Term Limits: What's in a Word?

It was the French historian and philosopher Voltaire who once declared the Holy Roman Empire was neither holy nor Roman nor an empire. Indeed this was the case, for the territory in question had no formal ties to Rome; actually consisted of numerous principalities, duchies, countries, and cities that often were in conflict with each other; and certainly functioned in a manner that could not be recognized as holy. And yet it hung on for nearly 900 years until dissolved as an imperial entity by Francis II in 1806.

By coincidence, this is precisely the problem that has dogged the medical sciences, particularly chiropractic, acting as a drag to the progress that should have been made to this moment. As Linda Richman used to say in a "Saturday Night Live" skit when none of the terms she introduced really meant what it was supposed to denote, "Talk amongst yourselves. Discuss!" And so we shall. Consider a few choice topics: relevant to chiropractic.

Primary Care

The debate as to whether chiropractors could be considered primary care providers has extended for decades, perhaps reaching a zenith in the 1990s with the study conducted by Abt Associates.¹ But the argument becomes infinitely more complex when you consider the multiple definitions of primary care that have been offered:

• 

  Barbara Starfield: First contact, longitudinal, coordinated and comprehensive care in which the practitioner should take care of the majority of problems without referral.²
• Public Health Service Act: Services which require family medicine, internal medicine, pediatrics, obstetrics/gynecology, dentistry, or mental health as provided by physicians or other health care professionals.³
• Institute of Medicine: Emphasis upon accessibility, comprehensiveness, continuity and coordination.⁴
• Alma Ata, USSR: Health for all by the year 2000.⁵
• Craig Nelson: Care that most persons need most of the time.⁶

This so-called Rashomon effect (multiple narratives of a given phenomenon) could easily warp one's mind into a pretzel without the help of numerous studies which scrupulously substituted operational definitions instead of glib terminology. For instance, two such approaches might offer the possibility of corralling the key definitions of primary care into two schools of thought:

1. Medical: In which an individual in an encounter-based system uses the biomedical paradigm, with services provided by a physician or other health care professional.⁷
2. Health: A community-oriented approach that focuses on a definite population or on a health care system in which services are provided by a health care team rather than a physician.⁸

What primary care comes down to is the fact that, in the words of Linda Bowers and Robert Mootz, nobody trains this way. Instead: (a) Primary care is a way of delivering health care, not a body of knowledge as such; and (b) primary care is more characterized by the organization of care, rather than practitioner type.⁸

Indeed, the Abt study itself concluded that chiropractic and interdisciplinary panels of health care professionals did not significantly differ in their ratings concerning the scope and importance of activities for good health; and that chiropractors were poised to make therapeutic contributions in more than half of the conditions identified.¹

Alternative / Mainstream Medicine

Once again, arguments as to whether chiropractic is a mainstream or alternative means of health care delivery are wrapped around a pole by a multiplicity of definitions attempting to pin down just what alternative medicine is:

• Nicht-Schulmedizin: Health care practices not taught at university medical facilities or medical schools.
• David Eisenberg: Health care practices not paid for by my insurance and about which I do not tell my primary care doctor.
• Office of Alternative Medicine (predecessor to the National Center for Complementary and Alternative Medicine, now National Center for Complementary and Integrative Health): Any health care practice which is not politically dominant at the time.

Indeed, the birth of NCCAM was not helped by early usage of the term unconventional medicine, which raised all manner of hackles, since there seemed to be an exclusionary, even pejorative aspect to it. Even substituting the term alternative didn't seem satisfactory, considering some of the darts thrown at its practice by Arnold Relman in a debate with Andrew Weil:⁹

• "Integrating alternative medicine with mainstream medicine, as things stand now, would not be an advance but a return to the past."
• "Most alternative systems of treatment are based on irrational or fanciful thinking"
• "It [alternative medicine] could not be woven into the fabric of the medical curriculum without confusion, contradiction, and an undermining of the scientific foundation upon which modern medicine rests."

Statements such as these make me suspect the term complementary had to be plugged in to the naming of NCCAM to throw oil onto raging waters. But was that sufficient? The whole debate might come down to what was expressed by Joe Jacobs, one of the first directors of the Office of Alternative Medicine at the NIH: "I'm neither a proponent nor a naysayer, but there's a whole grey zone there, and eventually it will just be a matter of different approaches."¹⁰

Evidence-Based Medicine

Facing a firestorm of criticisms, definitions of evidence-based medicine (EBM) have morphed in the literature in a manner reminiscent of Mohammed Ali (then Cassius Clay) dancing around the boxing ring in his prime to dodge the onslaughts of his opponent. Inherent limitations and a variety of flaws in a number of published randomized clinical trials, and signs of bias and arbitrariness in representative meta-analyses, are among the reasons that (a) Sackett first expanded EBM's definition to include clinical judgment,¹¹ and (b) recognition of patient values in a clinical encounter added a critical third element to the definition of EBM.^12-13

These developments, plus numerous perceptions that published guidelines put a chokehold on effective practices, most likely led to the tactical retreat of the term EBM to the kinder, gentler designation, evidence-informed medicine.^14-15 A more complete description of the deconstruction and rebuilding of EBM concepts has been published elsewhere.¹⁶

Subluxation

Jeez, do I have to go there? The word has been practically beaten to death, and there is enough debate to fill a book here; in fact, many books, the most prominent of which is Gatterman's second edition.¹⁷

The vicissitudes and ambiguities of terminologies in the face of reality were perfectly encapsulated by one of Yogi Berra's immortal quotations: "In theory, there is no difference between theory and practice. In practice, there is."

To sum up, our entire obsession with terminology – the "Name That Tune" concept of medicine – needs to be refreshed with the insights of Hyman,¹⁸ who points out that proper pathological assessment and diagnosis, while essential, is merely the beginning of the analysis and not the end.

Rather than ask, What is the pathology?" one should ask, "What biochemical, basic science, observational and clinical data are available to support an integrative approach to normalize function?" In this manner, form follows function, disease follows disturbed biochemistry, and phenomenology follows physiology. It is with these neutral, observational concepts that we can expect a less hindered, more efficient approach to health care in the 21st century.

References

1. Gaumer G, Walker A, Su S. Chiropractic and a new taxonomy of primary care activities. JMPT, 2001;24(4):239-59.
2. Starfield B. In reply. JAMA, 1993;270(20):2434.
3. Budeti PP. Achieving a uniform federal primary care policy. Opportunities presented by national healthcare reform. JAMA, 1993;269(4):498-501.
4. Barondess JA. The future of generalism. Ann Intern Med, 1993;119(2):153-60.
5. Bryant JH, Zuberi RW, Thaver IH. Alta Ata and health for all by the year 2000: the roles of academic institutions. Infect Dis & Clinics, N Amer, 1991;5(2):403-16.
6. Nelson CF. Chiropractic scope of practice. JMPT, 1993;16(7):488-97.
7. National Center for Health Statistics. National Ambulatory Medical Care Survey: 1992 Summary 253. Aug. 18, 1996.
8. Bowers L, Mootz RD. The nature of primary care: the chiropractor's role. Topics Clin Chiro, 1995;2(1):66-84.
9. Bunk S. Is integrative medicine in the future? Debate between Andrew Weil, M.D., and Arnold Relman, M.D. The Scientist, 1999;13(10):10-11.
10. Jacobs J. Time (Special issue), Fall 1996:40-42.
11. Sackett DL. Evidence-based medicine. Seminars in Parinatology, 1997;21:3-5.
12. Fisher CG, Wood KB. Introduction to and techniques of evidence-based medicine. Spine, 2007;32(195):566-72.
13. O'Connor A. Using patient decision aids to promote evidence-based decision making. EMB Notebook, 2001;6:100-2.
14. Glasziou P. Evidence based medicine: Does it make a difference? Make it evidence informed practice with a little wisdom. BMJ, 2005;330(7482):92(discussion 94).
15. Rycroft-Malone J. Evidence-informed practice: from individual to context. J Nursing Manage, 2008;16(4):404-8.
16. Rosner A. Evidence-based medicine: rebuilding the pyramid of priorities. J Bodywork Move Ther, 2012;16(1):42-9.
17. Gatterman M. Foundations of Chiropractic Subluxation, 2nd Edition. St. Louis, MO: Elsevier Mosby, 2005.
18. Hyman MA. The real alternative medicine: reconsidering conventional medicine. Alt Ther Health Med, 2005;11(5):10-12.