Bringing Chiropractic Into the Mainstream in the 21st Century - Part I

Most chiropractic physicians and those involved with chiropractic would agree that the profession has made great strides in its 110 years of existence with regard to acceptance by the public, as well as by governmental and health care decision-makers. From the earliest days of imprisonment of practitioners for the crime of trying to help ailing patients, to the current official recognition by the U.S. military and the American Public Health Association (APHA), we have overcome incredible obstacles. Yet in 2005, we find ourselves still seeing less than 10 percent of the population.¹ Reimbursement for our services by third-party payers continues to be lopsided, when compared to other disciplines. We are severely lacking the cultural authority² that is required to expand our sphere of influence in the health care system of the United States and the rest of the world.

Part of the problem can be seen as arising from within our own ranks. In the U.S., we have two national associations, of which less than half of the profession are members. There are several states with multiple professional associations fighting among themselves. We find countless examples of charlatanism and quackery that go unchecked, and are even tolerated, throughout the profession. Our chiropractic colleges are struggling as a result of tuition dependence. Only a tiny percentage of the profession reads our own scientific journal(s), let alone other scientific literature. Finally, the profession suffers from general misunderstanding and disrespect from much of society.

In a rapidly changing health care environment, our profession must act now, so we can be assured of our place at the health care table in the 21^st century. We must take immediate action to address the obstacles to this progress, in order to avoid being further marginalized, and to decrease the risk of chiropractic ultimately being seen as irrelevant and replaceable.

A substantial segment of society views chiropractors as a marginal group of loosely affiliated individuals; we are tolerated at best and vilified at worst by this segment. Our efforts are needed to transform societal perceptions of chiropractic, ensuring that our members are seen as high-quality and ethical physicians, and that our profession is widely considered prominent and influential in the health care system.

We have delineated several areas we believe are critical to address if we are to advance our standing in the eyes of those involved in the health care system and society as a whole. The chiropractic profession must address these issues in our unified effort at reform. In future articles, we will expand upon the items that are briefly presented here.

1. Education reform - The chiropractic educational process, particularly with regard to clinical training and the development of critical thinking skills, is severely lacking. Some of us are involved in education within other health care fields, including medicine and physical therapy, and by comparison, have identified deficiencies in our own educational process. We need to significantly upgrade chiropractic education in several key areas.

In particular, chiropractic schools need to properly prepare students to thrive in the emerging evidenced-based practice environment. In this environment, doctors of chiropractic will regularly be faced with challenging diagnostic and treatment situations. As we become more fully integrated into mainstream health care, chiropractors will have to communicate effectively with other practitioners, using a common language of best practices. This will require enhanced critical-thinking and research-interpretation skills; an appreciation of the importance research has in improving clinical practice; and increased practical clinical experience. The schools must rethink the current approach of teaching individual "chiropractic technique systems," which are often contradictory and rarely demonstrate evidence of reliability, validity and efficacy. The colleges also have to make a concerted effort to improve the clinical experience of interns, to ensure that we graduate competent practitioners who have been exposed to a wide variety of conditions under proper supervision. Finally, the chiropractic colleges must move toward developing a true residency program in a multidisciplinary environment, in which all graduates gain valuable experience evaluating and treating a wide variety of health complaints.

2. Research reform - Support for high-quality research in the profession is significantly lacking. We hear "lip service" regarding chiropractic research, in the form of, "I will support research as long as it seeks to prove chiropractic" (whatever that means). Honest and respectable research does not seek to "prove" anything. It simply asks questions and open-mindedly seeks the answers. We need to create for the profession, in the words of Dr. Scott Haldeman,³ a "research milieu," in which students, practitioners, and especially faculty members, are all involved in the development of new knowledge in the field. The development of this new knowledge must be focused on a dispassionate search for better ways to diagnose and manage the ailments for which patients seek our care, and not on "proving what we already know to be true." Research reform has to start with the chiropractic schools requiring faculty to become scholars involved in research, so that they can model as well as teach our students important critical-thinking skills and an appreciation for the scientific method.

3. Regulatory reform - Fraud, abuse and quackery are rampant in the profession, and their prevalence severely impacts the reputation of the chiropractic profession, particularly in the minds of those in the insurance industry and those involved with regulatory bodies outside of the profession. We must take a "zero tolerance" stand on the unacceptable and damaging behavior of some of our practitioners. As a profession that is attempting to improve its image in society, we have far less leeway with regard to the public display of charlatanistic and other questionable practices. If people see a medical doctor engaging in fraudulent or abusive practices, this usually reflects on him or her individually. If people see this sort of behavior by a chiropractor, it reflects on the entire profession. This differential perception may not be "fair," but it is our reality, nonetheless.

We feel that a large part of the problem is that decision-makers in the health care world, and society at large, view the chiropractic profession as tolerating, and even supporting, fraud, abuse and quackery. Part of the solution lies in our regulatory boards on the state and national level; they have the ability to put an end to fraudulent, abusive and "unscientific cultist" behavior among chiropractors.

4. Practice management reform - One of the most common criticisms of chiropractors is the perception that we see patients as opportunities for financial gain, rather than as opportunities to serve. Clearly, understanding how to operate a profitable professional practice is essential to the success of the individual DC, and the profession as a whole. However, we feel that practice management firms should teach chiropractic physicians how to thrive by providing honest, patient-centered, and outcome-driven care, rather than doctor-centered or profession-centered care. We consider it inappropriate for practice management firms to encourage overutilization of chiropractic services, use of questionable coding practices, and indoctrination of patients into "lifelong care," without regard for functional restoration and the promotion of independence and self-care.

In part II of this article, we will discuss further areas in which the profession must reform, including our public image, marketing, interaction with other health professions, and reimbursement by private third parties and Medicare.

References

1. Barnes PM, Powell-Griner E, McFann K, Nahin RL. Complementary and alternative medicine use among adults: United States, 2002. Adv Data 2004;343:1-19.
2. Keating J, Hyde T, Menke M, et al. In the quest for cultural authority. Dynamic Chiropractic, Dec. 16, 2004: www.chiroweb.com/archives/22/26/09.html.
3. Haldeman S. Research and Interprofessional Cooperation as the Basis for Future Understanding in Neck Pain. In: Chronic Neck Pain - The Chiropractor's Role; Bournemouth, UK, 2000.