Legitimacy vs. Cultural Authority

Logan Basic College of Chiropractic, 1961: My profession was the abused step-child of the healing arts, shunned by other health care practitioners and viewed with some suspicion by many divisions of society (including the public) who might benefit from our services. Chiropractic education was not recognized by federal authorities, and four states still didn't license us (Louisiana, Massachusetts, Mississippi and New York). Basic science laws and examinations still held a few of us back from obtaining licenses, and, unbeknownst to us, the AMA was gearing up for a renewed campaign to "contain and eliminate" the chiropractic profession.¹

It was said (with considerable justification) that, unlike the new MD in town, whose status was practically guaranteed by the letters after her/his name, the chiropractor had to establish credibility and respect on an individual basis, based upon his or her own personality and involvement in the community. Many DCs did just that, of course, often becoming pillars of their respective states, cities and towns. Indeed, a chiropractor was elected governor of Maine² around the time I began my studies at Logan. However, inevitably, DCs had to work hard to establish their personal authority and legitimacy; there were no professional coattails on which to cling.

Times have certainly changed, in some respects, at least. We've been licensed in all states for more than a quarter-century now, and the Council on Chiropractic Education (CCE) has enjoyed recognition by federal educational authorities for an equal duration. Although we are not satisfied by the reimbursement from various third-party payers (Medicare, HMOs, insurance, etc.), it's a far cry from the cash-only practices of 40 years ago. We have established ourselves as contributing members of the American Public Health Association and the International Society for the Study of the Lumbar Spine. Chiropractic scientists now find their research accepted for publication in an ever-increasing range of prestigious, interdisciplinary journals. Federal grants for chiropractic investigations and facilities, once unthinkable to us, have now become a reality, even if still meager. Despite ongoing conflicts, a Veterans Administration project nevertheless bodes well for our men and women in uniform; the 85-year-old dream³ of chiropractic care for veterans and those on active duty is becoming a reality. And the Nov. 18, 2002, issue of Dynamic Chiropractic brought news of chiropractic students' new option for loan forgiveness through participation in the National Health Service Corps. Holy schmoley!

Sociologists and profession-watchers suggest American chiropractors have acquired most of the formal attributes of legitimacy (e.g., licensure, educational accreditation, federally guaranteed student loans, insurance reimbursement) a profession can attain.⁴ And yet, for all these genuine hallmarks, our profession is still held up for ridicule, and frequently suffers at the hands of the press and elements of organized medicine. For every piece of positive press we receive, at least one other paints us as incompetents - or worse. Sometimes, the bricks hurled at us may be justified, but as the testimony at the recent coroner's inquest in Toronto has shown, reason and logic often eludes our critics by a mile. After more than a century of chiropractic, we're still painted as "rabid dogs and killers" in some quarters, often without a sober review of facts. The taint of quackery and charlatanism is still with us; we still lack the "cultural authority"⁵ that enables organized medicine to be presumed correct.

Part of our problem can be attributed to the arrogance of political medicine, and to an anti-competitive spirit (that's what Wilk vs. AMA was all about). However, if we try to see ourselves as others do, it's hard to avoid the realization that we look different... peculiar. Part of the problem is also our own arrogance. Our multiple, competing state and national organizations send conflicting messages to government. Our schools teach a diversity of conflicting practice ideologies. In our offices, we offer such a variety of practice styles and methods that a patient never knows what to expect when he or she transfers from one DC to another. A few of us are still talking about "silent-killer-subluxations," and all too many of us continue to make claims for chiropractic care that exceed, if not defy, reason and the available research database. We're unable to send a coherent message to the public we hope to serve, because we don't yet agree among ourselves about what a chiropractor is, what he or she does and doesn't do, and why.

Yes, we are legitimate, in all the formal ways, but we're not yet believable. If we wish the world to adopt a more favorable and less confused image of chiropractic, we must continue to change and reinvent ourselves, and resolve our own internal differences, before we can speak with one voice to the public. We also need to speak in more precise, evidence-based ways than we are accustomed to doing. Like it or not, the epistemology of science is a common denominator in the healing professions. (And I would remind all that scientific research has served chiropractic well this past decade.)

We need to infiltrate the wider health care arena to a much greater extent, both in terms of patients and other providers (multidisciplinary clinics, hospitals, the military, state universities, etc.). The isolation of our past should give way to a much broader integration of chiropractic services and individual practitioners. As Palmer College's former board chairman, the late Joe Mazzarelli, DC, suggested,⁶ medicine, even manual medicine, will be little, if any threat to chiropractic, when we become established players inside the system. If my own experience in collaborative practice with allopathic physicians is any guide, the simple process of working side-by-side with other types of doctors breeds familiarity, mutually enhances our clinical skills, and breaks down the unreasonable barriers of old.

"Cultural authority" is not an impossible dream for the profession, no more than college accreditation or federal grants were. We set those goals and reached them through hard work, determination and the willingness (grudgingly at times) to improve ourselves - to change. As we progress into our second century, we must resolve to make the tough choices that will promote our image as "real doctors."

How far we've come! How far we have to go!

References:

1. Trever, William. In the Public Interest. Los Angeles: Scriptures Unlimited, 1972.
2. Tribute paid to Dr. Clauson. Journal of the National Chiropractic Association 1958 (Nov); 28(11): 38-9.
3. War resolutions. Fountain Head News 1917 [A.C. 22] (May 5); 6(34).
4. Wardwell, Walter I. Chiropractic: History and Evolution of a New Profession. St. Louis, Mosby, 1992, pp. 229-7.
5. Starr, Paul. The Social Transformation of American Medicine. New York: Basic Books, 1982.
6. Mazzarelli, J.P. Manual medicine a threat to chiropractic? Archives of the California Chiropractic Association 1981 (First Half); 5(1): 59-61.

Arlan Fuhr, DC
Phoenix, Arizona
awfuhr@aol.com