Integration or Isolation: What Price?

Are we part of the conventional health care system? Are we part of CAM? Perhaps we are neither or some of each. From the perspective of other CAM professions, we look rather "mainstream," given that we have licensure in all U.S. jurisdictions and many foreign countries, not to mention fairly routine inclusion in many insurance reimbursement systems. On the other hand, only a miniscule proportion of chiropractors practice in conventional and integrated health care settings. In fact, the percentage of DCs who indicate they practice in such settings has not changed in a decade.¹ Surprisingly few DCs partner fully with other CAM providers, and many integrated CAM clinics do not include chiropractors.²

Despite all of the advances and inroads our profession has made, we remain outsiders in many ways, particularly in the world of conventional health care. In the past, this was due in great measure to the ostracism of organized medicine. Today, I suspect it is primarily our own fear of success and all it might entail. As a profession, we want the accolades and rewards that mainstream recognition has to offer, but often seem to shun the responsibilities, competition, and additional work required to achieve it.

Although we might like being "conventionality chameleons" when it suits our agendas, I believe we have progressed beyond the days where we can get away with being moving targets of convenience. I liken the moving-target approach to an allopathic, symptom-oriented clinical intervention: Whenever a symptom (or issue) pops up, one can simply consider the immediate agony and reduce the suffering in the current situation (or prevail in the current crisis) with nary a concern for long-term effects. Frequently (and this is a human nature trait, not something unique to chiropractors) we get so comfortable and set in our ways, we become uncomfortable with change, particularly when our popularity increases, the spotlight shines on us, and new opportunities and their resultant responsibilities crop up. I contend that this trepidation is unfounded, and may be a sign of weakness and fear.

One example of taking a risk to step out of our isolation took place here in Washington, when the state association decided to partner with the University of Washington and the Department of Labor and Industries to conduct research to determine if the work chiropractors do in caring for patients is equivalent to that of other physicians. The state's DCs had been at odds with several state agencies regarding being limited to only two unique chiropractic treatment codes when they wanted to use the range of E/M codes and something more like the osteopathic manipulation codes. Since chiropractors were not included in the work for resource-based relative value schedules (RBRVS) originally, the state needed hard data to justify a major, potentially costly policy change. There was no guarantee that the result would come out in chiropractic's favor, but the association leadership took a deep breath and jumped in. The confidence paid off, work was indeed similar and the workers' compensation (WC) fee schedule was improved.³ But the more important spin-offs from taking a chance on behaving like the mainstream have been substantial. Not only did DCs go from two codes to 12 in workers' compensation, DCs have become a more integral part of many aspects of WC policy, leading multidisciplinary conferences, being included in important policy discussions, and now being outinely included by default in many aspects of health policy in the state. Although the system still has its problems, the playing field has been dramatically leveled. Prior to taking the risks in reimbursement to engage in the mainstream like others, this was not the case.

Another example of jumping into the mainstream fray is the Consortial Center for Chiropractic Research (CCCR) funded by the National Institutes of Health. The requirements for handing federal research grant dollars are incredible, and the responsibilities to conduct scientific work on par with the mainstream scientific community are phenomenal. The risk of failure was quite high. There is need to work with others outside the profession and follow accepted standards not developed by DCs. Chiropractic scientists and projects have been placed in the same field of competition as the established professions with extensive track records. Yet the CCCR is actively funding and conducting studies, with accolades from respected researchers at some of the nation's best universities.

Further, and much more importantly, chiropractic scientists are developing research skills and refining the designs of research studies and techniques to ask the right questions. They are uncovering new knowledge that, over the next several years, will help refine chiropractic procedures and next generation studies, all for the purpose of improving cthe are we offer to patients. The result is we find ourselves included in more mainstream scientific circles and are better positioned to engage in the discussions and decisions that will be made about heath care. Still a long ways to go, but seats at the table have been secured as a spin-off to this kind of commitment and risk-taking.

Given this and countless other examples where we have moved into positions of mainstream responsibility without losing our identity of control of our destiny, I am astounded when our professional schizophrenia and paranoia make us behave as isolationists. The recent effort by Palmer, my alma mater, to actively scuttle the first publically funded chiropractic program at Florida State University (FSU) befuddles me. Perhaps the greatest remaining obstacle to chiropractic becoming fully accepted is the (now) self-imposed isolation that exists in chiropractic education. The proposed FSU program was established as independent within the university, just like other graduate programs, including its own funding resources, control of the curriculum, and a direct chain of command reporting to the university hierarchy. It was not under the control, or even under report, to the FSU School of Medicine. In fact, it even ended up proposed for a different campus all together.

Rather than harming existing chiropractic colleges, a chiropractic school at a major public research university would open the doors for inclusion in all kinds of mainstream academic circles, with growth opportunities and resources to boot. The fact that the school would be made of DCs (a rarity at universities, and nearly nonexistent in academia today) would provide more influence for the profession and an incredible shot to efforts in the political world. The precedent alone would have currency for other schools in terms of offering additional training opportunities for graduates, advanced standing, and access to more publicly supported clinical settings. Although the possibility for a program at FSU remains, and will likely come up in the future, this setback paints chiropractors as isolationists. Are chiropractors, their intellect, and chiropractic principles so weak that they could not withstand the test of participating in publicly funded higher education? In my opinion, isolationism in the face of a major opportunity like this reflects something like fear or special interest agendas, not the interest of the profession at large.

We have two things going for us: We have some incredible, committed, talent comparable to that of the "best of them." We have a principled approach to health care that fills an important need, which has the ability to sustain its identity and contributions on its own merit regardless of the circumstances it is provided in. In the past, isolation allowed us to evolve our own culture, camaraderie, and identity, and in the past, that has in part contributed to our strength and self-reliance. But today it makes us weaker.

What if the Beatles had decided when their popularity was on the rise that it was just too risky for them to take their act to the big time?

"Others will steal our sound from us!

"But if we play the big tours with other big names, we'll lose our own identity and our sound will become contaminated by everyone else's!

"We will lose our uniqueness and become corrupted by the crooners from the 1940s!

"We can better control our destiny if we only play one small club in Liverpool and only sell our record directly to our fans!"

Believe me, if they had not stepped into the spotlight and taken the risk, someone else would have, and the Beatles would not have become the main-streamers, even though their music would have.

And that is my biggest concern. The "secret of chiropractic" is already out of the bag. If we choose to isolate ourselves and resist mainstream integration, others are ready and willing to take on those risks. I don't believe for a second that the chiropractic profession will be able to compete in the health care world merely by "containing and eliminating" rival professions that decide to practice the way we do. If we learned anything from our battle with organized medicine, it is that we need to take on the cultural authority of expertise and leadership, rather than putting resources into holding back the competition. We may win the occasional political skirmish, but lest we forget that we developed the standard for countering organized ostracism (be it medical or chiropractic), we must win by being the best and stepping into the spotlight.

If the only way we can hold our own is to isolate ourselves from everybody else in society, especially in the world of education, how substantive can our contribution really be? If it cannot withstand scrutiny, if only "the chosen few enlightened ones" can perpetuate it, how legitimate is it?

After 13 years of practice, and almost that many in the world academics and health policy, I am firmly convinced chiropractic and chiropractors can stand toe to toe with the best that anyone in health care and academia can throw at us. I just hope as a profession we can believe in ourselves enough to quit resorting to diatribe and fear mongering to perpetuate our self-interests. Our patients and future chiropractors deserve far better.

References

1. Christensen MG, Kerkhoff D, Kollasch MW (eds). Job Analysis of Chiropractic: A Project Report, Survey Analysis and Summary of the Practice of Chiropractic in the United States. Greeley, CO: National Board of Chiropractic Examiners, 2000.
2. Hanks JW. Chiropractic inclusion in complementary and alternative medicine clinics: analysis of current trends. Top Clin Chiropr 2001;8(2):20-25.
3. Hess JA, Mootz RD. Comparisons of work estimates by chiropractic physicians with those of medical and osteopathic providers. J Manip Physiol Ther 1999;22(5):280-291.