Australians Draft Chiropractic Clinical Parameters

Row 2: Stephen Crean, Odette Reader, JoAnne Maire, Rod Bonello, Mick Marsden, Laurie Power, Mary Ann Chance, Geoffrey Wynn, Keith Simpson, Bob Scott.

Row 3: Peter Cowie, Stephen Bardsley, Bevan Goodreid, John Kelly, Michael Epstein, Chris Hume-Phillips, David Montgomery, Malcom Rutledge, John Waterhouse, John Sweaney, Dennis Middendorp.

Row 4: John Drinkwater, Wayne Minter, Paul Searle, Adrian Wenban, John Hinwood, Tony McLindon, Max Joseph, Geoff Airey.

bleed photo 1: Conference site: Burton and Garran Hall, Australia National University, Canberra, ACT, Australia.

bleed photo 2: Phillip Ebrall, CPAPC chairman (at the computer) awaits clarification on a point of deliberation.

bleed photo: Mary Ann Chance, DC, FICC: "... my expectations were guarded at best, so I was surprised and delighted to see the almost palpable level of commitment, focus, and mutual support that quickly developed as the group approached its task."

CANBERRA, Australia -- On Sunday, December 3, 1995, the first consensus conference on the Clinical Parameters of Australian Chiropractic Practice (CPACP), sponsored by the Chiropractors' Association of Australia, successfully completed a draft document after three days of intensive discussion and revision. The draft is currently undergoing final editing. Early in 1996 it will be presented to the CAA Board of Directors to determine what further stages of refinement and ratification it should undergo before being released as a public document.

This is the culmination of more than three years' work by the association. At the beginning of 1992, Dr. Phillip Ebrall, chairman of the CAA Clinical Practice Committee (CPC), attended, as an observer, the final consensus conference which generated the Mercy document. Since then, the committee's work has been focused on determining the most appropriate process of developing clinical parameters which would be truly relevant in Australia. A peer-review system had already been established by a number of third-party payers in Australia, and because the National Health and Medical Research Council, through its Quality of Care and Health Outcomes Committee, was in the process of developing formal guidelines for Australian medical practice, there was a degree of urgency for the chiropractic profession to proactively articulate its own parameters.

Conditions of chiropractic practice in Australia differ significantly from the usual pattern in North America, so it was clear from the beginning that neither the Mercy guidelines nor the Glenerin (Canadian) document could be adopted without question. On the other hand, there is insufficient manpower in the profession in Australia to generate an entire document of this magnitude de novo. The CPC therefore decided to use the two existing documents as a starting point, and worked with about 20 practitioners Australia-wide who read the material and commented on its suitability or otherwise for Australia. A search of the chiropractic and biomedical literature and Australian legislation and case law was conducted to update references.

A year ago, an all-chiropractor team consisting of 12 section chairs, each to be responsible for drafting a chapter, and six other functioning as support and management personnel, attended a workshop conducted by Dr. Dan Hansen of Olympia, Washington on the methodology of the consensus process. Over the next 12 months, each of the chairs gathered a team of eight to ten chiropractors to assist with the development of their section. In addition, carefully selected consultants were canvassed for expert opinion, and in some cases were involved in overview of specific chapters. Through the monthly newsletter, Chiropractic Australia, CAA members were kept informed of progress and urged to make input through the section chairs.

In August, the date, venue, and voting personnel of the national consensus conference were announced. It was to be held at the Australian National University in Canberra from Thursday, 30 November through Sunday 3 December. The 38 voting members were to be the 12 chapter captains; two members of the management committee; the presidents of the eight branches of the CAA; the CAA national president; the support team of the editor, the lawyer and the treasurer; a representative each of the International College of Chiropractic and the World Federation of Chiropractic; two representatives of the Chiropractic Society of Australia; a nominee from each of the two Australian universities offering chiropractic degree programs; and six nominees from the open market, elected by the chapter captains. Members of the profession were invited to nominate as candidates for the six open-market positions or to seek status as non-voting observers. In addition, they were invited to attend a pre-conference meeting in Canberra in October, following the CAA National Conference, to address any questions or misgiving they may have to the CPC members or section chairs.

On Thursday evening, 30 November, when most of the voting participants had arrived in Canberra, the pre-conference briefing was conducted by the non-voting chairman, Dr. Phillip Ebrall, and the facilitator, Dr. Dan Hansen. They familiarised us with the layout of the facility, the infrastructure of the conference, the consensus process and the rules of consultation.

A computer fitted with a projector would facilitate the task of re-drafting recommendations, and an "engine room" had been set up with a number of computers, a shared printer, a collating photocopier, and staffed by a full-time typist, so that print outs of new drafts could be produced and distributed in a matter of minutes. A giant water cooler, self-serve hot drink facilities and plenty of snack food were also provided in (or within ear-shot of) the meeting room. Over the next two and a half days, we became increasingly grateful for these, as work sessions began each morning at 8:15, continuing until late in the evening, with two 45-minute meal breaks each day and no other refreshment breaks. On Saturday night when the pressure was on to fine-tune whole sections of the document, some of us wouldn't even have any sleep.

Very early in proceedings, it became obvious how well the group had been chosen. There had been a deliberate attempt to include as wide spectrum as possible of backgrounds, viewpoints and affiliations, not only to provide a rich source of information and expert opinion, but also to ensure that the document would reflect and appropriately guide the real world of chiropractic in Australia. Based on my past experiences with meetings representing such divergent elements, my expectations were guarded at best, so I was surprised and delighted to see the almost palpable level of commitment, focus, and mutual support that quickly developed as the group approached its task.

Over the next two days, as each chapter was discussed in turn, the chair introduced the material and responded to questions. Most recommendations were assented to with minor change; those on which consensus could not be reached efficiently in plenary session were referred to the evening workshops for redrafting. At the end of each chapter session, the facilitator led applause for the chair's effort. As everyone thrives on being appreciated -- but it does not come naturally for Australians to be demonstrative in this way -- this was a notable contribution which I think had a lot to do with building a constructive group dynamic.

Saturday evening was devoted to workshops, scheduled in such a way that each participant could contribute to multiple chapters. When the formal workshops concluded, many continued to consult in small groups well into the early hours of the morning, and a few worked right through the night. On Sunday morning, consultation began on the recommendations which had been redrafted in workshop. By early afternoon, consensus had been reached on every recommendation, and the section chairs presented their final drafts to the chairman of the meeting.

There is no doubt that development of this evidence-based document will enhance the credibility, and thereby protect the self-determination of the chiropractic profession in Australia. It is a monument to the pioneering efforts of the teams which produced the Mercy and Glenerin documents, the foresight of the CAA Board of Directors, the hard work of the CPC and the 150 or so others involved in the process, as well as the generous financial support of the Chiropractors' Association of Australia and the Motion Palpation Institute which made it possible to pursue the task to a successful conclusion.

It is equally certain that those who were present at the consensus conference will never be quite the same again. We developed strengths we never knew we had, a deepened respect for each other a special bond which is difficult to talk about, but is perhaps akin to the indefinable spiritual glue which kept chiropractic together through the early persecutions and upheavals. Just as important, we learned that in making group decisions, the consensus process is more successful and in many ways stressful than the adversarial method.

Mary Ann Chance, DC, FICC
New South Wales, Australia