In 2005, the WFC released its findings on the chiropractic identity survey it conducted the previous year.1 Results, based on 3,689 complete responses, showed a strong consensus (74 percent) that the profession should have a clear public identity and a good consensus (56 percent) that we suffer from a lack of one. The survey also revealed that chiropractors consider the nervous system of central importance (85 percent) to practice and identity, with the spine in second place, at 72 percent.
The survey also found that both the profession's and the public's view of the profession are equally important. The majority of the profession feels we should be perceived as primary care providers, yet only 41 percent of the public sees us as such. Our perceptions of how the public should see us differ greatly with our perception of how it is perceived currently in several key areas: primary health care, wellness care, nondrug/nonsurgical health care, and the management of spinal, neuromusculoskeletal and subluxation problems and their impact on health. Both perceptions of the profession regarding the management of spinal problems are in line with the majority of the public which views us as back and neck pain managers. Nearly half of the medical doctors also seem to be confused as to what we are all about.
While such numbers are disturbing, the end result of the survey and recommendation was that the profession should focus on a public identity as "spinal health care experts in the health care system."2 The report outlines our international identity, three linked image concepts, foundation and personality, and then goes on to define the roles of the WFC and member associations.
Are we short-sighting ourselves by accepting a level at which we already are viewed (as spinal health care specialists) and enhancing this image? Agreed, a lack of identity is a major detriment to the profession. However, to focus on a role that equal amounts of the public and the profession already see seems like a waste to me. Hoof beats are thundering behind us, with physical therapists attempting to establish a role as direct contact providers, as well as upgrading their academic standards. Yet we choose to maintain the status quo and play in the same field, while the PTs are trying to carve out a niche. They already have the things we lack: medical acceptance; credibility with medical doctors and insurance carriers; a strong national organization with growing support; and a defined strategy to improve their status in the health care milieu.
Futurism
As an amateur futurist, I suggest we look at the issues identified in the two studies by the Institute for Alternative Futures (IAF) on the future of the chiropractic profession, and ask ourselves if we would be better off designing our future rather than focusing on a narrow spectrum and letting the chips fall where they will. Podiatrists and osteopaths asked themselves such hard questions years ago, and started focusing their attention on the future and how to carve out a niche with some substance and credibility. They also suffered from the bastard child syndrome of being outside the "family." Now, both have seemingly been well-integrated, while also maintaining separateness. They fought off the incessant AMA attacks by addressing the issues and integrating into the system.
The solution to our future may well be in the area of future or foresight studies. In future studies, scenario development is an effective tool used to identify future possibilities. Normally, four scenarios are developed, based on future trends. The IAF completed two evaluations of the chiropractic profession, the most recent in 2005. The IAF identified four scenarios for the profession,3 which I have summarized/paraphrased below:
- Scenario 1: Slow, steady growth with somewhat better integration into mainstream health care and competition from DPTs, massage therapists and DOs. A possible geriatric niche evolves from this scenario.
- Scenario 2: Downward spiral due to cost squeezes, falling standards of care, professional behaviors and diagnostic incompetencies, supported by meager evidence for our effectiveness with little to provide over other competitors.
- Scenario 3: Evidence-based collaboration with consumer-directed health care growth, resulting in a cost-effective niche in the neuromusculoskeletal (NMS) arena as specialists. Enlightened health plans require a trial of manipulation prior to authorization of expensive surgeries or medicines. Chiropractic offices include sophisticated data systems with linking capabilities to genomic information and coaching.
- Scenario 4: Healthy life doctors evolve with a mind shift among individuals and health care systems. Competition will exist with other providers as well. Competition in this area is primarily from the naturopaths, who currently are licensed in only a few states, but are growing.
Although I have some issues with the IAF scenarios, it would seem a better way to approach this issue than just surveying chiropractors and the public to determine their perceptions and desires and formulating a limited program to establish a professional identity - in my opinion, a short-term fix. We have bigger fish to fry. A preferred solution would be to establish a research base of trends; develop more comprehensive and possibly different scenarios; agree as a profession, with expert input, as to the most likely and preferred visions, and establish a vision; and then evolve the strategies and tactics necessary to preserve the vision in the future, with contingency plans for evolving trends. In other words, let's design our future and take the steps necessary to make it a reality, with flexibility and foresight.
Designing the Future
Designing our future would require several important decisions and events to take place. First and foremost is professional unity, which the IAF pointed out as a major issue for the profession. The chiropractic profession, in my opinion, cannot survive the long term without unity. Our competitors/threats have it. Some states are becoming enlightened enough to put aside turf wars and recognize the need to become unified in order to address the evolving issues. Michigan is a recent example where they are establishing unity and attempting to restore previously held practice rights lost while the turf wars were underway.4
Professional unity will allow the leaders to establish consensus on where the profession should focus health care, technological and social trends, and facilitate the formulation of strategies to successfully position for the future. This is not an easy process, but it is necessary. It also will prevent us from working at cross purposes and confusing decision-makers, as was noted during our integration into the VA.
The IAF pointed out our competitors as massage therapists, PTs, and DOs. There also is some minor competition from the NDs in the manipulation market. Massage therapists are limited in scope, although I have experienced some therapists manipulating patients in violation of practice laws. DOs seem to be more interested in practicing more in the allopathic arena, with few specializing or even utilizing manipulation. In my opinion, PTs are the biggest threat. They are making efforts in most states for direct access and are developing DPT programs oriented toward manual medicine (conservative). The programs at which I have looked are mostly online with weekend workshops, suggesting an inferior level of manipulation training. However, they do not drive a subluxation philosophy, and benefit from widespread acceptance by the medical, Medicare and insurance industries, and the public in general. Their focus is on evidence-based care (a recommendation for DCs from the IAF). NDs are of little threat on the manipulation market. However, they are expanding with licensing recognition in several states in recent years, and if they continue to succeed, they could move to the forefront of alternative medicine.
Spinal Health Care Experts: Our Identity for the Future?
What does defining ourselves as the spinal health care experts do for us as a profession? We will be the small fish in the sea of orthopedists and physical therapists competing in an environment that fights to not recognize us as legitimate. We will be fighting for a niche with a lack of unity, consistent scopes of practice, consistent philosophy, consistent licensing criteria and interchangeability among states. The MDs, PTs and DOs already possess these things. So, do we want to define ourselves in a manner that puts us in competition with others who possess a better public image and stronger foundation? Perhaps there are other options and broader opportunities. Or do we want to broaden our scope and become primary care doctors in the alternative arena?
One Possibility - Less Limiting
After fixing lack of unity, scopes of practice, professional philosophy (not sure why that should be a driving factor - perhaps it should be thrown out), licensing transferability, etc., what are our options? Do we stay pigeonholed in the "spinal health care specialist" bailiwick and talk about our focus on natural health care, or do we take a broader position and develop it? Perhaps there are other scenarios that might take advantage of the trends identified by the futurists. Here is just one possibility.
Scenario 5: Alternative health care doctors. Recognize the importance of the geriatric and healthy life doctor, and the niche available to become a comprehensive alternative health care profession. Approach the naturopaths and develop strategic foresight to define a comprehensive alternative medicine profession, with the best of both worlds, by merging the two professions. Integrate both health care philosophies and evolve the specialties within the profession necessary to establish credibility: radiology, natural medicines (herbal, nutrition, functional), manipulation, orthopedics, women's health, gerontology, etc. Initiate a strong push for the research funding necessary to evolve evidence-based, natural medicine protocols, thereby establishing credibility. Develop a strong research focus with an emphasis on natural medicine alternatives. This scenario would help the naturopaths solve licensing issues and expands the clinical armament of the chiropractic profession. Other scenarios may play out, depending on evolving health care trends, but here is one specific scenario with a possible alternative. We might have to change our names to doctors of natural medicine (DNM) and throw out the subluxation focus, which is an antiquated and limiting concept, in my opinion. Another issue also might involve the use of limited prescription rights so we can effectively manage cases needing more aggressive intervention without having to send them to the MD/DO.
Several major issues need to be addressed as a profession for long-term stability and political clout. Unity within chiropractic is a must, and unity with the naturopathic profession might be worth consideration. It is professional suicide to have multiple organizations working at cross purposes. Licensing uniformity and interchangeability is necessary to establish a consistent professional image and the ability of experienced doctors to be able to move across state lines without the burdensome testing processes currently in place. It also will add to public perceptions of our image by making us consistent with other providers. We are the only large health care profession with such limited mobility and scope variability. Continued improvement in academic depth and admissions selectivity is needed. In other words, we need to continually upgrade our educational standards to stay on par with other health care professions. We need an entrance screening examination, such as a CCAT or MCAT, to weed out those ill-suited for professional training. The educational evolution must take place in synergy with the strategic plans of a unified profession.
The Future
The future is not predictable with any certainty. Unforeseen events can change trends and seriously upset timelines. However, not stepping back and looking at the possibilities and attempting to anticipate the trends and events affecting our long-term viability is an amateurish and reactive approach. Let's be professional and look at the future with foresight and intent, as most businesses do these days. Instead of reacting to events and threats, let's look at designing our future and strategically putting into place the necessary elements for long-term success. We are likely to have a better image and professional viability than if we wait for others to design it for us, or continue in a reactive mode to professional threats from the medical community.
To categorize us as spinal health care experts narrows our identity. It limits us to a specialist category in which the profession and the public view us already. It limits us to spinal conditions (not extremities, by definition) and further narrows our scope. I believe we need to take a serious look at where we are going and the future impact of our decisions. We need to design our future, instead of constantly putting out fires and reacting to threats from other professions. These threats often are strategic reactions to information/research. One example is the AMA's recent efforts to highlight academic credentials as an issue, after a JAMA study showed their patients were seeing alternative providers as much or more than them (money and control). Another example is the Texas Medical Association's5 suit questioning needle electrodiagnostics and other scope issues, when these same procedures often are done by technicians within the medical professions (again, money and control). They are watching our behaviors regularly, and we need to tighten up our ship and take control of our destiny, with the intent to establish a solid niche in the health care market - however it ultimately is defined. Otherwise, our competitors will be all too happy to marginalize us.
I'm sure I have ruffled a few feathers with the above comments. However, change is difficult, and it is hard to move out of comfort zones. Change is inevitable and necessary to the future survival of the chiropractic profession. We need to either lead or be at the mercy of others by reacting and following.
References
- "Surveying Chiropractic Identity: WFC Releases Findings." Dynamic Chiropractic, April 9, 2005. Available at: www.chiroweb.com/archives/23/08/16.html.
- "Unanimous Agreement on the Identity of the Profession. 'Historic Milestone' Achieved at WFC Congress in Sydney." Dynamic Chiropractic,Aug. 13, 2005. Available at: www.chiroweb.com/archives/23/17/19.html.
- Institute for Alternative Futures, The Future of Chiropractic Revisited: 2005-2015. Alexandria, Va., 2005. Available at: www.altfutures.com.
- MCS/MCA Merger Efforts Approaching Completion. Available at: www.michiganchiropractic.org.
- "Texas Arm of the AMA Strikes Out at Chiropractic." Dynamic Chiropractic, Nov. 8, 2006. Available at: www.chiroweb.com/states/texas.html.
