all these words referring to human healthcare providers, they are all considered “protected” titles by their profession, at least in the United States.

What this means is that those who claim to practice techniques such as chiropractic, nursing, physical therapy and osteopathy should hold a license in that field. Nonetheless, mistakes happen. 

A few years ago, the president of the American Chiropractic Association told a reporter for a national news outlet “a chiropractic treatment plan may include physical therapy.”

This drew an icy response from the director of public and media relations at the American Physical Therapy Association, or APTA.[i] 

“’Physical therapy’ is not a generic term,” he said. “It describes only those services provided by a licensed physical therapist.  Chiropractors may provide some of the same treatment modalities as physical therapists, but they should portray their services as chiropractic and not as ‘physical therapy.’” 

Along similar lines, it would seem prudent for veterinarians and veterinary technicians who perform techniques such as therapeutic exercise, ultrasound therapy and functional restoration to call them rehabilitation and not “PT.”

This type of tension between professionals and scope of practice is not new. 

It spawns debates ranging from ethics to practice rights, many revolving around the terms chosen to describe what falls within the scope of practice.  Discussions of the differences between the words “manipulation” versus “mobilization” serve as one example.[ii] [iii]  

According to the APTA, “Over the last several years there have been challenges in the various state legislatures against the physical therapy profession via legislation promoted by chiropractors attempting to prohibit qualified physical therapists from performing spinal manipulation – a technique that has been part of the PT scope of practice since its inception.”[iv] 

The impact for human healthcare providers relates not only to scope of practice limitations[v] but may also affect insurance compensation, further heightening interdisciplinary tensions.[vi]

Consider, too, the term “nurse,” which a growing number of veterinary practices seem to be substituting for “veterinary technician.” Perhaps they are doing so unknowingly, as “nurse” is a protected title for human healthcare workers in a majority of states in the U.S.[vii]

According to the American Nurses Association, “Restricting use of the title ‘nurse’ to only those individuals who have fulfilled the requirements for licensure as outlined in each state’s nurse practice act is protection for the public against unethical, unscrupulous and incompetent practitioners.  Nurse practice acts describe entry level qualifications such as education, practice standards and code of conduct for continued privilege to practice nursing.”[viii] 

The term “veterinary nurse,” in contrast, has earned no such protection in both the United States and the United Kingdom, thereby allowing essentially anyone to claim the title.[ix]  In fact, juxtaposing the word “veterinary” next to “nurse” reportedly raised ire in New York several years ago, causing registered nurses to submit a complaint to the state veterinary board to “ensure naming rights to the term and to limit its designation to the human nursing profession.[x]

The latest terms in the protected title entanglement are “osteopathy” and “osteopathic manipulation.”  In the U.S., where osteopathic medicine began, a doctor of osteopathic medicine must graduate from an osteopathic medical school accredited by the American Osteopathic Association’s (AOA’s) Commission on Osteopathic College Accreditation.[xi] 

As indicated by the AOA, “The curriculum at osteopathic medical schools consists of four years of academic study. Reflecting osteopathic philosophy, the curriculum emphasizes  preventive medicine and comprehensive patient care. … After completing osteopathic medical school, DOs obtain graduate medical education through internships, residencies and fellowships.  DOs specialize in all areas of medicine, ranging from such primary care disciplines as family medicine, general internal medicine and pediatrics to such specialized disciplines as surgery, radiology, oncology and psychiatry. … DOs are complete physicians, fully trained and licensed to prescribe medicine and to perform surgery. [N.B.: Emphasis is mine.]

In contrast to how the osteopathic profession in the United States defines osteopathy, we see a different reading by those who write about and teach “veterinary” or “animal” osteopathy, viewing it more as a means of musculoskeletal or visceral manipulation than the practice of medicine. 

There is at this time no requirement that the practitioner of equine osteopathy, for instance, hold a degree from an AOA-accredited osteopathic medical school.[xii]  [xiii]  Those treating animals with “osteopathy” or claiming to be an equine “osteopath” may be following trends in Europe, where the training to become an osteopath differs from that in the United States.[xiv]   

Nonetheless, even osteopaths in the United Kingdom must have veterinary consent prior to treating an animal.

Regarding animal osteopathy, the Texas State Board of Veterinary Medical Examiners lists the requirements under which “chiropractic and other forms of musculoskeletal manipulation (MSM)” may be performed.  The Texas Administrative Code states, “Animal chiropractic and other forms of MSM in nonhuman animals are considered to be alternate therapies in the practice of veterinary medicine.”[xv]  [N.B.: The Texas Board of Chiropractic Examiners defines “chiropractor” as a person licensed to practice chiropractic by the board.[xvi]

This change prompted a plea and a petition to “save equine osteopathy in Texas,”[xvii] [xviii] generated in conjunction with an animal osteopathy school in Texas, along with a suit against the state board, according to a Facebook post, and a request for contributions to offset legal fees.[xix]

In some ways, this situation sounds similar to the suit brought by massage therapists against the Arizona State Veterinary Medical Examining Board for requiring that massage be practiced by or at least supervised by a licensed veterinarian.[xx] [xxi] 

That is, in both cases, disgruntled non-veterinarian manual therapy practitioners are taking legal action against a state board of veterinary medicine because laws limit their independent practice. 

However, this situation differs in that the misuse of the term “osteopathic” by non-physicians carries additional implications. 

According to an article in The DO, i.e., the osteopathic profession’s journal for its members, the use of “osteopathic” to describe non-physicians is inappropriate. Even within the human realm, referring to non-physician practitioners as “osteopaths” may lead to “considerable confusion to the public, government regulatory bodies and insurance companies, jeopardizing the integrity of the osteopathic medical profession while placing the public at risk.”[xxii] 

Leaders of the Canadian Osteopathic Association (COA) wrote, “To protect the public and the reputation of our profession, we would like to encourage all AOA and COA affiliate organizations to continue to promote comprehensive osteopathic medical care as taught by AOA-accredited institutions, to continue to pursue title protection of the osteopathic medical degree in North America.”

It seems reasonable to assume that if a school lacking accreditation by the American Veterinary Medical Association were granting certifications involving the term “veterinary” or “veterinarian,” this would not sit well with the veterinary community. 

Shouldn’t we bestow the same respect for human protected titles?

References

[i] Rouco EJ.  APTA responds to FoxNews.com article on use of term “physical therapy.”  American Physical Therapy Association (APTA) website.  May 4, 2012. Accessed on 02-21-15 at www.apta.org/Media/Releases/APTA/2012/5/4/ .

[ii] APTA website.  Manipulation/Mobilization.  Accessed at www.apta.org/StateIssues/Manipulation/ on 02-21-15.

[iii] Editorial Staff of Dynamic Chiropractic.  Chiropractic board fines PT for performing spinal manipulation.  Dynamic Chiropractic.  2003;21(5).  Accessed at www.dynamicchiropractic.com/mpacms/dc/article.php?id=9048 on 02-21-15.

[iv] APTA website.  Manipulation/Mobilization.  Accessed at www.apta.org/StateIssues/Manipulation/ on 02-21-15.

[v] Huijbregts PA.  Chiropractic legal challenges to the physical therapy scope of practice:  anybody else taking the ethical high ground?  Journal of Manual and Manipulative Therapy.  2007;15(2):69-80.

[vii] American Nurses Association.  Title “Nurse” Protection.  Accessed at www.nursingworld.org/MainMenuCategories/Policy-Advocacy/State/Legislative-Agenda-Reports/State-TitleNurse on 02-21-15.

[viii] American Nurses Assocaition.  Title “Nurse” Protection.  Accessed at www.nursingworld.org/MainMenuCategories/Policy-Advocacy/State/Legislative-Agenda-Reports/State-TitleNurse on 02-21-15.

[ix] Royal College of Veterinary Surgeons.  RCVS calls for a Private Members’ Bill to protect VN title.  May 16, 2013.  Accessed at www.rcvs.org.uk/news-and-events/news/rcvs-calls-for-a-private-members-bill-to-protect-vn-title/ on 02-21-15.

[x] Khuly P.  Nursing a grudge:  RNs wage a war of words against veterinary technicians.  PetMD.com.   June 1, 2008.  Accessed at www.petmd.com/blogs/fullyvetted/2008/june/nursing-grudge-rns-wage-war-words-against-veterinary-technicians-5745 on 02-21-15.

[xi] American Osteopathic Association.  About osteopathic medicine.  Accessed at www.osteopathic.org/osteopathic-health/about-dos/about-osteopathic-medicine/Pages/default.aspx on 02-22-15.

[xii] Student AHVMA website.  Osteopathy.  Accessed at www.students.ahvma.org/complementary-medicine-modalities/ on 02-22-15.

[xiii] Anonymous.  Using osteopathy to diagnose and correct a displaced ovary in the “grumpy” mare.  Integrative Veterinary Care Journal.  2014-2015 Winter Issue.  Pp. 48-51.

[xiv] Akehurst S. Equine Osteopathy. (Part 1).  Horse Times Magazine.  Accessed at www.horsetimesegypt.com/pdf/articles/MEDICAL/Equine_Osteopathy_%28Part_1%29.pdf on 02-23-15.

[xvi] Occupations Code.  Accessed at www.statutes.legis.state.tx.us/Docs/OC/htm/OC.201.htm on 02-23-15.

[xviii] Ipetitions. Save equine osteopathy in Texas.  Accessed at www.ipetitions.com/petition/save-equine-osteopathy-in-texas/ at 02-23-15.

[xix] Facebook on “Save Equine Osteopathy in Texas” site.  Accessed at www.facebook.com/SaveEquineOsteopathyInTexas/posts/496301313798067 on 02-23-15.

[xx] NEWStat.  Canine massage therapists sue Arizona.  Accessed at www.aaha.org/blog/NewStat/post/2014/12/01/946208/Canine-massage-therapists-sue-Arizona.aspx on 02-23-15.

[xxi] Robinson N.  Arizona animal-massage therapists sue for access to veterinary patients.  Veterinary Practice News.  June 2, 2014.  Accessed at www.veterinarypracticenews.com/Arizona-AnimalMassage-Therapists-Sue-for-Access-to-Veterinary-Patients/ on 02-23-15.

[xxii] Fiddler D and Church JB.  Misuse of osteopathic in nonphysician titles a setback for profession in Canada.  The DO.  February 17, 2011.  Accessed at thedo.osteopathic.org/2011/02/misuse-of-osteopathic-in-nonphysician-titles-a-setback-for-profession-in-canada/ on 02-23-15.

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