The chiropractic profession is 107 years old, and September 18, 2002 marked another Founder's Day. With so much focus on mourning the loss of lives due to the attack on the World Trade Center on September 11, 2001, additional reflection on September 18 might be in order as we weather the first years of the 21st century. Chiropractic came into being in 1895, at a time when confusion about health was widespread. Tools in the conventional medical armamentarium were scant. The famous Flexner Report (Medical Education in the United States and Canada, Abraham Flexner, 1910, Carnegie Foundation for the Advancement of Teaching, Menlo Park, California) had not yet been commissioned, and health care in the U.S. in general could only be classified as dismal (at best) or futile (at worst).
The issues relative to health care at the turn of the century were what to do with infectious diseases, epidemics and plagues. Bacteria were yet to be discovered, and the "magic bullet" of antibiotics (and their creation of a false sense of security) was not yet a reality. There was little research into molecular biology, and the many incredible innovations in surgery would not take place for another 75-100 years. As we look back during that era, the progress of medicine was stellar, we might ask - what about the progress of chiropractic? What role does chiropractic play in health care today, 100 years after its discovery?
Has the chiropractic profession achieved the recognition it fought for so vigorously during a century of struggle? Has it defined its goals? Has leadership clearly articulated to each practitioner what the struggle chiropractic has endured really means? What message has the chiropractic profession conveyed to those consumers of health care who are the ultimate reason every profession exists - about where we fit in today's health care delivery system? Has the consumer been told why the profession exists, what it does and who its practitioners are?
In today's media-driven, ever-changing health care environment, the challenges to the existence of every profession are clearly based upon the needs, wants and perceptions of the public. Sophisticated health care consumers, particularly the "baby-boomers," are more willing than ever to seek chiropractic and many other conservative, nonmedical interventions. One only has to observe the escalating use of acupuncture; massage; spiritual healing; nutrition; herbs; aromatherapy; music therapy; homeopathy; naturopathy; and a host of other lesser known interventions. These are also being researched, scrutinized and demanded by the new, informed 21st-century health care consumer.
Consumers recognize that health care and benefits are among the most discussed, costly and debated topics regarding employment. They recognize the ultimate financial loss that will occur in the event of a catastrophic health care crisis, and that looms heavily on the minds of every citizen - young or old. The public seeks to make intelligent decisions regarding what each profession offers on behalf of improving human health. They are not interested in self-interest discussions about fees or protecting providers; they are interested in how the health care reform will affect them.
Chiropractic has achieved a certain degree of parity and recognition, but it has failed to satisfy the essential question regarding identifying the real value of chiropractic to the health care consumer. If chiropractic provides cost savings to health care, and potential improvement to the quality of life for its consumers, it has not expressed these benefits clearly.
The fragmented leadership in chiropractic has not defined the purpose or function for the chiropractic profession in a singular and common vision. Rather, it has confused the public and the profession with multiple, disparate definitions of chiropractic. If this dilemma is not clearly defined soon, there will be a significant disconnection between the legitimate expectations of the public and the unrealistic benefits sought by the chiropractic profession.
If it is determined that a chiropractic adjustment is the only differentiating quality of the profession, how has this uniqueness been clearly articulated to the public as being different from osteopathic manipulation, physical therapy mobilization, or myriad other manipulations that have entered the marketplace since manipulation has become "mainstream?" In the minds of the perspective patients, they want and have a "choice," and what that "choice" ultimately translates into is the value "perceived" by the patient to the value "received" from the service.
The public clearly recognizes that others can deliver a manipulation, adjustment, mobilization, or whatever name is given to the correction of a spinal dysfunction. What, then, will create the differentiation for the public to have a preference (demand) for the services of doctors of chiropractic in lieu of other providers?
The question regarding the focus on adjustment/manipulation can be significant, even if DCs are the best skilled and most proficient at delivering this service. Has the question been asked, "Does delivering a good adjustment provide enough differentiation to distinguish the chiropractic profession from others who offer similar or expanded services?" Distinguishing chiropractic as viable and valuable health care must be viewed as more than the singular delivery of a singular intervention. Discussions by some chiropractic leaders have included the unique and distinctive paradigm of wellness, and a focus on the enhancement of the qualify of life of the individuals who are cared for by DCs.
Some leaders have demanded that lifestyle education; nutritional advice; proper exercise; low-tech rehabilitation; integration of the biopsychosocial model; and ultimately the mind-body connection, must be incorporated into the chiropractic paradigm. To my knowledge, no global analysis to determine what is currently being sought by those who are in search of health and wellness and what is offered by the chiropractic profession has been done. If we find that the model is broad and wellness-oriented, are we prepared as a profession to fill that need, to place the distinctive differentiating aspects of chiropractic clearly in the public forefront? Are we ready to find out what the desires and wants of the public are, or will we simply make our internal determination and try to sell that to an unwilling public?
The history of chiropractic is rich with depictions of the profession's struggle for survival, the perseverance and passion for recognition and the fierce determination to maintain distinction. That was the foundation upon which chiropractic was built, and it may have been proper for the time. The question for 2002 and beyond, however, remains vague, confusing and largely unanswered.
The many milestones achieved by the chiropractic profession - licensure in every state, CCE accreditation, the passage of Medicare, victory against the AMA, inclusion in the VA - have left considerable excitement and havoc in the path of progress.
The political debate over health care reform has changed the landscape and refocused the debate on how, why, where and to whom health care will be delivered; the focus is a patient-centered, not provider-centered model. Has the chiropractic direction for this century been defined and redirected to meet this new paradigm? Has a new emphasis on cost, quality and outcomes demanded by the consuming public and policymakers been addressed satisfactorily? Has the debate over the new health care delivery system prompted (or will it ever prompt) the appropriate response and proactive role for chiropractic to assume as it moves through the 21st century?
Daily information in the news, including that of hormone replacement therapy (HRT); the value of knee replacement; the advocacy of acupuncture; and the daily dose of vitamins as acceptable in a recent JAMA article, has all changed and reframed the health care debate. The changing world and the changing delivery of health care is incorporating items previously unfathomable into its decisions: the genome project; nanotechnology; smart drugs; and advances in laser surgical techniques. All these new technologies provide significant hope for conditions that were once terminal, viewed as "crises," or nontreatable disease issues. There is no limit to what the future may hold for technology. What was lost in the technological euphoria was the debate regarding the ineffectiveness of these new advances in meeting the needs of the "chronic illness crisis," exploding in terms of numbers and economics.
Chiropractic functioned for decades on the concept that illness first needed a weakened host, providing an environment hospitable for microbes. Though initially spurned, this has begun to be discussed as a new concept or breakthrough. It has been embraced by DCs for many decades, and yet no attribution to the profession can be seen. The teaching of the underlying biological model upon which chiropractic is based could be one of the distinctions that clearly differentiates the profession from others. This teaching may identify that tomorrow's health care for those who are chronically ill is not to attempt to treat those who are sick to regain health, but to intervene with those who are not yet sick, and teach them the most desirable ways to enhance health. The "health-care-coach" model, as espoused by Clem Bezold,PhD, of the Institute for Alternative Futures in the monograph Complementary and Alternative Healthcare, clearly identifies the doctor of the future.
What factors does the neuromusculo-skeletal system (NMS) play in the maintenance of health and the reversal of disease? After 100 years of research that suggests there may be a role for the NMS to play in health maintenance and that NMS dysfunctions may require the unique adjusting skills of doctors of chiropractic, this has yet to be offered as a compelling health care concept model for tomorrow.
This article was not written to provide answers, advocate direction or determine solutions. It was written to provoke thought relative to the celebration of 107 years of chiropractic on September 18, 2002.
What will the legacy be for the chiropractic profession? Will chiropractic have best served the needs of the patients of the world by attempting to revert back to a very limited role, or will we make an equally serious error by attempting to become so like the medical health care model we have fought against for so long as to be virtually unrecognizable?
Chiropractic must walk a delicate line. We do not want to be perceived by the public as so far from the mainstream that we are "fringe," or so close to mainstream medicine that we lose our identity. Being "against" disease is not the same as being "for" health, any more than being "against" war is being "for" peace. Chiropractic must guard against opposing medicine, which is not the same as embracing a different health paradigm. DCs must also collectively begin to recognize that American social issues are equally as important as advocating specific chiropractic interventions.
We must take socially responsible positions in public health, such as, but not limited to: anti-smoking; obesity; air, water pollution and other environmental threats; and helping those underprivileged who require help. We must consider our role (or historic lack thereof) in helping to determine health care policy, recognizing that the silence from the chiropractic community has been deafening regarding issues of healthy lifestyles and public policy.
September 18, 2002, only a week from the first annual observation of the day that changed America forever, has caused me to reflect on where we are as a profession, and how to seize the opportunity provided by the colliding of the paradigms of the new health care consumer and the recognition of the value of a chiropractic model of health care. This new awareness should provide a basis for determining where we want to be as a profession, and what our role might be in the 21st century. Maybe it is time to begin anew!
Louis Sportelli,DC
Palmerton, Pennsylvania
