The recent article "In the Quest for Cultural Authority" by Keating et al.1 indicates the re-emergence of a valuable dialog concerning the appropriate role of scientific evidence in making decisions about chiropractic identity and practice. The positions are familiar. On the one hand, we have a call to recognize the tenuous scientific basis of subluxation and related chiropractic theories. On the other, we have a real need to politically unify the profession around a unique, powerful, and easily identifiable niche in the fast evolving world of health care. I see the need for both, but the way by which we arrive at an appropriate solution is hard to see. It does seem risky to stake our profession's future on a yet-to-be thoroughly tested set of neurological hypotheses, but it also seems risky to continue to confuse the public and professional communities about chiropractic's role and value.
Regarding this conundrum, it is timely that a very interesting paper was recently published in the journal Social Science and Medicine entitled, "Evidence-Based Medicine and its Implications for the Profession of Chiropractic," authored by Dr. Yvonne Villanueva-Russell, a sociologist from Texas A&M University.2 As an outsider and a sociologist, the author dissects the effects and implications of developing practice guidelines, one of the products of an evidence-based approach to clinical decision-making. She notes that the evidence-based movement has created a new set of imperatives for orthodox medicine, and that they also spill over onto those professions that are seeking to enhance their own cultural authority. As she says, the quantitative, positivist and empiricist assumptions underlying the evidence-based approach increasingly dictate which approaches to treatment are legitimate and worthy of reimbursement and public support. For many in the chiropractic profession, including myself, this appears to be a logical, appropriate and even necessary way to make policy, especially given the alternative methods, which mostly involve only power politics and economic clout.
But voices of caution about the wisdom of relying only on certain kinds of scientific evidence to make policy decisions should receive attention. Dr. Villanueva-Russell points out that chiropractic's original epistemology of vitalism is not amenable to the evidence-based approach, and that attempts to make it that way have major implications. She goes on to describe the history of the evidence-based approach and the promise it holds out for helping to legitimize chiropractic and solidify its professional position. She succinctly summarizes the significance of evidence-based medicine in the larger context of the health care industry, and the historical roots of chiropractic theory and practice. Her main contention is that the evidence-based approach is an obstacle to the professional legitimacy "posed by not one, but two different sources of dominance in the health care system: orthodox medicine, and from the managerial ideology of managed care organizations."
Dr. Villanueva-Russell goes on to describe the Mercy guidelines and the controversy the guidelines ignited. Why was the process so threatening? Because, for a significant segment of the profession, it did not appear to accurately reflect how chiropractic is practiced, and because the process appeared to devalue clinical experience. Mercy became so controversial because it inadvertently became symbolically more than an attempt to simply summarize extant evidence. It came to represent the fundamental differences between vitalism and biological mechanism, and the straight and mixer approaches to practice "philosophy." Mercy became a political tool, something it was never meant to be. One of her most important points is that chiropractors do not agree on what constitutes "legitimate knowledge."
Space precludes a detailed discussion of the many additional salient and debatable points raised by this well-written paper. It is important sociologically because it is one of the few objective examinations of the legitimization path being followed by a number of emerging health care professions. It is important to chiropractors because it clearly lays out an agenda for dialog. Chiropractic leaders and policy-makers should pay close attention as they attempt to find ways to unify and strengthen the profession.
Dr. Villanueva-Russell does not provide easy solutions, but she does ask very important questions. How can vitalism become amenable to positivism and empirical science and hence be incorporated into evidence-based chiropractic? How do we unify seemingly disparate approaches to knowledge as we attempt to constantly improve chiropractic care and access to patients? Her final words are sobering:
"For the sake of quality patient care, for protection from interlopers, for legitimacy against third-party payers and malpractice suits, chiropractic needs to define for itself what the parameters of the profession are, and how to legitimate and validate these knowledge claims. Unfortunately, this does not seem imminently possible with the host of forces mitigating these efforts both from within and outside the profession."
The question is: is her pessimism warranted? Is there no way to bridge the considerable gaps in chiropractic? Are efforts at developing practice guidelines and best practices doomed to political extinction?
If you want to become personally engaged in this discussion, you should attend the next Association of Chiropractic Colleges and Research Agenda Conference (ACC-RAC). It is being held March 17-19, 2005 in Las Vegas. Regarding the topic of this column, Dr. Villanueva-Russell will present her findings from her research as part of a major panel discussion. Audience participation is highly encouraged as the participants grapple with the implications of evidence-based chiropractic. As always, the rest of the conference will be a provocative mix of speakers, panels, workshops, and research presentations. Of further note, the keynote speaker will be Wayne Jonas, MD, former director of the National Institutes of Health (NIH), National Center for Complementary and Alternative Medicine (NCCAM), and a big supporter of chiropractic research. Dr. Jonas is now the director of the Samueli Institute for Information Biology. Other important speakers from the NIH and the Veterans Administration have also been invited.
References
William Meeker, DC, MPH, FICC
Principal Investigator,
Consortial Center for Chiropractic Research
Davenport, Iowa
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