What does the future of chiropractic look like? The groundwork for the next 25 years has been laid by the events that shaped the profession in the past century, particularly with respect to the political and legal struggles chiropractic has endured. At the heart of it all has been the fight for professional and public recognition - under the constant watch of the medical profession.
Let's begin in 1933, when the American Medical Association (AMA) House of Delegates declared, "The physician who maintains professional relations with cult practitioners would seem to exhibit a lack of faith in the correctness and efficacy of scientific medicine and to admit that there is merit in the methods of cult practitioners." While doctors of chiropractic were not mentioned specifically, the intention was clear.
Nearly 30 years later, the House of Delegates issued another proclamation, this one more specific to chiropractors: "It is unethical to refer to, to accept referrals from, consult with, teach, or in any way professionally associate with doctors of chiropractic." A year later, Robert B. Throckborton, legal counsel of the Iowa Medical Society (and later general counsel of the AMA), introduced what would become known as "The Iowa Plan." Among his comments, presented at the North Central Medical Conference in November 1962, was the following: "Organized medicine should undertake a more clearly defined program to solve the chiropractic problem."
The Iowa Plan was specific and ominous. It outlined how the medical profession could deal with "the chiropractic menace" - by encouraging chiropractic disunity; opposing chiropractic inroads in health insurance, workers' compensation, labor unions and hospitals; and containing chiropractic schools, all with the goal of facilitating "the decline of chiropractic."
In 1963, the AMA established the Committee on Quackery, whose stated mission was "the containment of chiropractic, and, ultimately, the elimination of chiropractic." The committee authored a Statement of Policy on Chiropractic, released in 1966. This policystatement said, in part:
"It is the position of the medical profession that chiropractic is an unscientific cult whose practitioners lack the necessary training and background to diagnose and treat human disease. ... Chiropractic constitutes a hazard to rational health care in the United States because of the substandard and unscientific education of its practitioners and their rigid adherence to an irrational, unscientific approach to disease causation."
In 1970, the Joint Committee on Accreditation of Hospitals enacted Standard X, which dictated that hospital accreditation of the nation's 6,500 acute-care hospitals would hinge on each hospital's enforcement of the ban on members of its medical staff associating with any doctor of chiropractic. This effectively extended the boycott of chiropractic from individual medical societies to medical physicians. Standard X was written verbatim by the AMA.
Around this same time, as the AMA propagated its anti-chiropractic plan, a few interesting things happened. In a 1967 article in the Journal of the American Medical Association, Dr. John Wilson Jr., chair of the AMA Section on Orthopedic Surgery, stated: "The teaching in our medical schools of the etiology, natural history and treatment of low back pain is inconsistent and less than minimal." In 1971, an Oregon workers' compensation study found that of workers treated by chiropractors alone, "82 percent resumed work after one week of time loss." By comparison, only 41 percent of workers treated by medical doctors resumed work after one week of time loss. A similar study in California in 1975 also showed better results from chiropractic versus medical care: 32 days of lost time per employee in the MD-treated group compared to only 15.6 days per employee in the chiropractor-treated group.
In 1972, the Social Security Act was amended to include the addition of chiropractic services, due in large part to a reported 3 million testimonials mailed to Congress by chiropractic patients. Two years later, Louisiana authorized the practice of chiropractic, and chiropractors could officially practice legally in all 50 U.S. states. Momentum was growing.
Then came Wilk, et al. v AMA, et al. On Oct. 12, 1976, Chester A. Wilk, DC, and four other plaintiff chiropractors filed suit in federal court against the AMA and 13 other defendants for violations of U.S. antittrust laws. The proceedings would last 14 years, including two trials and two appeals.
Perhaps due to this ongoing litigation, the AMA partially relaxed its boycott in 1979. Resolution UU stated that the AMA position on chiropractic "did not necessarily mean ... that everything a chiropractor may do ... is without therapeutic value" or that all doctors of chiropractic are cultists. Even this partial change of heart seemed to result in a significant jump in demand for chiropractic services and chiropractic income.
Also in 1979, the Royal Commission of Inquiry on Chiropractic in New Zealand determined "beyond any reasonable degree of doubt that chiropractors have a more thorough training in spinal mechanics and manual therapy than any other health professional. ... It would therefore be astonishing to contemplate that a chiropractor, in those areas of expertise, should be subject to the directions of a medical practitioner who is largely ignorant of those matters." The commission accepted the evidence of Scott Haldeman, MD, DC, PhD, and stated that "in order to acquire a degree of diagnostic and manual skill sufficient to match chiropractic standards, a medical graduate would require up to 12 months' full-time training."
On Sept. 25, 1987, U.S. District Judge Susan Getzendanner ruled that the AMA had engaged in a systematic, successful, illegal boycott against chiropractors and enjoined the association "from restricting, regulating or impeding the freedom of any AMA member of any institution or hospital to make an individual decision as to whether or not ... [they] shall professionally associate with chiropractors, chiropractic students, or chiropractic institutions."
That battle may have been won, but the war was not over, nor is it now. Since the Wilk decision, the medical profession and insurers have done their best to exclude or limit chiropractic. A few examples:
- In 1989, Leonard Chinnici, DC, filed a RICO-based action against more than 20 physicians at a suburban Chicago hospital for boycotting and destroying the career of a neurosurgeon who elected to form a health care partnership with a chiropractor.
- In November 1990, Congress passed a law requiring the Department of Health and Human Services to conduct a study on the extent to which Medicare HMOs/CMPs were providing chiropractic services to Medicare beneficiaries. HHS ignored repeated requests by Congress until December 1994, when it released Operational Policy Letter #23, which stated that managed care plans were not required to offer manual manipulation of the spine to correct a subluxation through chiropractors, and that non-physicans such as physical therapists could provide this treatment.
Ironically, the letter came six days after the Agency for Health Care Policy and Research (AHCPR) released guidelines that concluded spinal manipulative therapy is the most effective treatment for low back pain and that "[u]nlike surgical interventions, spinal manipulation offers both pain relief and functional improvement."
The ACA filed an official complaint against HHS Secretary Donna Shalala in 1998, seeking to compel the secretary to conduct the study ordered by Congress. Ultimately, HHS submitted a report on chiropractic in April 1999. The report showed an 85 percent decrease in the use of DCs compared with fee-for-service utilization in Hmos with a medical physician gatekeeper; and that 22 percent of the managed care organizations contracted with by Medicare did not even offer manual manipulation of the spine to correct a subluxation through chiropractors. It was not until 2002 that the HHS published a revised OPL #23 that included DCs. The policy letter provided "the definition of a physician for Medicare coverage purposes, which includes a chiropractor for treatment of manual manipulation of the spine to correct a subluxation." - In 2000, the American Chiropractic Association filed suit against Trigon Blue Cross Blue Shield (BC/BS) and the national BC/BS Association, alleging racketeering, extortion, mail fraud, antitrust violations and other state and federal violations.
So, what is the future of chiropractic? Believe it or not, despite the battles I have participated in against organized medicine, I believe it lies in research and integration. My vision for the future of chiropractic involves a profession serving 50 million or more Americans based on science. Who better to prove my point than Dr. Haldeman, chiropractor, neurologist and researcher. In 2000 at the International Conference on Spinal Manipulation, Dr. Haldeman stressed the importance of research:
"[S]cience is going to start driving the direction of clinical practice as well as theory. If chiropractors do not accept this change, many will find themselves in a kind of culture shock as the demands to follow this pattern pick up momentum. It must be realized that scientific research is forming the basis of the theories that direct future research and which therefore direct clinical practice."
What role should chiropractors play in research? In The Principles and Practice of Chiropractic, 3rd Edition (2004), Dr. Haldeman states, "To contribute to research, chiropractors should be abreast of the literature in the field, and be able to discuss adequately the research on the efficacy, effectiveness and safety of chiropractic care."
In terms of the value of integrated care in the next 25 years, Dr. Haldeman, again in ThePrinciples and Practice of Chiropractic, says the following:
"In the current health care environment, most chiropractors still practice in sole practitioner or small group practice settings. An emerging trend, however, is the integration of chiropractic with conventional medical and other alternative and complementary care practitioners.
"Integrated health care is an organized, cohesive, outcome-oriented plan of care across settings and disciplines that results in a seamless experience of care for the patient and family, with smooth transitions from one level or type of care to the other."
If lack of research and "science" left the chiropractic profession open to attack from the medical profession and elsewhere, it is research that will lead us into a future of increased acceptance, cooperation and co-existence, all for the benefit of the patient.
