Ipse Dixit: The Dance of Dogma

Dogma may serve a purpose. It holds ideas fast until they can be understood and wisely applied. But eventually, dogma must be traded for thinking if a person or a profession is to mature. Ipse Dixit is Latin for an unsupported dogmatic assertion.

She was told she could never have children after a .32 caliber bullet wound to the spine at age 11. The doctors were wrong: my mother had four children over five years, starting at the age of 19. As a mere child herself, she naively plunged into the selfless chaos of parenthood.

The small farm we inherited had the usual hazards, plus a few more that were unique: a creek, a pond, a monster Yahoo push mower without blade guards, trees for climbing, sharp and heavy farm equipment with power take-offs and belts, and a sickle bar mower. The land was intriguing, yet treacherous, as experienced by neighboring farmers who suffered serious accidents which resulted in lost limbs, and other fatal farm accidents as noted in the local news. Smaller bodies had much more to lose in an argument with a combine, corn auger, or hay bailer.

To grant some peace of mind for the grown-ups, farm rules had to be obeyed without question. No climbing on tractors or barn roofs; no fishing or ice skating without an adult. We were only the third generation there to hear, "Das ist Verboten!" in German, English, or worse. For my brother and me, power struggles erupted about matters such as why one could not ride a bicycle at night, or why a tree house could not be built. Fortunately, there was a final parental statement - however unjust, unscientific, or unsatisfying: "Because I said so, that's why." When we had reached the limit, we could be sure to hear that sentence. Thereafter, pushing was perilous; to be tried only under extraordinary circumstances or on birthdays. To my brother and me, "Because I said so" deserved testing at a later date. If lucky, we would forget the temptation and move on to the next bad idea.

Asking "why?" may be the very question separating humans from all other life on earth. In extraordinary circumstances, some adults must follow orders without question. Armies, complex projects, and disasters require a "general" who sees the big picture, and directs troops accordingly. We may appoint a "general" because he or she sees things better than we do.

Sometimes, it is the wrong general. Obedience works better when we strongly believe in a cause; trust a commander; or understand the big picture. However, after a long while, we can forget why we are following orders or adhering to rules that were always so. Obedience to ideas that once served us, or because an authority said so, is dogma; it is accepting truth without question: "Because I said so, that's why!"

Growing up in an uncertain and hostile world, dogma can be a survival strategy. In chiropractic, dogma averted almost certain destruction of the profession. A very polished set of congruent beliefs was an old friend to chiropractic in the midst of storms and hostile battles. But while beliefs may be congruent and compelling, they may be just as wrong as cold fusion.

Who are the Ipse Dixit prophets in chiropractic? In other words, who grants us their unsupported and unsupportable opinions? There are two broad kinds of heroes in chiropractic: those with certainty and those with money. Certainty relieves anxiety; "Every time you do this, you will get results," sounds especially good after a week of fighting with workers' compensation denials.

If the million-dollar docs are really worth a million, maybe you are, too. The "secret" I uncovered in their blarney was that what they taught worked for them, and I left still trying to figure out what would work for me. What they really conveyed was confidence. The secret, grasshopper, was that I had to find my own secret.

Certainty matures into confidence in the experienced healer - and in the mature profession. Doing your best builds self-confidence and your patients' confidence in you. Knowing whom you can help and knowing that you cannot help everyone is confidence. Confidence in a good prognosis with an acute, simple injury, a relatively young patient, and without suspicion of cancer or signs of disc pathology is real certainty. Knowing you cannot help someone and getting that patient to the neurosurgeon immediately is also certainty. Some lives may fall apart without you and your informed certainty.

Adding 10 percent toward a favorable clinical outcome of hypertension or asthma is a small certainty that informs better patient health-care choices. The patient may want medical care until he or she is 30 percent better before your extra 10 percent seems worth it. But this is informed clinical certainty. Better predictions may improve the odds for improvement up to 50-50. But they aren't getting better now and 50-50 is better than nothing.

This is certainty in an uncertain world. This is reducing uncertainty - the function of science. Reducing uncertainty engages chiropractic in a battle it can win. It grows chiropractic to be a leader in health care, because chiropractic's big idea is to restore health with a minimum of interventions, side-effects and costs.

True certainty is really just reducing clinical uncertainty. Certainty based on what some dead guy said is dogma.

So, when do we give up being "true believers" and get on to being clinicians? Can chiropractic survive without a core set of beliefs to set us apart as a separate system of health care? Of course it can. And it need not be accused of "going medical" in the process.

Some report that the wave of alternative medicines has passed - the only attendees at integrative medicine conferences now are true "believers." Those interested in data and seeing how it all fits have given up trying to pick their way through the precious dogma. As far as the rest of the world is concerned, chiropractors can now give up the dogma. Chiropractic need not be defined by beliefs, but more by clinical results. A few years ago, a chiropractic college VP scolded me for daring to say that chiropractic can help people. "Sounds too much like the Mercy Guidelines to me!" he said. But he and I shared a common understanding: When you say you help people with their problems, accountability cannot be far behind. I wanted step up to the plate; he did not. I did. I assume he is still fighting for the good old days, where chiropractors are victims of prejudice, etc.

Health care integration is the next step, if chiropractors want it. The invitation has been extended. B.J. can't take us there. We may be comfortable in the old familiar swamp, but chiropractors are also marginalized, excluded, and fighting for reimbursement armed with weak arguments such as, "Because patients like us." It would be great if the world would just leave us alone, not ask too many questions, and pay us what we ask.

Too late. We can't have it both ways: feed at the reimbursement trough and remain dogmatic. "Because I said so" went the way of cheap gasoline and disappeared at about the same time. Enlightened practice managers may steer you wrong, bend your ethics, set you in the sights of the FBI - or perhaps show you the light. Simply charging more for more visits by providing supportive documentation is risky. Beating the system may seem a justifiable short-term goal, but it poisons the well for future generations of chiropractors, by proving that chiropractic is expensive and inefficient, and just not competitive as a viable health care contributor. We need another way to establish and express value.

J. Michael Menke, DC
Department of Psychology Program in Integrative Medicine
University of Arizona
Tucson, Arizona
menke@u.arizona.edu