Chiropractic: Mainstream, Alternative, or Unconventional

The January 23, 1993 issue of the New England Journal of Medicine featured "Unconventional Medicine in the United States,"¹ a highly influential and highly cited survey conducted by David Eisenberg and colleagues.

In the paper, Eisenberg reported that during the time of the study one in three respondents used at least one unconventional therapy, and one in four who saw a medical doctor during that time also used an unconventional therapy. There were 425 million visits to providers of unconventional therapy at a cost of 11.7 billion dollars, outweighing visits to primary care medical physicians during that same time. The most common providers of that unconventional care were chiropractors.

Consider also the following recent developments:

1. the creation of the first chair of complementary medicine in the United Kingdom at Exeter University;
   
2. the movement of the Phillip Institute of Technology's chiropractic program into the Royal Melbourne Institute of Technology's department of chiropractic, osteopathic and complementary medicine;
3. the creation of several new journals devoted to alternative medicine: Alternative Therapies (with at least three people devoted to chiropractic on its advisory board -- Drs. John Triano, Anthony Rosner, and myself), Journal of Alternative and Complementary Medicine, and Complementary Therapies in Medicine (published in the UK);
4. the creation of the Office of Alternative Medicine at the National Institutes of Health, originally known as the Office of Unconventional Medicine. It had a chiropractor on its ad hoc advisory board (again, myself), and used a representative of the chiropractic research profession as a general advisor (again, Dr. Anthony Rosner). I was even fortunate enough to have written the entry in the Chantilly document on the profession.²

What you can see from perusing these developments is a clear trend to place chiropractic into a category of "alternative" or "complementary" medicine. This is the case with the situation at RMIT (Australia), OAM (USA), and in most of Europe (as seen in the Exeter situation). Indeed, at the time that I was nominated to be a member of the advisory panel at OAM, there was a great deal of concern raised by my college, the ACA and the FCER at positioning the profession as "alternative." Was it, is it, in our best interest to be seen in such a way?

Does it matter what we or others call ourselves? Are we "alternative" or "complementary," or are we mainstream? What advantages or benefits can be derived from being perceived or defining ourselves as "alternative?" Well, one is that it might help to position us in the eyes of the public as something different from allopathic medicine, that is, it could be used essentially as a marketing tool. It allows us entry into areas where we had been shut out in the past. It could open doors for use that were traditionally closed.

However, in terms of real impact on real patient care, it poses a number of risks:

1. We chance that our services are less likely to be recognized and therefore funded by government and/or other third-party payers, especially in light of the move toward evidence-based medicine. That is, if little "proof" exists, it won't get funded; everything outside the mainstream is generally perceived in that manner by lawmakers and politicians.
2. It makes it so much harder to create partnerships with medicine, osteopathy, hospitals and other more "accepted" mainstream providers.

There is sufficient proof of the effectiveness and cost-effectiveness of manipulation for low back pain and other conditions that, if nothing else, we now run the risk of having medicine rush in and attempt to exert its traditional control over this new (for them) market area. That, if nothing else, argues on behalf of our being mainstream. We need to carefully control this area of our art and science, so that we do not lose our identity.

Yes, chiropractic can rightfully claim to be holistic, and perhaps it is indeed complementary. I would argue myself that it is conservative and mainstream.

However, I am but one person and I cannot claim to speak for the profession. The issue regarding whether we are alternative, complementary, unconventional or mainstream and conservative is one that needs dialogue. This dialogue must not be limited to traditional areas of strength, such as the United States by simple virtue of its great number of chiropractors. It should involve the many different countries where chiropractic has made itself felt, through the auspices of the World Federation of Chiropractic (WFC) as the organizing group. Country organizations can discuss the issues with its members and bring to the WFC its issues, concerns and points of view. The WFC can then help to reach consensus on the issue, leading to international agreement.

I implore you all to begin consideration of this issue as soon as possible. The world of health care is changing continuously and will not wait for you.

References

1. Eisenberg DM, Kessler RC, Foster C, et al. Unconventional medicine in the United States: prevalence, costs and patterns of use. N Engl J Med 1993; 328:246-252.
   
2. Berman BM, Larson D, editors. Alternative medicine: expanding medical horizons. A report to the National Institutes of Health on alternative medical systems and practices in the United States. Washington, DC; United States Government Printing Office, 1995.