When Chiropractic Meets Mainstream Public Health, Part 2

The easiest way for chiropractic physicians and their associations to get involved in public health is to piggyback on the existing campaigns public health departments already sponsor. There are days, weeks and months dedicated to a particular goal, such as seat-belt use. There was a huge drive a few years ago against overdiscriminate or indiscriminate use of antibiotics. One program in our state is the Arthritis Project, which encourages arthritis patients to stay active.

There is no reason why we can't promote these causes in our clinics and add our dimension to them. State health department Web sites list what special events will be celebrated and can be contacted for brochures and posters. Coupled with materials from chiropractic suppliers with the same message, they result in a ready-made PR campaign. In fact, when patients see or hear the state public health PSAs, the connection between the chiropractic clinic and the message will be made. The chiropractic physician is part of the mainstream public health team. 

For further involvement in a project, DCs can join the sponsoring committee. Because these are state-sponsored programs, our profession should be able to contribute. We cannot redirect a grant or usurp a department's authority, but we can participate in government projects. Most of the chairmen of these projects are very happy to have interested professionals who support their goals. Many even welcome a new perspective, especially if a doctor is willing to work as a member of a team. We need to be proactive but work within the structure. In Arkansas, when the legislature set up a separate board for radiology technologists, one of the positions on the board was for a "physician." Because Arkansas doctors of chiropractic are "physicians" by law, we submitted a list of candidates and one of them was chosen. When his term expired, another DC replaced him. They were extremely instrumental in assuring that the new radiology rules and regulations addressed public safety while accommodating the concerns of chiropractic offices (such as the use of chiropractic radiology technologists).

Another way some of our state's DCs have worked within the system is by becoming certified as "scoliosis screeners." One of the first chiropractors who served on the Board of Health helped rewrite the scoliosis screening regulations. These put chiropractic physicians on par with other providers, both as screeners and as specialists for referral. A number of DCs have gone through the certification training and have assisted in school screenings.

One of the biggest mistakes often made by our profession is not playing well in the interprofessional sandbox. My three personal rules related to multidisciplinary interaction are be there, be willing to empty wastebaskets and follow through. If you attend all of the meetings and take notes, you become the authority when others miss. If you respect others' opinions and are willing to share some of the "grunt work," you demonstrate team spirit. If you volunteer and do the job, you demonstrate dedication. Sometimes, chiropractors come to the interprofessional table with a defensive and almost imperious attitude. Sometimes, lack of skills in certain medical areas may make them hesitant to join in. Sometimes, if a project doesn't show immediate payoff, they give up. There are so many opportunities lost because doctors don't see the big picture.

The most frustrating (and embarrassing) experiences I have had as state president, and as a Board of Health member, involved getting a DC placed on a committee or project and finding out later that he or she was too busy or too bored and quit. The DC didn't understand that public health functions in a bureaucracy. The process may move slowly, but the contacts you make also linger. Ironically, the players also change hats and positions much more rapidly than in the private sector. The nurse who serves on the child car seat project may be the future chairman of the public health safety committee who remembers the professionalism and dedication of their past partners.

One sad example of this lack of interprofessional cooperation happened early in my Board experience. A number of health professions had special public health events with PSAs produced by the state. The director of the health department agreed to do one highlighting back safety and asked for our input. Because some of the chiropractors insisted on the inclusion of the term "subluxation" and because some DCs objected to including osteopaths in the project, we missed that opportunity. Funding for all of those PSAs subsequently dried up.

One time when we really did work together well was at a health summit at which numerous "breakout" rooms featured different topics regarding the future of health care in Arkansas. Every room had a DC in attendance who volunteered to take the notes, thus becoming the official reporter. Each of us made sure "chiropractic" was mentioned in the discussion, written down and included in the official state report. There was nothing obnoxious about it. We honored everyone else's comments, but made sure ours went on the record. Unfortunately, our state  has continued our intraprofessional bickering to the point that multiple associations make coordinated involvement in public health projects difficult, if not impossible.

I have now been on the Board for 12 years and am second in seniority. I have not really experienced specific malice toward me by any Board members. Any negativity or exclusion seems to be more from ignorance of what we do than from directed prejudice. I actually treat a number of health department employees. What I have found is that because we are not in the standard medical model, we are frequently an oversight. This is frustrating, because it requires increased diligence in keeping up with committees and projects that are available. I don't think I have ever been turned down when I have raised the question of our inclusion. It would be nice to think that my tenure on the Board would get us permanently on the "dance card," but unfortunately, old thought patterns die hard. It is interesting to sit in meetings at which the group is charged with thinking outside of the box, only to have the whole discussion revolve around the participation of the medical society, the nursing association and the hospitals.

Relative to public health, the true challenge for our profession may not be others' prejudice against us, but our own difficulty in defining ourselves and our own inertia in accepting the role we can play. We need to learn the language of quality research and statistics. We also need to take responsibility for what we preach. If we disagree with the medical approach to an issue, are we willing to remain in the game and continue to provide a viable option? Do we offer the tools necessary for a patient to follow lifestyle and wellness advice? Are our physicians willing to reside in underserved communities and offer ongoing care to individuals outside the mainstream, in order to optimize and maintain their health? Public health is designed not only to protect the health of citizens in general, but also to provide services to those with special health needs and no means of acquiring assistance.

TB and STD patients, patients suffering from food, water or vector-borne diseases, low birth-weight babies - what can we offer them? Do we offer our services in a partnership with medicine or in a vacuum? Do we stop at rendering an adjustment at a "free clinic," or are we capable of addressing the lifestyle changes needed by the individual and providing supportive follow-up care? These are all questions we need to face as a profession and as individual physicians.

I am pleased that chiropractic colleges are offering more public health education. The ACC and individual colleges of chiropractic have welcomed presentations by APHA members and many students have joined the chiropractic section of the APHA. Chiropractic physicians with advanced public health degrees serve on faculties and in the research departments of chiropractic colleges. The service opportunities offered to chiropractic students through low-income clinics and community public-health projects are excellent ways of gaining experience in public health work and developing interprofessional relationships.

I have been fortunate to have served with three health department directors who have never expressed bias against my profession. I do know there are individuals in the state medical community who are prejudiced; some because of "cultism" propaganda, some, perhaps, because of perceived competition for the shrinking health care dollar, and some, unfortunately, because of a past negative encounter with a specific chiropractor. We still have to be proactive to ensure our inclusion in state projects. Although included in Medicaid and similar state programs, chiropractic in those programs is still not on par with other health professions. At the federal level, chiropractic still experiences discrimination against our participation in the Public Health Service and in the National Medical Disaster Services. Old opinions, the inertia of bureaucracy and funding issues keep us at arm's length, despite the need for all health care providers. Perhaps our recent entrance into the VA and DoD arenas will demonstrate our value in the system and lay groundwork for further formal chiropractic participation in public health.

I am proud of the strides Arkansas has taken to improve public health. Our state is one of the only ones to use 100 percent of its tobacco settlement money for health issues. We have been told that we are ahead of most other states in preparation for a pandemic or bioterrorism. We continue to have many areas of frustration for all public health care providers. Obesity, heart disease, diabetes and drug abuse are major issues still with us. Chiropractors, as primary health care physicians, can be significant providers in overcoming these demons. We have the skills. We need to continue to seek the opportunities and assume the responsibilities of partnership in public health.