Looking Forward to Chiropractic's Future

"The reason people find it so hard to be happy is that they always see the past better than it was, the present worse than it is and the future less resolved than it will be."

- Marcel Pagnol

Iam in my 45^th year of practice, so I believe I can recall with some relevance to our early history when chiropractors began service to an ailing humanity, in an era before the arrival of what we think of today as "scientific medicine." My image of chiropractic, as well as the image held by the public, was that DCs were those unconventional low-tech, high-touch practitioners, those "kyropraktors," as many called us; those doctors who took time with people and talked with them, comforted them, related to them and truly cared for them. We offered hope, relief and empathy to many patients whose "other" doctors provided little resemblance of that kind of care.

Our theories and methods were simple but oftentimes effective, and almost always less hazardous than the orthodox medical alternatives. Our practices in those days were mostly anecdotal - based a lot on faith, practiced mostly in a nonempirical, monocausal theory-of-disease model. And though today many chiropractors have abandoned such early concepts, they served our patients satisfactorily in days gone by. We used our hands to detect and correct areas of the spine we felt were dysfunctional and our patients, and often the doctor, were frequently delighted and surprised with the results. This result-based early model formed the basis of a referral practice - in a nutshell, satisfied patients referred other patients!

We were overwhelmingly solo practitioners whose patients paid cash for our services, which not only enabled us to pay the bills, but also reinforced our (as well as their) belief in the value of our services. Free care was provided to the indigent - and to legislators in every state with whom we hoped would favor our cause with a licensing statute. We were delighted when an occasional insurance company honored our claim for compensation, but this was the exception rather than the rule. For the most part, we were isolated from hospitals, universities, and most other traditional health care providers and reimbursement schemes. We were essentially totally outside the "system."

In some ways we epitomized the 19th- century country doctor, in that we got to know our patients well - as well as the whole family - and we treated them with a mutual respect and affection. Those early chiropractors were not only practitioners, but also educators who taught an appreciation for nature and its healing potential in each human life. We were often the family confidant whose advice and counsel was sought in many areas unrelated to the patient's health problem. Our patients were our neighbors and friends, and hard as it is to believe today, it was rare indeed that any of them brought a legal action against us. Malpractice cases against chiropractors were all but nonexistent. When political medicine sought to press criminal charges against doctors of chiropractic for unlicensed practice, they had to hire stooges (sham patients) to testify against us in court. Prosecutors soon learned that a sure way to lose a case against a chiropractor was to force (subpoena) a chiropractic patient to testify against their doctor.

Times have certainly changed! We've undergone more than 70 years of standardizing and upgrading in our educational system and a quarter century of clinical research, often conducted by dual-degreed doctors of chiropractic. Most DCs in the U.S. now operate within a third-party payment system that places heavy emphasis on the empirical outcomes of health care: symptom reduction, patient satisfaction and health care costs. We have not yet arrived at the status of full-fledged, evidence-oriented clinicians, but many chiropractors now recognize this is the inevitable future and direction we must pursue. Neither have we managed to fully shake off the stigma of quackery and integrate with the rest of the health care community as we should - for the sake of our patients and the advancement of our discipline. But I am happy to say we have started down that path and are making phenomenal progress.

Today, most DCs have grown beyond the "one cause, one cure" mentality that so retarded our scientific, educational, social and political growth, and reinforced our ostracism from the rest of the professions. Most of us who practice every day do not yet possess the habits and cognitive skills necessary to fully interpret - let alone contribute to - much of the scientific literature in our own field, but there is an ever-growing awareness that this is the future for all health care providers. Chiropractors today do have the training to make excellent differential diagnoses appropriate to the patient populations that present in our offices; we know when to seek consultation, co-treatment or referral to other types of doctors. There is a sense of trepidation about developing formal standards of care (guidelines or best practices), but we also increasingly recognize that we must be involved in establishing these practice criteria or suffer their imposition by outsiders. We are just beginning to appreciate what fully informed consent means.

We have managed to integrate low-tech and high-touch to a significant extent. But there is a concern among a segment of chiropractic that we may lose our "manual superiority" as other groups seem to embrace the traditional hands-on spinal manipulation and we look to high-tech - no-touch approaches. Our training today provides us with the cognitive skills to make good use, when necessary, of sophisticated diagnostic imaging and laboratory studies. And though we still confront turf battles over our use of many increasingly sophisticated but nonetheless conservative assessment methods, we have done a commendable job, in the spirit of Hippocrates, of pursuing the gentler remedies first. Spinal and other articular adjustments, manipulations and therapies are among the safest of all health care interventions, and we need to recognize that and promote the safety and efficacy of this conservative approach.

Many are apprehensive, and rightfully so, about abandoning what has been our central clinical construct: the subluxation-complex/syndrome. Some of us have clung to this notion so tenaciously that we have stifled curiosity and skepticism, the very ingredients essential to scientific studies. A few have gone so far as to have made a mockery of scientific investigation by employing subluxation research as a scheme to money-making patient-recruitment programs. Some DCs have even recommended abandoning the subluxation construct, although the research to date neither confirms nor refutes its meaningfulness at this time. In those famous words at the end of every research project, "Further research is needed." More important, however, whether we will be receptive to what the investigation(s) reveal.

Few of us in practice can engage in the rigorous and demanding work we need to experimentally explore the traditional chiropractic lesion as a clinically meaningful idea, but all of us are capable of contributing a legitimate case study now and then. All too many of us continue to insist and resist any other view than that subluxation must be real - because it defines us! We must move beyond this illogical reasoning to encourage and embrace hard data, with the expectation that if subluxation remains part of our thinking, it will probably be as one component in multi-factorial explanations of the pathophysiology patients bring to us.

The early years that focused on patient-centered care are important and must never be compromised. Some focus today on selling practice-building schemes and cleverly designed programs wherein doctors presume to know how many office visits a patient will need - even before the doctor has met the patient! The patient visit average (PVA) adulation has no place in yesterday's, today's or tomorrow's health care practice. I hope we can, in the famous words of the now-refuted AMA position paper, contain and eliminate this blight in our profession before it irreparably harms our future.

Our primary method of intervening in our patients' lives has fared well in this age of accountability for outcomes. The manual treatments we have trumpeted for so long have enjoyed some noteworthy success in more than 60 reasonably well-controlled trials of patients with low back pain, undoubtedly the most common disorder we see and one of the most ubiquitous health problems in civilized nations. This research success has translated into greater respect for the field doctor, who now has a greater opportunity and responsibility to leverage this scientific vindication into closer working relationships with the wider health care community and the third-party payment system. To do so, we must more universally learn and use the common language of biomedicine to communicate.

The future of chiropractic - as far as my crystal ball allows me to see - is complex.

Today we observe the beginnings of multidisciplinary-practice chiropractors working with many diverse providers to the advantage of patients. Undoubtedly, the spread of integrative health care practices in the traditional arenas where we have done so well (local communities) will continue, but also in the military, the Veterans Administration, in public and private hospitals, in ambulatory clinics, in university health centers, on the faculty of prestigious universities, on shop floors in large manufacturing plants, and perhaps even within the stores of the giant retailer Wal-Mart. However, wherever we practice in the future, we can expect to be held accountable for our methods and clinical outcomes.

If the data for our evidence-oriented practice is limited today, we can only hope science will lead the way to a more enlightened practice tomorrow. Today, the nature of diagnosis for most of the musculoskeletal problems that fill our offices is descriptive. We classify our patients based on the patterns of their signs and symptoms, rather than upon an etiological understanding - or even a pathophysiological understanding - of their low back disorder, neck pain or headache. And if our scientific studies do elucidate the seminal and precipitating causes of these and other health problems, we can only hope that this better understanding also will suggest improvements in the treatment we offer to our patients. These better interventions may or may not include the adjustment and other manual methods; only time and further research will tell. But we must be willing to accept the results of what these studies demonstrate.

Forgetting for a moment about musculoskeletal conditions, what about the epidemic of obesity currently rampant in the U.S. and the world? Will doctors of chiropractic be equipped to engage in the management of obesity? Which profession will be the competent counselors and health care coaches to millions of individuals in need of nutritional advice (the nutragenomics of the future)? Is chiropractic taking a leading role in this vastly uncharted world of nutritional education? What and how will nano- and biotechnology impact the manner in which we practice or alter the very essence of our future as conservative practitioners? These are the emerging issues facing health care, along with an enormous focus on longevity.

Chiropractic and medicine as health care professions are only performing at our current level of discovery. The entire health delivery system, even in 2008, is primitive and only as effective as the innovations that will take place in the next 25 to 50 years. Those innovations will have enormous impact on how health care is delivered, and those professions that are tuned to tomorrow will emerge successful.

Today's focus is on longevity medicine, which is touting hope via life extension to millions of baby boomers. Despite these exciting future concepts, a major question still remains. How will we (all health care providers) be paid? There are as many answers as there are candidates for the presidential office. The U.S. remains one of the few technologically advanced countries that does not provide national health care. How long will the U.S. continue to deny affordable health care for a large segment of its population is uncertain, but the political climate has almost reached a "tipping point" whereby it is now politically safe to support such a system. It seems clear, however, that the financial viability of chiropractors in this country surely will depend upon our continued involvement in the political and health-care-policy process within our borders.

The economics of chiropractic services in the U.S. will be increasingly impacted by the emergence of a doctoral-level physical therapy profession. Doctors of physical therapy (DPTs) now enjoy portal-of-entry status in more than three dozen of our 50 states. Most receive their training in state-university-based or state-funded schools, and upon graduation and licensure are welcomed into the health care community much more readily than are chiropractors. Chiropractors in the U.S. have made a living for more than a century by capturing 7 to 12 percent of the musculoskeletal patient population. We have managed to do so, in part, because our allopathic competitors had relatively little interest in and little to offer to musculoskeletal patients. The same cannot be said about DPTs. American DCs are attempting to prevent the practice of adjusting among DPTs through the political/legislative process, but this sort of turf-protection will fail sooner or later. Setting the standard for the process of what constitutes manipulation is a more viable approach. An alternative to competing with DPTs is to seek ways of joining them - not only for our own sake, but also for that of the patients. How will this cooperative effort look tomorrow? Only the creative willingness and innovative thinking of our leadership and that of the DPT will determine the outcome.

How far we have come, but boy, how far we have to go. Chiropractic - the profession and the practice - has changed dramatically in our 113 years and will continue to dramatically unfold. The societies we live in and the patients we serve have evolved in directions our professional ancestors could not have foreseen, and will continue to develop in ways that we cannot imagine. Given these challenges and issues, what we can and must do as practitioners is to commit our heads, hearts and hands to lifelong learning in the best interest of our patients. We must recommit ourselves to serving our patients, so that come what may, we will be there to meet the challenges that our conservative orientation to health care can best address. Tomorrow really is not about chiropractic; it is about the patients we serve and how we continue to serve them in a world that will radically change.

Health care is in the midst of a revolution. The past was about disease management and healing; the future will be about prevention and enhancement. From stem cell advancement to technologically superior devices, to robotic interventions at every level, the changes are rapidly upon us. Will we as a profession be involved as a participant or a spectator? This is tomorrow's challenge to our colleges and our researchers. Hopefully, they will help guide this profession to find our unique niche in the future delivery of health care.