Where Do We Fit?

Some years ago, I wrote an article titled "Data vs. Dogma," which caused a big stir. I didn't realize what I had gotten myself into. I was just beginning to look into clinical research, and it was a feeble attempt to force myself to think in scientific terms. Epistemology - that branch of philosophy which deals with the nature of knowledge - was an unknown term to me then. I graduated from Logan College in 1961, long before the subluxation was ever questioned to any significant extent by chiropractors. As well, the profession had not reached consensus about the nature and purpose of chiropractic services. Should we be primary care physicians or musculoskeletal specialists, or subluxation-correctors, or something else? Lots of choices! Today, the arguments still rage on. However, I have gradually come to recognize that the possibilities are more diverse than can fit on a simple continuum:

Last year, I began my journey into the Veterans Administration (VA) health care system with fear and trepidation. My anxiety began with the electronic medical records course required of all new clinicians. I was unsure whether I could even remember the access codes, much less learn the whole system. Some physicians (MDs) resisted its introduction and were discharged. However, a year into my career in "military medicine," I've come to appreciate the benefits this extra layer of (electronic) paperwork offers to our patients; for example, preventing unnecessary or dangerous duplication of services and allowing instant "portability" of patient information from one VA site to the next. Now we love the system, and we have access to all the diagnoses and treatment plans of the other members of the team.

There is also no overutilization in the VA system; instead, we have a never-ending supply of new patients. It's all we can do just to keep up with demand. (I suspect that if chiropractors did a better, more consistent, more rational, more coherent job of communicating who we are and what we offer to the public and to the rest of the health care community, we would have waiting lines in the private sector, too.)

Our new chiropractic service was supposed to be housed in the VA hospital's physical therapy department. However, as luck would have it, there was no room in that division, so we were given a place to practice in a primary care "pod." It's a really wild mixture. We have primary care, internists, HIV testing and all the nurse practitioners, nurses and the support folks who go together to form the health care team. Did you get that? Chiropractors on a team? Sure sounds a bit out of character!

About two months into our new chiropractic service, the clinical director of ambulatory care asked if I would speak at the monthly physicians' meeting. I accepted, and then wondered what I was going to talk about. I decided to take a freshly published JMPT paper on the current status of Activator Methods,¹ since that is the technique we use in the pod. I copied off a number of the papers, but suspected that I would probably hand out only one or two of them. At the meeting, I told the group that I was there to answer questions, and that if there was interest, I had copies of a paper to hand out. Lo and behold, hands went up all over the room and I distributed all the copies.

Then the questioning began. The first was: "Can we send acute patients to you?" "If you ever find any, we would be happy to see them," I replied. (The VA patient population is very chronic indeed.) The next question was: "What do you do for a flu patient?" I could feel all eyes on me as I answered: "Send them back to you - so I don't get the flu." Well, that brought the house down! More importantly, it let them know that I was part of the team and was not treading on anyone's territory. The very next week, we had 40 new referrals and we have never had fewer since. In fact, all sorts of health care providers have visited us while we take care of patients, and all leave with a new respect for chiropractic.

My VA experience has helped me to sort through some of the many visions of chiropractic that have come and gone and come again during the past 110 years. I feel that I have arrived at a comfortable spot in my understanding of this thing called chiropractic, and I know where I fit, at least within the context of my service to the VA and its patients. I'm not prepared to say that my comfort zone is the only viable niche for modern-day chiropractors, but I believe it is a sensible, coherent, logical and useful place, and one that enables us to function within the team that is the wider health care community:

This niche - evidence-informed, musculoskeletal care - is consistent with the broad mandate that chiropractors have consistently espoused for themselves. I'm reminded of a portion of the mission statement offered by the Canadian Memorial Chiropractic College some years ago:

Chiropractic articulates a philosophy of health. The chiropractic model of health care includes the art and science of prevention, diagnosis and treatment of abnormalities of structure and function of the neuromusculoskeletal system for the purpose of enhancing health of the whole person, primarily, but not only through the use of the chiropractic adjustment [The college's mission] is to benefit society through the pursuit of knowledge and the education of chiropractors so that they may acquire the understanding and skills necessary to apply this knowledge and contribute effectively to the health care team.²

I think time will take care of some of our traditional problems. As the research enterprise in chiropractic matures, the data will curtail much of the infighting. We will end up doing what is best for the patient because we will know what is best for the patient. In the meantime, each of us needs to make rational choices that enable us to function effectively within the health care system. Where do we fit? I think I've found one place that works for me and my team.

References

1. Fuhr AW, JM Menke. Status of Activator Methods chiropractic technique, theory and practice. Journal of Manipulative & Physiological Therapeutics 2005;28(2):135.e1-135.e20 [doi:10.1016/j.jmpt.2005.01.001].
2. CMCC Mission Statement; quoted in Brown DM. Oswald Hall, Ph.D.: chiropractic advocate, 1971 to 1998. Journal of the Canadian Chiropractic Association 2005;49(4);301-11.