Establishing Chiropractic Cultural Authority

How can we move chiropractic from the realm of "conversion experience" to the realm of accepted cultural practice? This is the question that concerned me last month in this column. I want to continue this discussion and get to the heart of what I want to say to individual chiropractors about their role in capturing a greater chiropractic authority in our culture.

If you talk to doctors throughout this profession, it's not uncommon to hear us voice a desire for a greater cultural influence, and then deliver the responsibility of winning that influence to the feet of our academic institutions, research bodies and national associations. I believe, however, that any chiropractor in practice who desires to expand chiropractic cultural authority can do so in their own community. Over time, this "grassroots authority" can be just as influential as political lobbying and research, especially when all three of these pursuits work together for the greater good of the order.

To show you why, I want to address two specific points: where our cultural health care authority comes from, and how individual chiropractors in practice can use this knowledge to build a greater influence for chiropractic in their community.

The Key Concepts, Revisited

Here are a few key concepts from part one of this article that will help us carry on the discussion:

• I defined cultural authority as the ability to impact public perception and influence the public, based on the perceived authority behind the person, institution or profession.
• I put forward the idea that authority has to be earned and can't be assumed.
• I said that cultural authority is a national and local phenomenon; there are a variety of ways in which our profession is respected or not, depending on the local climate.
• I proposed that our cultural authority will come when we do the right thing in the right time and place. Much of our history has been filled with examples of chiropractors either doing the right thing outside mainstream, or entering the public sphere improperly equipped to communicate effectively.

Where Authority Comes From

However you define it, chiropractic is squarely settled under the professional umbrella of "health care," and that means the gatekeepers to authority are those who define cultural authority in the Western medical model. To reiterate from my previous article: Patients cannot give us lasting cultural authority. Our gatekeepers are a loose network of medical researchers, doctors and teaching institutions who decide what's suitable for health care, based on their research, clinical experience and how they shape professional medical curriculum. Of course, economics and managed care play a huge role, too, and can't be underestimated. These gatekeepers aren't a homogenous bunch. Medical authorities often disagree about the significance of their data and experiences. Medical science doesn't mean uniformity of opinion. However, it does mean a kind of consensus about the way things work in order to improve patient care.

We could debate about why these gatekeepers of cultural authority in health care are our gatekeepers, but nonetheless, it's our reality. As it stands, we're considered practitioners of complementary and alternative medicine (CAM), which means we must labor under the handicap of having our methods considered outside the mainstream. Until the time when we can better describe the physiological mechanisms of the chiropractic adjustment, we will not have our own authority to enter into the health care consensus building. We have some remarkable and talented experts who have done much to advance our science and understanding of what we do. But compared to the expansive budgets of medicine, we remain too small to compete or cooperate on a national level at this place and time.

Grassroots Authority

"Bridge by bridge" is how you move and get things done during wars. I think it's a good phrase for the individual chiropractor's role in winning more cultural authority. Working bridge by bridge is what local doctors can do in their community to increase their cultural authority. Contributing financially to research and supporting the legislative agendas of our state and national organizations is one avenue for advancing our profession (although more participation in each of these is very much needed). However, this strategy cannot stand alone. It means doing the right thing, in the right place and time, in a way that's understandable to the gatekeepers of the health care authority in your community. I believe that working successfully in an integrated health setting is one of the most powerful of such bridges, and one of the best ways to grow local chiropractic authority.

Bridge One: Know the Gatekeepers

Recent articles in the chiropractic press have told of our educational institutions getting involved in local public health initiatives in their communities, like co-sponsoring smoking cessation days. This is a fine example of our schools knowing the gatekeepers in their area and working alongside them to support an aspect of their mission that chiropractic could support. It provided healthy public awareness of the schools within their community, and also placed students and administrators shoulder to shoulder with local health care cultural authorities. It sends a message that chiropractic is concerned with the greater health of the community, and not just "chiropractic things."

Who are the gatekeepers in your community? Here are just a few examples to consider:

• the local public health office;
• the board members of your community hospital;
• teaching clinicians at a nearby nursing or medical school; and
• the practice members of a nearby pain clinic.

How open are they to working with you? It could range anywhere from absolute rejection to indifference to excitement. The good news is that it won't be uniformly negative or positive. You might have to shake a few hands, but you're going to find someone who is willing to listen, especially if you express an interest in their concern. This is something that I learned in our process to bring chiropractic into the Phoenix VA Hospital. My military history and concern with helping veterans gave me a voice someone else might not have had. Just this morning, before writing this article, I gave an in-service lecture to the physical therapists at the VA. It was strictly informational, covering what a chiropractor does and how they are a part of the health care team, rather than in competition with other health care disciplines.

Bridge Two: Speak Their Language

For various reasons, our medical counterparts operate with far more oversight and scrutiny of their public communications than many chiropractors in practice. Chiropractic, on the other hand, has quite a history of claiming to cure the incurable, and has been quite public about using "fringe" diagnostics to assess patient health. (See my own discussion about the types of unproven claims in the archives.¹) Those with cultural health care authority in your community cannot risk their reputation on a CAM professional who is going to overstep boundaries and create hype that could potentially harm their reputation. This hype only damages our credibility. We need to know how to persuasively defend what we can verify about chiropractic, but be humble enough to admit we don't have the whole story researched yet.

Bridge Three: Come Prepared

What's the difference between a randomized control trial and a case study? What is evidence-based medicine? What kinds of conditions has chiropractic been shown to validly help, and what conditions are still considered experimental? What typical chiropractic diagnostics (palpation, leg checks) have been shown to be reliable between examiners? What are the iatrogenic risks associated with manual cervical manipulation? What are the defendable models of subluxation and the theoretical effects of manipulation? These are all questions to which you should know the answers if you're going to expand chiropractic authority in your community.

While credentials can definitely open doors, coming to multidisciplinary interactions prepared makes a more persuasive impression. Not knowing the basics behind what makes your technique reliable, or the evidence behind its effectiveness, is unhelpful. You're not going to be able to communicate as a health care peer. This is something that you need to be able to accomplish with confidence. After I lectured the physical therapists this morning, I passed out our latest peer-reviewed paper for them to study. Two years ago, I couldn't have done that.

Fortunately, in the past 30 years, a growing body of chiropractic research has allowed our own scientists to refine our knowledge and build a knowledge base that's accessible to any chiropractic professional. One first step would be to start reading the peer-reviewed journals, medical, osteopathic or chiropractic, on which chiropractors sit as peer reviewers. Start building a reference shelf of articles that will support your assertions when you talk to gatekeepers. Take special notice of the assertions that may reflect the concerns of the community authority that you wish to engage. The more you know, the easier the bridge is going to be built.

Local and National Cultural Authority

Our profession will continue to lobby Washington and expand our research initiatives in the coming years. These efforts greatly need your support. Over time, they will lead to an increased chiropractic cultural authority as we build and reform our knowledge. These aspects of the profession don't move as quickly, and aren't as powerful in your community as you are, however. Remember that cultural authority is a local and national phenomenon. What you do to build bridges within your community is going to do far more for chiropractic authority in your community on a daily basis than legislation or clinical research. While other DCs in your community will look to someone else to expand their influence, bridge by bridge, you can be the solution in moving chiropractic from the realm of belief to a status as accepted cultural practice, in your neighborhood and beyond.

Reference

1. Fuhr A. "Two Types of Unproven Claims." Dynamic Chiropractic, Dec. 16, 2004. Available online at: www.chiroweb.com/archives/22/26/08.html.