During the political election year, I was listening to a discussion about the impact of third-party candidates like Ross Perot. It struck me that if one likens health care to a political election, chiropractic has become like the third party. What that means is that we take a comparatively small percentage of followers away from the main candidate (establishment medicine), but many see our main function as being the one to bring up serious topics, which then are appropriated by the main candidate. Little attention was being given to lifestyle issues (exercise, diet, effects of stress, etc.) except by chiropractors. Finally, the popular media chimed in and, as usual, the last one on the bandwagon was the medical establishment, who took it over as if they owned the topic and became the instant experts on these issues.
The System Favors the Establishment
In the discussion of political parties, it was pointed out that the system actually is slanted toward favoring the two-party system, which makes it harder for a third party to compete. This is also true of chiropractic. If we accept that medicine is the front-runner, and that we can lump DOs and physical therapists as the also-rans, it is clear that chiropractic becomes the "reform party." It is tough for us to even get on the ballot. The experience with CHAMPUS, government workers' compensation, etc., demonstrates quite clearly that the members of our "party" do not have the luxury of an even playing field. It is tough for chiropractic doctors to compete with the PAC money available from the AMA, from pharmaceutical houses, from hospitals, insurance companies, etc. In fact, it is much like we have a multi-front battle constantly going on.
Our party is beset by attacks from all of the above groups, as well as our own members. The infighting which occurs between chiropractic organizations and between personalities in chiropractic makes a unified stand against the considerable challenges from these other factions almost impossible.
Negative Campaigning
Another aspect of political campaigns which has its parallel in the battle for dominance of the health care field is dirty tactics and negative campaigning. We have fought against this for years. Words like "quacks," "choirpractors," ad nauseam, combined with the ongoing bias of medical practitioners and physical therapists, as well as the odd patient who has had a negative experience visiting a chiropractic doctor, have created a climate in which people say such absurd things as "I don't believe in chiropractors" (as if we were faith healers and could not effect improvement without the faith of the infirm). The truth is, one doesn't overcome dirty tactics and negative campaigning by doing the same. You would be surprised at how quick people are to defend MDs against any negative statement such as, "They don't really care about the patient." The truth is that there are many cases of iatrogenic injury to patients which occur from the side effects of medication, misdiagnosis or mishandling of a case, but telling the public that is not going to convert them all to good chiropractic patients any more than telling the voters of the evils of the past administrations of both major political parties will turn everyone into a reform party supporter.
The reason is that the vast majority of Americans just do not believe that a third-party candidate is ever going to win, no matter how well-intentioned the candidate is or how hard their supporters work. And similarly, I assert that the vast majority of Americans cannot envision a health care system with chiropractic as the dominant force. Now, as with political candidates, I'm good at identifying a problem, but do I have a solution? No, I don't, at least not a quick fix: that doesn't exist. But I do believe there are many steps which can be taken to make our party larger, have more supporters, and be in a more advantageous position relative to the system at large.
Solutions
One essential step is to stop in-fighting. Only through unity will we be strong. Mixers and straights should quit this banter back and forth. It only weakens us and makes us look like the "big-enders" and "little-enders" from Gulliver's travels. The next thing (and I know this will be a major point of contention for many DCs) is that we must establish a broader scope of practice guidelines nationally. Whether doctors like it or not, manipulation only will make us (and our profession) obsolete fairly quickly. Chiropractic treatment does not seem to the lay public as a purist self-limitation, but is perceived as chiropractors not knowing how to prescribe drugs, do minor surgery, deliver babies or sew up wounds. Whether a DC decides to practice a broader scope of procedures or not, he or she should not stand against other DCs who are so inclined. This goes back to the nonsensical fighting amongst ourselves.
We far too often play right into the hands of the PTs, MDs, PAs, nurse practitioners, HMOs and others by hamstringing our own profession. You would never find a neurologist fighting against a neurosurgeon having the right to perform surgery. You would never find an orthopedist petitioning the state not to allow obstetricians to deliver babies. We are the only profession that I know of which is acting in such a suicidal fashion.
Broken Skin, Broken Bones, Broken Faith
Health care, like politics, involves many issues. To be a family doctor, one has to be able to treat more than subluxations. People still do break bones, slice their hands open, get STD infections, get appendicitis, etc. And unlike DOs and MDs, we have to throw up our hands and refer out to things that even the worst graduating MD is trained and qualified by law to handle. The family doctor role, good old kindly Marcus Welby, MD, is a very powerful one in this country.
Voting the MD Ticket
Now granted, the rise of HMOs, PPOs, etc., has had an impact on the choice people have for a family doctor, but let's face it, if a person develops an awful face rash, rather than go to a dermatologist, they will often go to the family doctor. And when someone is scared about a health problem and it is something that they have no idea what is causing it or how bad it is, they deliver themselves to the white-coated MD, the guardian of their health. They perceive the MD to be all-knowing. Having the doctor reassure them that if they use this ointment or take that pill that the problem will go away is a very bonding and positive interaction for patients. Whether you believe it or not, doctor, that patient has just become a voter in the health care election, and has voted the medical ticket.
Getting Out the Vote
The medical party, if you will, is a "shoo-in." You don't see MDs sitting in malls offering a free abdominal palpation or free drugs. You don't see neurologists setting up little "benign familial tremor screening tables" at nutrition stores. You don't see "free exam" offers in the yellow pages for ob/gyns. Why? You know why. As a profession, we have had nearly a century to make our case for our party and to present the issues. Many would say we have made great inroads, and yet if we were indeed politicians or legislators, we would be hamstrung to vote on only one issue, and would have to defer our vote on other issues to the main party. We would also be a party that, for the most part, allows the other party to draw up guidelines which legally govern us. This last comment is sadly demonstrated by the fact that here in Texas, it was a combination of a Houston MD and physical therapists that stripped away our legal right to call ourselves "chiropractic physicians".
Be More Political
I am not saying that we should try to become MDs. I am saying that when someone is winning, you look at why they are winning and how they are doing it. MDs have the lion's share of health care for many reasons. After losing control in the mid-1800's when state licensure laws were abolished for a time, they used money and political influence to reestablish licensure and scope of practice laws. Once they could control those, they had the legal power of the state behind them and could enforce their control of the system and their de facto control of our profession. The AMA, pharmaceutical houses, and physical therapists are all very politically active and spend a lot of money trying to influence legislation at the federal and state levels and have been very effective.
Our "party" must be more active and more aggressive politically if we are to survive. But I am not saying that this means just giving money to the state and national associations. We cannot abrogate personal responsibility for the health of our profession. Lawsuits are also very effective in achieving parity. Dr. Wilk's suit demonstrated this.
Conclusion
If DCs start teaching MDs to manipulate, and if we keep allowing MDs and physical therapists to configure our scope of practice, we will never become a major party in the politics of health care, but we may be forced out of the race altogether. Let's quit being an also-ran.
John R. Baker, DC
Austin, Texas
