"Turn, Turn, Turn"

Editor's note: Dr. Perle concludes his longtime service as a DC columnist with this article. We offer our sincere thanks for his contributions and expect nothing less from his successor, Dr. James Lehman, who continues the Ethics column in 2015.

Many people are credited with saying, "If you remember the '60s, you really weren't there." Given the fact I didn't become a teenager until 1970, I actually do remember the '60s (or at least part of it). And as a child of the '60s, I was, of course, influenced by the music. I don't recall The Limeliters' version of "Turn, Turn, Turn," but I do recall The Byrds' version. This all goes to say that after approximately 10 years and more than 70 columns on chiropractic ethics, I have decided "To Everything There Is a Season," and the season for writing about ethics is over for me. It is time to do something different. But first, a time to reminisce and predict.

Ten years ago, I started writing columns on ethics for DC. What got this going was a comment I made to someone from NCMIC. At a dinner, I talked about how I thought patient sign-in sheets were unethical. (Keep in mind that this was before HIPAA.) I thought they were an unreasonable invasion of privacy, as subsequent patients could see who had preceded them.

While I'm not a very private person, the sign-in sheet is something that has always bothered me. This probably was something my father instilled in me. When he was in high school in Brooklyn, local organizations set up dances for teens. They wanted people to sign in, but he wouldn't – at least not with his real name. He used names like George Washington, Thomas Jefferson, John Adams, etc. It is a story he told me often when I was younger.

Back to my dinner conversation about sign-in sheets, it resulted in an invitation to write about my views for NCMIC's newsletter, The Examiner. I wrote the article. Much to my surprise, NCMIC's president, Dr. Lou Sportelli, thought my article should be seen by a broader audience and suggested Dynamic Chiropractic. And so it began.¹

I have been keeping track of what I write about using a mind map and have tried to spread out the topics of articles across the broad area of ethics (both patients' rights and doctors' duties) and various aspects of professionalism. I've also been fortunate to have renowned chiropractors join me in writing columns, thus augmenting my own musings. It has been interesting to do this. It has made me think carefully about issues that frankly, I might not have thought about without the need to write a column every other month.

Although as an undergraduate (and in chiropractic college), I took a health-care ethics class, I'm sure my thinking was probably more stretched by a class titled "Science Fiction and Philosophy." With this background, I've found there is a moral implication to many different issues; thus, I have tackled a variety of things I saw as being within the broad domain of ethics.

In parting I'm going to summarize what I think have been the major ethical challenges for our profession over the past 10 years and look in a crystal ball at what I think are the challenges we face moving into the future.

The Past

The rapid market penetration and dominance of managed care has created challenges that weren't thought of in the '80s, when the chiropractic profession was first gaining a foothold in insurance reimbursement. The "Mercedes 80s" produced practice business models that may not have been sustainable while maintaining a strong moral footing in the 2000s. Decreases in per-patient income may have caused some to communicate in ways that stretched the limits of truth. Beliefs have superseded the evidence for some.

While that hasn't produced the profound cost it did to the profession in the United Kingdom,² there were ramifications, especially to doctors who used untrue marketing schemes provided by some suppliers of traction devices.³

When I graduated from chiropractic college in 1983, the relationship between the chiropractic profession and the medical profession was, to understate the point, strained. I recall at a cocktail party a medical doctor who, upon finding out I was a chiropractor, dropped my hand, mid-handshake, did a 180-degree spin better than a dancer, and walked away. But by the late '80s, an MD had sublet from me, and then in the 2000s, I began practicing within a large primary care group.

The thawing of the interprofessional relations created a new set of challenges. One challenge was how the cooperation was used to deal with managed care restraints.⁴ Another challenge was how to deal with not only our newfound "friends" in medicine, but also with other professions like the physical therapists.⁵

The advent of evidence-based medicine / practice has been a challenge for all health care providers. It has been a greater challenge for our profession for a number of reasons; not the least of which is the lack of a culture of research. I had no training in clinical research or evidence-based practice when I was in school (the term first appeared in the literature in the early '90s). I worked as a research assistant in chiropractic college, but never really saw research as a clinically relevant endeavor until a few years into practice.

Many chiropractors in practice today have had little in the way of training about the appropriate interpretation of research. They are hiring new graduates who have substantially more information about what the state of the literature is; and in some cases the managed care organizations are also operating using a body of evidence with which practitioners are not familiar. There is a significant moral challenge when our beliefs and experience are found not to be valid.

I've written about our fidelity duty to do what is consistent with the best evidence, as patients expect us to be up-to-date. The moral and intellectual challenge is acute when this is diametrically different than our current practice. We might honestly believe the old way is best, but fidelity demands seriously thinking about making changes when they are appropriate, and in the best interests of and consistent with the values of the patient.

Some of what I've written has been very controversial. I once wrote with a colleague about the fact that the reported incidence of side effects of manipulation was similar to the side effects of vaccination.⁶ This resulted in hundreds of comments on the DC website. The article was also picked up by a Time magazine blog and resulted in the California Department of Public Health inviting me to speak as part of a webinar it did on vaccines.

Nevertheless, this is a serious issue dividing the profession, with a very vocal minority challenging the majority and conventional thought.⁷ One might argue that this minority is behaving appropriately by having the courage of their convictions, yet flies in the face of all credible evidence and what the majority believes.

The Future

The long-term effects of the Affordable Care Act on the style and manner of chiropractic practice are unpredictable, but one thing is certain: Coordinated care is the future of health care. Chiropractic as separate and distinct may not be a tenable business model, as "separate" may mean not coordinated and thus not paid for by insurance. This will again create financial pressures, which can challenge a doctor's moral compass.

I suspect some DCs will find a place in Accountable Care Organizations (ACOs) and Patient-Centered Medical Homes (PCMHs), but while they won't have to worry about the challenges of a practice outside the system, being inside the system will create its own challenges. Thoughtful readers should consider the moral challenges being separate will bring compared to the moral challenges being coordinated within ACOs and PCMHs will bring.

Along with these challenges are the questions about what we as a profession want to be. Do we cling to the past because we believe it is right for our profession and patients? Or do we make changes in the care we deliver, and how we deliver it, because we believe that is the better course? Only the future will provide the answer.

Evidence-informed practice is not going away, any more than "Obamacare" will. How we adapt to the changing landscape of evidence will, I believe, have lasting effects upon us. Are you prepared for the changes in the health care system or will you be asking, "Who moved my cheese?"⁸

How individual chiropractors and our profession fulfill their moral duties to the public and patients is a challenge from our past that I'm sure will continue into the future. But for now, in the pages of DC that will be for someone else to muse over.

References

1. Perle SM. "Sign Out the Sign-in Sheet." Dynamic Chiropractic, Nov. 18, 2002.
2. Perle SM, Benepal J. "Dictated But Not Read." Dynamic Chiropractic, Aug. 1, 2013.
3. Perle SM. "Good Advertising." Dynamic Chiropractic, Sept. 10, 2007.
4. Perle SM. "Two Wrongs Don't Make a Right." Dynamic Chiropractic, Oct. 21, 2004.
5. Perle SM. "Are We All Ignoring the Golden Rule?" Dynamic Chiropractic, Nov. 18, 2010.
6. Perle SM, Ferrance RJ. "What's Good for the Goose Is ... Ethics and Vaccinations." Dynamic Chiropractic, Feb. 12, 2005.
7. McGregor M, Puhl AA, Reinhart C, Injeyan HS, Soave D. Differentiating intraprofessional attitudes toward paradigms in health care delivery among chiropractic factions: results from a randomly sampled survey. BMC Complement Altern Med, 2014 Feb 10;14(1):51.
8. Johnson S. Who Moved My Cheese? An Amazing Way to Deal With Change in Your Work and in Your Life. Putnam Adult, New York. 1989.