David A. Chapman-Smith
Chiropractic in the next 25 years - that's a long time in terms of change. Just look back 25 years to 1983. Defining features of the profession at that time were that it was basically North American, completely isolated from mainstream health care in education and practice, and had minimal infrastructure - no research capacity or literature.
Doctors of chiropractic were an isolated group of healers who had one huge thing going for them: a philosophy and set of clinical skills that resulted in many superb results for patients who then became extremely loyal and active for the profession. The good news was that there was no competitor in sight. The medical profession's position was that all forms of spinal manipulation by anyone were dangerous and inappropriate. Physical therapy was only beginning to show interest in manual therapy.
The bad news was that DCs were far down the food chain. Most patients tried almost everything else first. That is partly why there was such loyalty when patients recovered under chiropractic care. If and when those higher on the food chain improved their services, chiropractic became very vulnerable. It's also why, when I represented the chiropractic profession as legal counsel before a major Commission of Inquiry in New Zealand in 1978-79, we went with patient testimony. There was little else. We called the profession's one representative capable of impressing outside experts on the scientific basis of chiropractic - a young American named Scott Haldeman, DC, MD, PhD.
Since then, there has been much change. Chiropractic has the infrastructure of a significant profession: quality research and researchers, an expanded field of knowledge, numerous impressive texts, and sound evidence supporting major areas of clinical practice including management of patients with back pain, neck pain and headache. All of this is illustrated by the recently published report of the Bone and Joint Decade Task Force on Neck Pain; a report that will greatly influence management of neck pain for the next two decades.
This was a multimillion-dollar research venture by an elite interdisciplinary and international group of experts that will change a major area of health care. It was published in the leading medical journal Spine with ringing endorsements from medical peer leaders around the world - and two of the three leaders of the project were from the chiropractic profession, Dr. Haldeman and Dr. David Cassidy.
However, the most dramatic change, the specifics of which are probably not known to the majority of DCs in North America, is the growth of the profession around the world. Chiropractic is now a truly international profession. National associations in 90 countries are now members of the World Federation of Chiropractic, which has official relations with the World Health Organization (WHO). In Guidelines on Basic Training and Safety in Chiropractic (2005), the WHO recommends to governments worldwide that chiropractic is a valuable addition to their health care systems. The Guidelines have been translated and published in Chinese, Finnish, French, German, Indonesian, Italian, Japanese, Korean, Portuguese, Spanish and Turkish.
There are more chiropractic schools now outside than inside North America and most of them are in publicly funded universities. Students at UNEVE in Mexico City are fully funded by the government, not only for their studies but also for their first clinical year after graduation, which they serve in public hospitals. Chiropractic is most fully established worldwide in European countries such as Denmark, Norway and Switzerland, where it has government funding for education and clinical services, high integration within health care and a clear identity of mainstream rather than CAM.
Countries that have recognized and regulated chiropractic by legislation in the past few years include Costa Rica, Iran, Italy, Portugal, Thailand and the United Arab Emirates. A prestigious university near Madrid started Spain's first chiropractic school last year; the University of Zurich in Switzerland opens a Swiss program this year.
In the U.S., chiropractic has made some major advances, but is hamstrung by professional divisions, lack of serious money and public funding the profession needs and deserves, a compromised public image and the era of rabid managed care. While insurance understandably is a key focus for American DCs, it is a pendulum that will swing back in due course. Providers, predominantly medical, took too much in the 1970s and 1980s, and business struck back and asked for managed care. Managers are currently taking too much and patients are as upset as providers. This will balance out in the next 25 years.
And finally to the future. Health care generally, and spinal care specifically, is massive business. As Dr. Arlan Fuhr noted in this series (www.chiroweb.com/archives/26/03/14.html), there are many sharks. To swim with them and new competitors, chiropractic needs cultural authority, new allies and new resources. The era of asking practitioners to fund research and asking for private funding of tertiary educational institutions is gone. In the U.S., as is happening elsewhere in the world, there must be significant public funding for chiropractic education, research and practice.
Chiropractic is at a crossroads, to use a phrase from Drs. William Meeker and Haldeman. If it seeks to be on the road to the mainstream, committed to evidence and quality of care, demonstrating leadership in education, research and practice in its fields of philosophy and skilled manual care, and respecting and working with other stakeholders, it will continue its past impressive growth during the next 25 years.
In 2033, in the U.S. there will be chiropractic schools in several state universities, funding for research and education, and integrated and collaborative practice on levels not yet imagined. There will be DCs everywhere - in the DoD and VA systems, in integrated community and hospital settings, throughout university and professional sports medicine teams, in spine clinics, in wellness centers, affiliated with senior residences - and of course, in standard private practice. If chiropractic chooses to be on the road of complementary and alternative health care in the sense of rejecting a mainstream identity and preferring to go it alone, with only patients as its allies and with other providers and payors as opponents, it will watch others thrive while it wanes.
Today, chiropractic has the brain trust, patient support, recent successes and potential to swim with the big fish, as it must to protect and grow its heritage. That is already being demonstrated clearly in several countries. At a time when the public worldwide is reacting to the dangers and limitations of invasive and impersonal care that ignores the whole person and the real sources of health, this can be done without compromising the traditional philosophy of the profession on the basis of integrated care and patient choice rather than submission to another model.
I predict chiropractic will choose the mainstream and flourish. Those of us still here in 2033 will be as amazed then by progress as D.D. and B.J. would be by the international achievements of the profession today.
