In this questionnaire survey, the experiences and opinions of Swedish and Norwegian GPs about chiropractic were explored.
Just under half of the distributed questionnaires were returned, which is not unusual for studies of this nature [9]. As the responses were anonymous, it is not possible to perform an analysis to assess possible bias of this response rate. It is quite possible that the majority of the GPs (who did not return their questionnaires) had a totally different experience and opinion of chiropractic than what can be extracted from this study. However, the resulting picture sheds light of chiropractic’s position in the two countries, and seems to be informative regarding the matters under investigation. In Sweden, the survey was sent in handwritten envelopes. However, the response rates were almost identical in the two countries, leaving the importance of this additional effort subject to doubt.
As the survey is based on two Master-projects, they were distributed two years apart which may limit the comparison of the results between the countries. However, there were no changes in the legislation concerning chiropractic during these two years in either country, thus we do not believe that the time gap has any major role in the measured perceptions and opinions. Moreover, the experience of the first survey in Norway informed the space for additional comments in the Swedish version.
The Swedish sample of GPs was older than the GPs in the Norwegian sample. The importance of this finding on the results is unknown, but one may speculate that the older practitioners have a poorer knowledge of alternative and complementary medicine in general, which may be reflected in the results.
Opinions and experiences about chiropractic
There are clear differences between the GPs in the two countries concerning their perceived knowledge about chiropractic, with the Swedish GPs reporting poorer knowledge than their Norwegian colleagues. The difference in the age distribution mentioned above may be responsible for this disparity. Perhaps the younger GPs are more aware of complementary medicine? There might also be educational differences between the younger and older GPs influencing the knowledge of chiropractic. An alternative explanation may be that in Sweden there are fewer chiropractors relative to the size of the population compared to Norway, which makes the Swedish GPs less exposed to chiropractic which could possibly be reflected in their lack of knowledge about the chiropractic profession.
About half of the GPs in Sweden thought that chiropractic education was satisfactory for mainstream medicine, and 80% of the Norwegian GPs thought so. As there are differences in the educational standards for chiropractors practising in Sweden, the profession is less homogenous which may lead to a perceived variation in the quality of care reflected in the lower Swedish score.
Chiropractic terminology and mainstream medicine terminology are different and this may potentially be problematic. However, very few (11%) of the Swedish GPs thought so, but 25% of the Norwegian GPs were aware of this potential problem. One explanation may be due to protocol differences between the countries when it comes to communication between GPs and chiropractors. In Sweden it is not mandatory for chiropractors to contact the GP after referral, whereas in Norway the chiropractor is obligated to contact the GP under such circumstances, Therefore, more communication is taking place between the chiropractors and the GPs in Norway compared to Sweden, which might explain the differences between the countries for this particular question.
In rating their experience of chiropractic, there were also marked differences between the countries. In Sweden, less than half of the GPs reported a good experience, and 21% stated that they had no experience of chiropractic care. The corresponding figures for the Norwegian GPs were two-thirds with good experience and only 3% had no experience. Again, this could reflect the before mentioned poorer exposure to chiropractic and the variable quality of chiropractic education in Sweden.
Referrals
Chiropractic in Sweden is not part of mainstream medicine and GPs cannot refer patients for chiropractic care in the same way that they refer patients for physiotherapy as chiropractic is not included in the public health care system. Therefore it is challenging to compare referral patterns between the two countries. In Norway chiropractic is accepted as a viable option for patients with musculo-skeletal problems and is recommended by 79% of the GPs. This is almost twice the referral rate as in Sweden. Even if the Swedish GPs would like to refer patients to a chiropractor there are no official channels to do so and some GPs stated that they hesitate to refer patients because of the increased financial burden for the patient.
The conditions for which Swedish and Norwegian GPs refer patients to chiropractors are similar in the two countries. Acute and chronic low back pain with or without radiating leg pain were the conditions chiropractors were deemed competent to treat, which is consistent with the available evidence and for the scope of chiropractic care. The large difference in referrals for paediatric chiropractic care between the countries might be due to the fact that the ban on treating children in Sweden was only recently lifted, thus no tradition exists for this option. It may also be related to differences in recognition of the chiropractic profession in general.
There was agreement between the Swedish and Norwegian GPs that there were poor levels of reporting back to the GP. This pattern is seen in similar studies [9–11]. We speculate that an explanation for the poor levels of reporting back to the GPs might be differences in expectations of when a report is needed. Perhaps the GPs expect a report back for every patient they refer to the chiropractor and the chiropractor only reports to the GP when the patient’s condition change to a non- biomechanical condition that cannot be managed by the chiropractor. This is possibly an area where the chiropractic profession has room for improvement. If chiropractors reported back to GPs more frequently, the knowledge and understanding of chiropractic care would potentially improve.
Poor knowledge and not being certain of the effectiveness of chiropractic care were the most common reasons for GPs in both Sweden and Norway for not referring to a chiropractor. It is likely that poor knowledge and doubtfulness about the benefits of chiropractic care are influenced by each other. The growing evidence base of chiropractic care being effective in the treatment of acute and chronic low back pain, [12, 13] was possibly reflected in the fact that these were the most common reasons for sending patients to the chiropractor. However, there may be other reasons responsible for the fact that many GPs doubt the effectiveness of chiropractic care. As mentioned in the comments, misconceptions about risks associated with chiropractic care, economic reasons and not being up to date with the latest evidence may all play a part. However, investigating these factors further was beyond the scope of this study.
Referring patients for physiotherapy was a very common option for the majority of GPs in both Sweden and Norway. This was an expected finding as physiotherapy has been within mainstream medicine for a long time and the patients in both countries receive financial subsidisation for this type of care.
The negative comments from the Swedish GPs may offer some insight into why the referral rates in Sweden are lower than in Norway. The GPs’ comments about different levels of education are justified because that is the case and a cause for concern in Sweden. To date, there are more chiropractors practicing in Sweden who are graduates from The Scandinavian College of Chiropractic than chiropractors from ECCE accredited colleges. Without a minimal level of academic quality in chiropractic education it might be difficult for the chiropractic profession to convince the medical profession that chiropractic is evidence based, effective and safe.
The comments concerning safety are linked to poor knowledge about the latest evidence. The most recent research suggests that there are very low risks associated with chiropractic manipulation [14].