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

In part one of this article, we discussed the current state of the chiropractic profession, expressing our concern that, while we have made great strides in public acceptance and in legislation over the 110 years of our existence, we face significant obstacles that must be overcome if we are to establish our profession as a central member of the health care team. We talked about various areas in which the profession must reform if we are to accomplish this goal, including the areas of education, research, regulatory bodies and practice management. In this article, we continue that discussion, focusing on additional areas in which we feel the profession must reform if we are to successfully transform ourselves from a marginal, underutilized group of individuals to a mainstream and widely respected profession.

1. Public image reform - Chiropractors are the most disrespected and mistrusted health care practitioners, as demonstrated in a recent CNN/USA Today/Gallup Poll,¹ regarding people's opinions about the honesty and ethics of various professions. We must respond firmly to the fraud, abuse, charlatanism and quackery, as we feel that this is likely the primary reason for our low ranking in the public's perception of honesty and ethics among health care providers.

Only a small portion of the public actually has a clear understanding of the nature of chiropractic care and its role in the health care system. We should note, however, that those few people who do know about chiropractic overwhelmingly view us as neuromusculoskeletal (NMS) specialists.² As we take a realistic look at our abilities and at the types of ailments we can be most helpful in managing, a professional identity as NMS specialists appears to us to be the most credible and the most promising.

The area of NMS disorders is the one in which no medical specialty has been able to have a significant impact. It also happens to be perhaps the largest market in all of health care. If we are to move the profession from its current state of seeing 7.5 percent of the population³ to seeing potentially 100% of the population, we must move aggressively in the direction of establishing ourselves in the minds of the public as the masters of NMS disorders. It is unlikely that the majority of people think of a chiropractor when they think of a nonsurgical NMS problem - they are more likely to think of an orthopedist, in spite of the fact that orthopedists are surgeons whose training typically focuses on surgical management.

Though there are those among us who wish to be seen by patients as their "family doctor," few people actually think of chiropractors in this way. Recent evidence suggests that chiropractors do not generally provide primary care services.⁴ Our patients see us for NMS conditions, even in practices claiming to treat a high percentage of non-NMS problems.⁵ We may fool ourselves into thinking that people see us for more than NMS conditions, but if we are to thrive in the future, it will be as NMS specialists, and not anything else.

Some may suggest that chiropractors should promote themselves as the experts in "correcting vertebral subluxation." However, the scientific literature has failed to demonstrate the very existence of the subluxation. Until and unless sound research published in credible journals demonstrates the existence and reliable identification of vertebral subluxation, and vertebral subluxation is found to be an important public health problem, society at large will not care about its correction. Thus, "subluxation correction" alone is not a viable option for chiropractic's future.

2. Marketing reform - Millions of dollars per year are spent on advertising by chiropractors in the Yellow Pages, newspapers, periodicals, television, radio, brochures and other means in an attempt to "get the message" out there, regardless of what that message might be. Advertising can be very positive and beneficial, achieving better public awareness of the appropriate role of chiropractic while increasing business for the advertising chiropractor. However, many of our colleagues subscribe to ethically questionable and potentially damaging advertising practices that tarnish our professional image. For example, the practice of providing "free" consultations and examinations creates the image that our diagnostic skills are inferior to those of our medical counterparts. In addition, the unfounded claims that are often made in chiropractic marketing tools (including, amazingly, those of some of our major organizations⁶) contribute to the mistrust of our profession. We as a profession must collectively condemn unethical and unprofessional advertising. If the money spent on this type of advertising were turned into funds to promote research, our image would improve considerably, resulting in a reduced need for individual advertisements.

3. Professional interaction reform - It is time to silence the hypocritical anti-medical rhetoric that echoes through our classrooms, offices and seminars. In a recent survey of students of various health disciplines, chiropractic students had the most negative perception regarding cooperation with and understanding of other professions.⁷ Yet, we tend to think that other professions view us negatively. It is not uncommon in our experience for people who have both DC and MD degrees to say that they receive far more criticism from chiropractors for being a MD than from medical doctors for being a DC. This would suggest that anti-medical biases among chiropractors are far more common and pervasive than are anti-chiropractic biases in medicine. Continually trying to tear down another profession is hardly conducive to creating a public image of a profession that cares about the welfare of members of society. Rather, it comes across as competitive and self-serving.

If the chiropractic profession is to take a prominent seat at the health care table, it will have to do so in a spirit of cooperation. Continually pointing out the flaws and shortcomings of another profession only serves to keep us marginalized.

4. Reimbursement reform - There likely is not a chiropractor in North America who does not lament the fact that our reimbursements from third-party payors pale in comparison to that of other practitioners for the same or similar services. Our payments typically range from insufficient to downright degrading. What is worse is that those third-party organizations that are operated by chiropractors are often the worst offenders, demonstrating the least respect for our services, and exploiting the low value that is placed by many in society on what we have to offer.

A radical change in this area is in order. But this change must first come from within our profession, in the form of improving our image in society as a whole, and ending the fraudulent and abusive practices that are so common, in order for our services to be seen as valuable and worthy of better reimbursement. Only then can we have the economic clout to confront the disparate reimbursement practices of third-party payors. Chiropractic third-party organizations should incentivize best practices. These organizations should promote active care approaches among chiropractors through appropriate reimbursement of those services that have been demonstrated to have the greatest efficacy, and should operate within the accepted treatment guidelines that have been established.

5. Medicare reform - We must expand the range of reimbursable services by Medicare. It is not acceptable that in 2005, "manipulation for the purpose of correcting a subluxation" remains the only chiropractic service for which Medicare will pay. A radical change must take place to secure fair payment for all reasonable services we provide, especially Evaluation and Management (E+M) services. But first, we must demonstrate to policy-makers and society as a whole that we have the knowledge, skills and credibility to warrant Medicare's expansion of its definition of eligible services by a chiropractor. The current Medicare Demonstration Project is a big step in the right direction, but it is imperative that the participating doctors act responsibly through appropriate use of coding, procedures, and visit frequency.

We envision a chiropractic profession in the future that will be seen by society as a vital part of the health care system. We envision chiropractors playing important roles in policy-making regarding public health measures, health care strategic planning, and public health advocacy. We envision the chiropractic physician being seen as the specialist to consult or to refer a patient to for the diagnosis and effective management of nonsurgical NMS conditions. We envision chiropractic schools being widely recognized as first-rate, with quality chiropractic clinical residency programs being the norm throughout the profession. We envision chiropractic physicians being widely respected for their knowledge and abilities in the care of patients with NMS conditions. We also envision chiropractic physicians being widely respected for their integrity and reliability. We envision the chiropractic profession as being fully integrated at the heart of the health care system.

In short, we envision the chiropractic profession as finally establishing itself in the mainstream of our society. But we also recognize that a great deal needs to be done to reform the profession in the areas discussed here (and upon which we will be expanding in future articles) before our collective vision comes to fruition. We hope that anyone who has a sincere desire to see our profession at the forefront of health care will join in our vision, and will support all efforts at positive professional reform.

References

1. CNN/USA Today/Gallup poll, 2003.
2. Coulter ID, Hurwitz EL, Adams AH, et al. Patients using chiropractors in North America: who are they, and why are they in chiropractic care? Spine 2002;27(3):291-298.
3. 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.
4. McCann JPR, Green LA, Fryer GE. Chiropractors are not a usual source of primary health care. Am Fam Phys 2004;69(11):2544.
5. Hawk C, Long CR, Boulanger KT. Prevalence of nonmusculoskeletal complaints in chiropractic practice: reports from a practice-based research program. J Manipulative Physiol Ther 2001;24(3):157-169.
6. Grod JP, Sikorski D, Keating JC. Unsubstantiated claims in patient brochures from the largest state, provincial, and national chiropractic associations and research agencies. J Manipulative Physiol Ther 2001;24(8):514-519.
7. Hawk C, Buckwalter K, Byrd L, et al. Health professions students' perceptions of interprofessional relationships. Academic Med 2002;77:354-357.