This issue's article is written by Christopher Kent, DC.
Victories and Challenges
During my 30 years as a student and doctor of chiropractic, I have seen tremendous victories achieved by the profession: Chiropractic was legalized in the last "holdout" states, Louisiana and Mississippi; the chiropractic profession became involved in university-based research; and peer-reviewed chiropractic journals were born. Allopathic facilities, which once shunned DCs and their patients, began actively soliciting referrals. Chiropractic began to enjoy external validation.
These have been tremendous victories won against great odds, but today things are different. Have we lost sight of the reasons why we sought recognition? Are we prepared to accept the challenge of leading the reform movement in health care? Are our current strategies effective?
Less than 20 percent of the profession maintains membership in any of the four associations. Infighting has led to an "us against them" mindset, and the expenditure of tremendous resources - limited resources we desperately need to apportion wisely if we are to seize our newfound opportunities.
Challenges and opportunities now face the chiropractic profession. Doctors of chiropractic have traditionally been strong individualists. Such personalities were necessary to ensure individual survival in the hostile environment of the profession's first 90 years. DCs were plagued with economic disincentives for patients seeking chiropractic services, and a constant perceived need to establish legitimacy and cultural authority.
The very survival strategies that brought us our successes have become millstones inhibiting continued progress. The staunch individualism of chiropractors is admirable, yet our associations are riddled with power struggles, ad hominem attacks, backstabbing, name calling, and covert actions aimed at destroying a perceived enemy. The real enemy is our own inability to see the futility of such strategies.
The last decade has been characterized by radical changes in the health care delivery system. The cultural authority of allopathic medicine has eroded, as a growing number of Americans seek other approaches to achieve health and improve their quality of life.
Eisenberg1 wrote: "Americans made 425 million visits to alternative health care providers in 1990, a figure exceeding the number of visits to allopathic primary care physicians in the same period," and that "people seem quite willing to pay out-of-pocket for these services."
A 1998 study published in the Journal of the American Medical Association2 reported that 40 percent of responders had used some form of alternative health care during the past year. The top category was chiropractic, with 15.7 percent. The reason cited for doing so was "largely because they find these health care alternatives to be more congruent with their own values, beliefs, and philosophical orientations toward life and health."
The catalyst for this cultural revolution is the growing number of empowered patients with the information and inclination to become actively involved in making health care decisions. The uncritical idolization of the physician is a thing of the past. As Astin2 observed: "Education emerged as the one sociodemographic variable that predicted use of alternative medicine; individuals with higher educational attainment were more likely to use alternative forms of health care."
Unity vs. Unified Action
In this author's opinion, many members of the profession are calling for "unity" without defining the term. A plea for unity at a seminar will bring thunderous applause. Yet, if you ask the doctors in attendance what they mean by unity, they appear dumbfounded.
Do they mean a merger between the American Chiropractic Association (ACA) and the International Chiropractic Association (ICA)? What about the World Chiropractic Alliance (WCA) and the Federation of Straight Chiropractors and Organizations (FSCO)? Can they be ignored? Does unity require everyone to practice the same technique, or follow the same clinical practice guidelines? Are we to abandon our diversity?
Two things seem certain:
- It is disingenuous of any chiropractic organization to claim exclusive representation of the profession; and
- Any effort toward unity or unified action will be doomed if it fails to consider the interests and values of the disenfranchised - the more than 80 percent of the profession who do not belong to any national association.
It is unrealistic in the foreseeable future to expect the ACA, ICA, WCA, and FSCO to merge, and the rest of the profession to join a new umbrella organization. Each organization has a constituency, structure, and agenda. It is quite appropriate for different organizations to engage in the free exchange of ideas, and promote their views on key issues. It is unhealthy, however, for intolerance to interfere with achieving shared goals and promoting common values.
Once the issues are drawn out, what most chiropractors clamoring for unity really want are:
- an end to vicious infighting, to be replaced with collegial diversity; and
- an end to contradictory representations to persons outside the profession.
These goals are attainable. Much of the division in our profession is attributable to confusing the differences between goals and strategies. For example, "unity" is not a goal. It is a strategy. Interchanging goals with strategies can result in ignoring viable alternate strategies better suited to achieving goals.
Unified action can only occur once core values are defined and agreed upon. I suggest that as a first step, we seek unified action in the area of legislation. The strategy for implementing this goal begins with defining core values and areas of commonality. This author urges the profession to implement a goal of unified action in areas of shared values, rather than pursuing the rather amorphous strategy of unity.
Defining Core Values
Three decades ago, chiropractors defined themselves as "straights" or "mixers." This is an excellent example of confusing strategies with goals. The labels have stuck, and issues of technique, adjuncts, etc., have obfuscated the view of our common goals.
In 1996, the Association of Chiropractic Colleges took a giant step forward in defining core values. Position Paper No. 1 states, in part:
"Chiropractic is concerned with the preservation and restoration of health, and focuses particular attention on the subluxation."
A significant number of chiropractic organizations have officially adopted this position, while others echo similar values:
According to the WCA website: "We promote chiropractic as a drug-free, subluxation-based health care approach providing lifetime, family wellness care."
An "open letter" from the ACA states that chiropractic is "a drug-free, nonsurgical, subluxation-based, separate and distinct healing art."
If you visit the FSCO website, you will find this definition of chiropractic: "a non-therapeutic primary portal of entry health care profession whose objective is to contribute to health through the correction of vertebral subluxation."
ICA's policy statements provide that a chiropractor is a "portal of entry, primary health care provider," that "Subluxation is a responsible and credible diagnosis," and that chiropractic is drugless.
If you weren't told the sources of these statements, could you have correctly matched them with their organizations? It appears that there is profound agreement on core values.
An idea is only as effective as its implementation. Therefore, let us progress to specific strategies:
It must be acknowledged that everyone is a player, and exclusion guarantees division. For example, the Council on Chiropractic Practice (CCP), WCA, and FSCO have been consistently excluded from leadership conferences, legislative task forces, and other meetings. This is unfortunate, because such actions force isolationism, and each has much to contribute.
For example, the WCA is active within the United Nations system, including the Department of Public Information, the NGO Health Committee, and the World Health Organization. It has the only chiropractic member of the White House Commission on Complementary and Alternative Medicine Policy. It has an office in Washington, DC, and a powerful lobbying firm. CCP produced chiropractic guidelines accepted for inclusion in the National Guideline Clearinghouse, and distributed copies to every known U.S. and Canadian DC.
The other chiropractic organizations could enjoy significant benefits by working synergistically with these and all willing participants.
In observing the various national associations, it is clear that while there are some areas of overlap, there are areas where each clearly excels, and there are activities, which, if coordinated, could complement one another and lead to powerful, focused, unified action.
Unified action in legislation is a logical starting point. WCA has proposed five points on which unified legislative action may take place. They relate to inclusion of vertebral subluxation as a basis for chiropractic care; direct access without referral or mandated medical diagnosis; acknowledgment that chiropractic is drugless; and inclusion of any licensed chiropractor that wishes to participate. It would appear from the statements of the four organizations cited above, that agreement has already been reached!
Chiropractors should be encouraged to support and participate in research. More emphasis needs to be placed upon issues affecting wellness. We must determine the benefits of chiropractic care for all patients, not just those with musculoskeletal pain. To achieve this, research should be directed toward health-related quality-of-life indices, improvement in physiologic indicators (such as autonomic function), effects on immune function, and the development of improved clinical strategies and techniques.
Our colleges should reflect the core values of our profession, and should become meccas of clinical and academic excellence. Basic science faculty needs to effectively integrate chiropractic concepts and values into their teaching. There must be a concerted effort to improve the clinic experience, with exposure to a wide variety of real-world cases. Finally, chiropractic education should be a nurturing experience, which places profound value on the dignity of each student, and fosters spiritual and academic growth.
An area for unified action, which has not yet been effectively implemented, is the mobilization of "patient power." Patients wield tremendous political clout. An effective patient organization would also contribute tremendously to our culture.
Chiropractors should develop alliances with individuals and organizations committed to health freedom issues, and establish strategic alliances with them for joint legislative action.
Will OVCA survive, grow, or will it die following the publication of five articles by its elected leaders? I believe it has great potential to reach the disenfranchised majority of the field, and provide them with a way to be heard. To this end, I would suggest that the OVCA be independent, and not associated with any other organization or publication.
A website could be constructed where each DC would have a password. Discussions of key issues could take place, and the website could also provide for voting. All chiropractors and their leaders could access these discussions and vote tabulations. This would provide for "grassroots" input without dues, meetings, or "Robert's" rules, the only requirements being: no anonymous posts, and courtesy and respect for our colleagues.
The profession has made significant progress in defining our core values. Unified action on key issues is possible without sacrificing our diversity.
The challenge to meeting the cultural demands for leadership in the health care revolution will require more than just vision, passion, and commitment. It will require separating personalities from issues. We need leaders who are as skilled in the ways of diplomacy as they are in the techniques of war.
- Eisenberg DM, Kessler RC, Foster C, et al: Unconventional medicine in the United States: prevalence, costs, and patterns of use. N Engl J Med 1993;328:246-252.
- Astin JA: Why patients use alternative medicine. Results of a national survey. JAMA 1998;279(19):1548-1553.
Ramsey, New Jersey
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