October of this year marked an anniversary for me ... 10 years since my first halting steps into the scholarly/research arena in the chiropractic profession. That first conference at the Hilton Hotel in Sunnyvale, California left me amused, intrigued, puzzled, unsure of my decision to join the faculty at a chiropractic college. That first conference convinced me that chiropractic was different from anything else I had encountered in health care and in higher education, but how different? Would there be room for academic freedom? Could one return to mainstream academia, or would the "aura of weirdness" (as George McAndrews puts it) that surrounds chiropractic so taint my curriculum vitae that my opinions would be limited?
A decade has passed, and along the way a certain addiction has developed ... less a conviction than a passion to see the potential in chiropractic develop. My good fortune has been to watch the profession evolve, and even if the process has been maddeningly slow, the direction has sometimes been quite positive. Of course, there is the all too frequent tendency to take two steps forward and one or more steps backward. Consider:
The Colleges:
- Several chiropractic colleges have developed serious intellectual subcultures. Schools such as National, Canadian Memorial (CMCC), Los Angeles College of Chiropractic (LACC), Northwestern and Palmer/West have developed small (but not always or self-perpetuating) masses of scholarly producers in clinical science and substantive philosophy. They fill the pages of our best journals with new data, critical thought and a no-nonsense attitude toward professional ethics. A subset of these schools has reached the stage of self-propagation, wherein we can reasonably expect that at least some of the graduates will continue in the admirable pathways their mentors have carved out. While National College deserves recognition as the leading producer of new knowledge in the profession, to CMCC and the affiliated College of Chiropractic Sciences goes first place (in my book) for deliberate efforts to nurture future generations of clinician-scholars with which to populate the ranks of our faculties. I believe it is no accident that CMCC, although a medium size school, has been among the top two or three leaders in numbers of scholarly contributions to the chiropractic literature (Keating et al., 1989).
- On the other hand, several of the largest and some of the smallest student bodies in the profession today are found at institutions that emphasize biotheology, vitalism, pseudo-science, and marketing values. I don't think they need to be identified here ... most in the profession are aware of where the "phooolosophical" leaders in chiropractic education reside. These schools are busy turning out "brand new, old fashioned chiropractors" (DeBoer, 1988), investigating Innate (that's capital "I") and "proving" what they always knew was true (no doubt about it: no questions asked)! We should perhaps not be too surprised at their financial success, for it is much less difficult to turn out new doctors in great quantity than it is to emphasize and achieve great quality in education. And, although many graduates of these theological institutions can be expected to reject the most absurd ideas promoted by their presidents and boards (if history is any guide), we are faced nonetheless with the alarming reality that a whole new generation of (well meaning) dingbat doctors, peterpan principles, advertising fanatics, and evangelical ideologists will be with us for many years to come.
- A third recent development is the coming of university-based chiropractic colleges. No, I don't mean those chiropractic schools with pretensions to university status, but rather the adventures underway at the Royal Melbourne Institute of Technology in Australia, the University of Odense in Denmark, the University of Quebec in Canada and the University of Bridgeport in Korea (I mean, Connecticut). We have reason to hope that the traditional scholarly values of the university (and perhaps also greater access to financial, scientific and clinical resources) will produce a new level of scholarship and professionalism in chiropractic. Only time will tell. Unfortunately, with the exception of CMCC's persistent (albeit unsuccessful) efforts, I am not aware of sustained attempts at our best existing schools to establish university affiliation. I am of the opinion that the profession cannot reach its potential for excellence as long as out schools continue to be poverty-stricken, tuition-driven, free-standing institutions. I wish our leading colleges would put more thought and effort in this direction.
- The LACC has shown exceptional leadership in the development of its Advantage Program, a self-directed, problem-focused, outcome-oriented approach to learning the basic and chiropractic sciences. While there are debates about the relative merits of traditional vs. such innovative curricular strategies in other health disciplines, there seem to be special advantages for chiropractic education. Doctors trained by the new method will necessarily have become familiar, even thirsty, for the latest scientific information that may bear on the problems and questions that arise within the practice of chiropractic. They will know their way around the library, and may be more likely to demand that postgraduate instructors keep current with the state of the literature. Honorable mentions in this area are also deserved by the National College, which is implementing Advantage-like changes in the ways that chiropractors are trained, and the Western States Chiropractic College's "Mentor Model" of clinical supervision during the chiropractic internship. A combination of creative program restructuring, capable clinician-supervisors and a small supervisor-to-intern ratios (1:6 to 1:8) has produced a far more thorough and academically challenging environment.
- On the other hand, relatively little leadership nor innovation in scholarship is apparent among the affiliated educational agencies, such as the Council on Chiropractic Education (CCE) and the National Board of Chiropractic Examiners (NBCE). The scholarly output from our schools seems to weigh rather low in evaluating institutions, and very few scholars with established track records have ever participated in the visitation teams, let alone the CCE's Commission on Accreditation. Similarly, the new graduate's ability to interpret the developing knowledge base presented in our scholarly and scientific journals is not among the criteria judged for licensure. Neither the CCE, in its evaluation of the colleges, nor the NBCE, in its evaluation of our graduates, have created much of a demand for scholarship.
The Literature:
- In 1983, when I first dabbled in chiropractic, there was the Journal of Manipulative & Physiological Therapeutics (JMPT). Period. This profession owes a great deal to the wisdom of National College's leaders, especially Drs. Joseph Janse and Roy Hildebrandt, who determined that chiropractic must have a legitimate scientific and professional forum. Since then a number of older periodicals have evolved into high quality, blind-peer-reviewed sources of information for the profession; among these have been the Chiropractic Journal of Australia, the European Journal of Chiropractic, and the Journal of the Canadian Chiropractic Association. Meanwhile, several new and worthy periodicals have made their debut, including the American Journal of Chiropractic Medicine (now defunct), Chiropractic Sports Medicine, and Chiropractic Technique. Suddenly, we have become saturated with legitimate places to record our emerging data base. The development of the CLIBCON Index to the Chiropractic Literature and the emergence of CHIROLARS, a computerized data base of chiropractic and related literature, have further served to make our knowledge base more accessible. The American Chiropractic Association has committed to distributing a new periodical, the Journal of the Neuromusculoskeletal System, to its membership, and a first issue appeared for March, 1993.
- Unfortunately, we now seem to be witnessing a flood of new journals whose quality seems rather questionable. The flake element in the profession seems determined to mimic the substantive journals, and to test the limits of the criteria typically applied to scholarly publications. "Peer-reviewed" and "indexed" status have become buzz words, and several new publications claim these distinctions. The shallow character of these magazines is readily apparent to any scientist, but many chiropractors continue to be unable to distinguish between substantive research and scholarship vs. fluff and pseudo-science. Meanwhile, several older trade publications continue to print garbage (McGregor, 1993; Nelson, 1993). As the number of scientific and pseudo-scientific publications grows, the readership of the most legitimate journals has declined. For instance, the circulation of the JMPT, which peaked at more than 6,000 in the mid 1980's, has now sunk below 4,000. As ever, the profession itself is both the perpetrator and the victim of these trends.
What will the next 10 years bring? We have reason to expect that, as the pressure from government and third-party payers for hard data increases in this age of accountability in health care, the chiropractic profession will react. The Mercy Conference Clinical Guidelines document suggests our ability to do so, within the limitations of the current knowledge base in the profession. However, if the scatter of purposes and perspectives among chiropractors persists, the coming decade could be quite painful. Considerable growth in our colleges and literature are two important areas for scholarly development. The slow progress we have seen during the 1980's will not meet the profession's needs; chiropractic must emerge from its adolescent search for identity or risk being left behind.
References
DeBoer KF. Eine Kleine nacht musing. American Journal of Chiropractic Medicine 1988 (March); 1(1):41-3
Keating JC, Booher JA, Door FA. JMPT: a 1987-88 update. Chiropractic Technique 1989 (November); 1(4):146-9
McGregor M. Chiropractic Magazines. Journal of Manipulative & Physiological Therapeutics 1993 (January); 16(1):4-6
Nelson CF. Five steps to your own technique: the Nelson method. Journal of Manipulative & Physiological Therapeutics 1993 (February); 16(2):115-7
