"But That's Not Chiropractic..."

In the lore of Cleveland Chiropractic College in Kansas City, where I am now in my ninth year as a teacher, there is a famous story of an instructor's pithy response to a common student complaint. Anyone who's worked at an educational institution is familiar with the refrain, "Nobody told me that..." Rather than giving a long explanation about the merits of active learning and personal responsibility, this instructor defiantly placed a new sign on his door. It read, "Dr. Nobody."

Another frequent refrain from students is, "But that's not chiropractic." I always get a kick out of this one, because it seems odd to me to have a classroom filled with students, each of whom has his or her own definition of chiropractic and a technique preference - and on day one of chiropractic college! As the research instructor here, I have, for years, heard students complain about how unnecessary it is to study research - after all, what does research have to do with being a chiropractor?

Despite these experiences, I was still unprepared for my first foray into teaching public health to chiropractic students. I had already looked at the course content closely and developed a plan that I thought would make public health principles more relevant to a practicing chiropractor. I was focusing on the major modifiable risk factors: how to take a risk factor history, how to counsel patients on healthy lifestyles, how to develop health contracts. Projects in the class allowed students to develop patient education materials; or actually practice guiding another student through a health care contract for weight loss or smoking cessation.

By and large, students seemed to enjoy the course, but there were still the occasional hiccups. They usually centered around the notion of what chiropractic is and what a chiropractor should do. For instance, students in nearly every class would look at the list of key risk factors and indicate that they didn't believe chiropractors need to spend much time considering oral health, sexual behaviors or sun protection. While I don't think these issues are the central focus of chiropractic care, they are certainly significant factors in the promotion of health. So, we would discuss how simple it is to notice the state of someone's teeth and oral hygiene during the case history and physical examination. Or, we would address the fact that during a spinal and postural examination, one can see the skin on the back and should be cognizant of changes that might indicate the need for referral to a dermatologist - as well as provide the opportunity to remind the patient of the importance of sun protection.

In discussing these issues with students, I would always relay to them the fact that for the majority of my life, I have seen chiropractors for my health care, only accessing medical providers when conservative methods haven't succeeded (not often), or to receive screening exams that chiropractors didn't provide. I have been comfortable with this approach to managing my health because I have been privileged to receive care from chiropractors who are attentive to more than just the state of my spine. Don't get me wrong: They have all always checked for subluxations and adjusted them; but they have all also been able to consult with me regarding other primary health issues. They have been willing to refer when necessary. They have been concerned about diet and exercise and other health habits. In short, they have been centered on me - not on subluxation, spinal hygiene or a particular technique.

When students say that something is not chiropractic, it worries me. As I understand it, chiropractic is an approach to providing health care to people who need it. It is informed by a particular philosophical perspective and has a basis in science. Its purpose is the "restoration and preservation of health. "Much of what chiropractors do is uniquely chiropractic, and I wouldn't want to lose that uniqueness. But I wouldn't want to elevate that uniqueness above the needs of the patient - and sometimes, the patient needs to be told to quit smoking. Why shouldn't a chiropractor be the provider to tell him or her? Sometimes, a patient needs help understanding how to eat a healthy diet. Why shouldn't his or her chiropractor provide that understanding? Sometimes, patients need to be reminded to wear helmets while riding bicycles and motorcycles, or to wear seatbelts while driving a car. When chiropractors are so often consulted for the injuries that result from accidents, it just makes sense for chiropractors to be involved in the preventive counseling on these topics.

No one health care practitioner can be all things to all people. It is possible, though, for one practitioner to offer much of the conservative care that is most useful for health promotion and disease prevention. I think chiropractors are ideally suited for this role. Because we are health-oriented, we are uniquely positioned to provide not only sound structural care to our patients, but also information and education on those lifestyle factors that have the most impact on quality and quantity of life.

I teach my students that the focus isn't the subluxation. The focus is the patient's health - where the patient is now on the health continuum/biological spectrum, and in which direction he or she is moving; and I encourage students to do those things that are conservative, effective and within their scope of practice to get the patient moving in the direction of optimum health and wellness. I encourage them to think of an encounter with the entire community, not just with one patient at a time - even if that means that in addition to finding and correcting subluxation, they will have to talk about diet and exercise, the environment, smoking cessation and moderate alcohol consumption, and avoiding risky sexual behaviors.

Being an active member, attending annual meetings, and serving as an officer in the Chiropractic Health Care Section of the American Public Health Association (APHA) have increased my own awareness of how public health focuses on the entire community, the impact of its environment, and the lifestyle choices made by its citizens. I try to impart some of that increased awareness to my students. Being active in the APHA has definitely enhanced my teaching of public health to chiropractic students. The APHA has long acknowledged that excellent medical care alone does not guarantee health, and perhaps without being heretical, we chiropractors could admit that excellent chiropractic care alone does not guarantee health, either.

One common definition of public health used by the APHA is: "The application of medical, social, and allied disciplines in an organized community activity designed primarily to protect and advance the health of the people. "Public health has also been defined as: "What we do as a society to provide an environment for health. "Don't those definitions sound compatible with chiropractic philosophy, chiropractic history, chiropractic care, and the chiropractic lifestyle? I certainly think they do, and I teach my students that they do. Healthy people in healthy communities is an APHA goal. And wanting to help achieve that goal, well, that's chiropractic, too!

Ashley E. Cleveland MA, DC
Interim academic dean - Cleveland Chiropractic College, Kansas City
Section councilor and newsletter editor,
Chiropractic Health Care Section - American Public Health Association