Professionalization as a Political Process: Are We Moving in the Right Direction?

The ethical concerns I voiced in my previous column, "Diagnosis Is Your Legal and Ethical Responsibility" (Dec. 1, 2015 issue) focused on the Colorado Chiropractic Association's new standards of care, which appear to negate the need to make a diagnosis prior to providing chiropractic services. Since then, it has been reported to me that a group of younger members of the CCA and graduates of a "straight college" entered the meeting room at the end of the meeting and became the majority. At that time, the majority voted to create the new standards.

Although the young CCA members may have followed parliamentary process at the meeting, it appears the group avoided the majority of issues discussed at the meeting. This group of young chiropractors intended to change the association's standards of care without regard for the desires of the majority of the membership. This behavior raises a question in my mind: Did this group action demonstrate professionalism?

The RAND Corporation recently produced a report by Patricia M. Herman and Ian D. Coulter that discusses a problem which confronts the complementary and alternative medicine professions (CAM), including chiropractic medicine.¹ The authors asked why insurance companies, governmental agencies and other organizations define CAM professions politically by their treatment modalities, rather than by the full professional scope of each profession. It is important for chiropractors to realize a political process, which requires professional behavior by members of the chiropractic profession, affects the definition of chiropractic medicine and its scope of practice.

The Value of Professionalization

"Historically, professions arose out of guilds and were given extraordinary independence, authority and power by the state. This occurred through what has come to be called the social contract. In return for certain responsibilities, the professions were given extensive powers and privileges. In the health field this could be the power to control entry to the profession, to accredit the institutions of education and training, to discipline members, to disbar members, to set standards, to claim exclusivity for practices/modalities, to conduct human dissection, to prosecute any others who might trespass on their scope of practice, and to virtually define what constitutes health, acceptable health care, and healing."²

Professionalism is a vital role, one that must be embraced by the chiropractic profession. It requires observance of standards of care / behavior espousing altruism, a commitment to patient-centered care and evidence-based practice behavior. "Making decisions without sufficient information is a form of arrogance."³

Leaders and members of the profession should avoid destructive arrogance. Making decisions to change standards of care with insolence and a lack of empathy for colleagues and patients is an example of paternal arrogance.

I suggest that rather than commandeering a board meeting in order to create new standards of care, the group of CCA chiropractors should have behaved in a manner demonstrating professionalism, as described below by the Canadian Association of General Surgeons. If we expect respect, we must demonstrate respect for our colleagues:

"The primary rationale for professionalism and collaboration is to promote patient safety. Health care is delivered by teams of professionals who need to communicate well, respecting the principles of honesty; respect for others, confidentiality and responsibility for their actions."⁴

The actions of chiropractic associations and colleges are becoming increasingly open to the public because of the Internet. The profession must voluntarily regulate itself, and its colleges should provide continuing education and postgraduate training that support the chiropractic scope of practice or endure regulation by non-chiropractors, such as experienced in Texas.⁵

The Council on Chiropractic Education claims the credibility gained through recognition of chiropractic resident training is an important factor for the future chiropractic practice. The completion of a chiropractic professional program indicates the student/graduate attained only the minimal level of training necessary to care for patients. The completion of chiropractic board specialties lays the skills foundation in a chiropractic specialty and indicates an exceptional level of training necessary to care for patients.⁶

Reynolds published an article in 1994, "Reaffirming Professionalism Through the Education Community." A re-examination of the role of the educational environment in fostering professionalism during medical training involved an extensive review of the literature and revealed barriers to professionalism in medical education.⁷

I am aware of the position of the University of Bridgeport College of Chiropractic (where I am a professor) regarding chiropractic education and professionalism. Yet I wonder if any of our graduates would participate in an effort to create new standards of care that reduce or eliminate the need to make a diagnosis prior to treating a patient?

Why is our preservation of professionalism so important? As Herman and Coulter state in their RAND report: "In summary, professionalism is a social construct shaped through a political process, and what the state has the power to give, it can also take away. Professions that have won privileges may lose them again. Professions still without desired privileges must constantly lobby, organize, and persuade those who grant the privileges to act on their behalf. Patients can, of course, be recruited to help in this process."⁷

References

1. Herman PM, Coulter ID. Complementary and Alternative Medicine: Professions or Modalities? Policy Implications for Coverage, Licensure, Scope of Practice, Institutional Privileges, and Research. Published by the RAND Corporation, Santa Monica, Calif., 2015.
2. Mootz RD, Coulter ID, Schultz GD. "Professionalism and Ethics in Chiropractic." In: Haldeman S (editor): Principles and Practices of Chiropractic. New York: McGraw Hill, 2005; pp. 201-219.
3. Ingelfinger FJ. Arrogance. N Engl J Med, 1980;303;1507-1511.
4. Warnock GL. Reflection on principles of professionalism. Can J Surg, April 2008;51(2);84-85.
5. Rock CN. "Texas Medical Association Sues Board of Chiropractic Examiners." Available from HG.org Legal Resources.
6. Lehman JJ. "Continuing and Postgraduate Education for Today's Chiropractic Clinician." ACA News, June / July 2014.
7. Reynolds PP. Reaffirming professionalism through the education community. Ann Int Med, 1994;120;609-614.