Healing the Division of the Vision, Part I
By Dean Black and Neil Stern, BS, MD, DCIn a July 14 Dynamic Chiropractic article, Dr. Reed Phillips, president of the Los Angeles College of Chiropractic, issues an appeal for chiropractic unity: "What a wonderful feeling ... ," he says, "to think of the potential as a united profession." He also discusses two threats to that unity: (1) "significant differences regarding the value of academic performance," and (2) "attitudes of anti-intellectualism." He links these threats to "dogmatists" and "spiritual healers," and calls for "leadership around which those who desire can rally as we separate and segregate ourselves from the faith-based fundamentalists of the profession."1 Dr. Phillips doesn't label those who desire to "separate and segregate" themselves from the faith-based fundamentalists of the profession, but "science-based intellectuals" probably comes close.
But how can segregating science-based intellectual chiropractors from faith-based fundamentalist chiropractors unite the profession? It cannot, of course, unless one or the other gets eliminated in the process. Zealots in both camps may wish to eliminate the other, but that's unlikely to happen. Do we not therefore need leadership that bridges not segregates the camps?
We must recognize, first of all, that the profession needs both camps. The Wilk case affirmed that we are intellectually weak. It resulted from the AMA's attempt to segregate medical doctors from chiropractors on the grounds that chiropractic is "unscientific." The AMA's defense was that chiropractic is unscientific, and Judge Getzendanner essentially agreed. We need science-based intellectuals to allow us to discourse with, and to establish our place within, the community of scientific health care disciplines.
But the Wilk case also revealed a tremendous underlying strength, for Judge Getzendanner also ruled that the AMA's segregating was economic rather than scientific; that it amounted to a conspiracy to "contain and eliminate" the chiropractic profession. Surviving this conspiracy surely required an element of faith. And if that faith drifted toward antiscientific fundamentalism, perhaps that's a consequence of the conspiracy itself, whose essence after all was misdirection, waving the banner of science as a cover for economic mugging. Should we be surprised that it inspired somewhat misdirected contempt?2
We also see the need for both camps in the fact that they transcend chiropractic; they even transcend time, and simply will not go away. To Neils Bohr, who won a Nobel Prize in physics for developing the atomic theory, this timelessness meant that they were complementary perspectives: irreconcilable opposites (like breathing in and out) that belong together because they complete each other by balancing each other's strengths. He first proposed complementarity in physics, where it resolved the division between particle theory and wave theory, and led to the quantum revolution. He then applied it in physiology to the division between vitalists and mechanists: faith-based fundamentalists and science-based intellectuals, which is how it applies to us.3
Medical historian Arturo Castiglioni echoes Bohr's call for complementarity. He calls the two perspectives "analytical" and "synthetic," and says that each checks the excesses of the other. "Thus the analytical doctrine returns in a period in which aggravated metaphysical tendencies render absolutely necessary a very strict control of the method of reasoning, while a synthetic tendency with its vitalistic attitude appears ... when a system has taken the inflexibility of a program so as to acquire the authority of a dogma." To illustrate analytical thinking, he cites Galen and the 19th-century German physiological school headed by Rudolph Virchow, which undergirds much of modern medicine. To illustrate synthetic thinking, he cites Hippocrates, Paracelsus, and Samuel Hahnemann, founder of homeopathy. He might also have cited D.D. Palmer and his faith-based fundamentalist heirs.4
As a profession, we must import analytical thinking to strengthen ourselves, while exporting synthetic thinking to strengthen our medical peers. Medicine's segregating has pushed the two modes of thinking into separate, hostile camps, where each, unchecked by the other, has grown to harmful excess. If we suffer a drought of intellect, medicine suffers a drought of spirit, and what Dr. Phillips wishes to segregate from our profession may in fact be one of our most exportable commodities, provided we can learn to package it in suitably marketable terms.
As Dr. Phillips points out, today's health care market is characterized by two forces. The first is a "health-oriented paradigm," which originates with patients, whose philosophic position matches the faith-based fundamentalists more than the science-based intellectuals. Educated patients in particular seek treatments that "are geared toward improving (their) own biologic and psychic capacity to counteract illness." They are particularly attracted to "the internal logic and global, mind-body emphasis" of the vitalistic perspective, which they find to be "intuitively correct and fundamentally appealing."5
The second force is "an evidence-based culture" which originates with third-party payers who will no longer reimburse ineffective therapies, and who are singularly unimpressed by "the internal logic and global mind-body emphasis" of the vitalistic perspective. They demand hard evidence of the sort only science-based intellectuals can provide.
In the face of these differing dynamics, are we not obliged to embrace both perspectives? They exclude one another in principle, as particle theory and wave theory in physics exclude one another in principle, but we can unite them in practice, as particle theory and wave theory have united in practice, by drawing on their respective strengths. Dr. Phillips essentially proposes this when he recommends to the profession an LACC position paper that "accepts many tenets of holistic and vitalistic concepts but places them in a more academic than religious context." But he then sunders what he unites by arguing that we segregate ourselves from the "faith-based fundamentalists of the profession," as if we may accept "many tenets" of their concepts without accepting them.
Since bodies manage themselves by balancing opposites -- opposite autonomic activities (sympathetic vs. parasympathetic), opposite hormones (agonists vs. antagonists); opposite chemical processes (anabolic vs. catabolic); opposite sides of the brain (right vs. left); and so on -- perhaps professions manage themselves in the same way. With that possibility in mind, here are some "opposites" that characterize our profession, and suggestions for how we might manage them.
Individual Choice vs. Regulatory ControlBy virtue of their faith in innate intelligence (which everyone is presumed to possess), fundamentalists typically favor individual choice, considering regulatory control too gross to handle the finer distinctions of life. In an era that minimized regulatory control, for example, early Supreme Court Justices placed the origins of wisdom in "those principles of abstract justice, which the Creator of all things has impressed on the mind of his creature man,"6 and in "the source of eternal justice as it comes from intelligence and truth."7
Intellectuals, on the other hand, by virtue of their trust in scientific knowledge (which only experts are presumed to possess), typically favor regulatory control, considering individuals too lacking in knowledge to make wise choices. For example, William T. Jarvis, president of the National Council Against Health Fraud, presents this point of view when he asks (in an article about chiropractors), "Should we license and give medicare dollars to alchemists, witches, herbalists, health food therapists, faith healers, etc., on the assumption that the consumer will be wise enough to choose the proper kind of care?"8 Similarly, Supreme Court Justice Felix Frankfurter cited individual incompetence as the basis of the 1938 Food, Drug and Cosmetic Act: "The purposes of this legislation ... touch phases of the lives and health of people which, in the circumstances of modern industrialism, are largely beyond self-protection."9
Although regulatory control is more typically the pro-intellectual position, it can also act against intellect. For example, Thomas Jefferson said, "I know of no safe depository of the ultimate powers of the society but the people themselves; and if we think them not enlightened enough to exercise their control with a wholesome discretion, the remedy is not to take it from them, but to inform their discretion by education."10 His point is that individual choice requires education, whereas regulatory control (which compels rather than instructs) does not. Even lobbying for regulatory control generally involves more name-calling than education, as when as FDA deputy commissioner, calling for greater regulatory control of chiropractors and other non-medical therapists, called them "gangsters motivated by greed and willing to exploit people who are desperately ill," all the while avoiding the intellectual issues involved.11
Dr. Phillips links his pro-intellectual position to a call for greater regulatory control. He proposes that the CCE require that chiropractic colleges award different degrees depending on their admission requirements. Specifically, schools with an entering GPA requirement of 2.25 would graduate "chiropractors," while those with an entering GPA requirement of 2.5 would graduate "doctors of chiropractic." He suggests that this difference in admission requirements is "probably" linked to other differences in "standards of training" that justify the dual degrees, but he does not specify what these other differences might be, nor does he give evidence that they exist. He also implies that those who disagree with him do so because they devalue academic performance, but it is possible to disagree with him simply by valuing individual (or institutional) choice.
What harm has the profession suffered by graduating students who entered chiropractic college with GPAs between 2.25 and 2.49? What other differences in "standards of training" exist? How will a quarter-point increase in the entering GPA requirement correct them? Could they be corrected by applying present CCE requirements more rigorously? If new requirements are necessary, could they be more directly tied to specific deficiencies? Could dissenting college administrators be educated into accepting them rather than compelled? Will the benefits of dual degrees justify the labor required to define and regulate their respective rights and privileges? Will colleges denied the right to graduate "doctors of chiropractic" not eventually die?
Our profession needs regulatory control and it needs individual (and institutional) choice, yet each precludes the other. This dilemma faced out nation's founders during the summer of 1787, when they spent 115 days balancing the powers of government against the rights of individuals, and, within government, the powers of the federation against the rights of the individual states. The delegates formed themselves into opposing camps. They called each other names. They threatened to segregate themselves. But our nation survives because they overcame these tendencies, and found a "balance of power" that resolved the dilemma and settled the issues involved. Our profession requires no less.
Experience vs. ExperimentFaith in individual intelligence also inclines fundamentalists toward learning through experience. To a fundamentalist, treatment is a relationship in which the individual doctor's intelligence grapples with the individual patient's needs. Experience accumulates routinely across successive treatment sessions. Learning by experience unites practice and research in the same setting. It embraces any relevant observation, and it leads to individual judgment, not shared knowledge. And it offers case studies as its evidence.
By the same token, trust in scientific knowledge inclines intellectuals toward learning by experiment. To an intellectual, treatment is a relationship in which abstract therapies produce abstract effects in abstract patients. The abstractions are defined in a "model," which reduces reality to a manageable number of parts and relationships. Intellectuals test these models in controlled experiments, whose purpose is "to 'stage' (reality) in such a way that it conforms as possible to a theoretical description."12 Learning by experiment places practice and research in separate settings. It covers only the factors defined in the model. It leads to shared knowledge, not individual judgment. And it offers statistical generalities derived from samples of patients as its evidence.
In principle, these opposite modes of learning preclude each other, but in practice, computer technology and the evidence-based culture are uniting them by drawing on their respective strengths. According to an article in Health Data Management, the pharmaceutical industry is "venturing into the health care information technology market." Glaxo-Wellcome has invested $43 million in a computer-based clinical records system. Eli Lilly wants to use "information technology to understand better the cause and effect of people's illnesses and well being." Upjohn plans to concentrate on "collecting and analyzing (clinical) data." An industry expert predicts revenues from health care information technology "will reach $20 billion by the year 2000."13
The point of health care information technology is to capture ongoing clinical experience for scientific analysis. In the words of a former Glaxo-Wellcome executive, proof of effectiveness requires "a different level of information than our normal clinical trials would provide." Instead, "Glaxo decided that only a longitudinal patient record could provide the level of detail needed to demonstrate the total value of a pharmaceutical treatment."14 A "longitudinal patient record" is a case study. The point of this technology is to record case studies comprehensively rather than superficially, and in computers rather than on paper charts, and then to analyze the cases scientifically to see what the outcomes are.
Though it addresses clinical experience, health care information technology requires more sophisticated model building than experimenting ever did. The computer's database must replicate the very structure of therapeutic thought, so that it can capture the structure of practice that flows from it, not just in some narrow, limited domain, but in depth, breadth, and detail. If the doctor sees something important, the computer must record it. If the doctor does something important, the computer must record it. If the patient reports something important, the computer must record it. The data structure must therefore anticipate, and find a place for, every important thing that might happen in clinical practice. And it must make data easy for the doctor to enter, and easy for the scientist to retrieve.
Our challenge as a profession is to develop just such a data structure for chiropractic. To that end, Parker College researchers are asking practicing chiropractors to help us model the structure of chiropractic thought, its highways as well as its side roads. And the faith-based fundamentalists are as open to this project as the science-based intellectuals. They see it as an opportunity to document their clinical results without having to follow a researcher's protocol rather than their own clinical judgment. They'll change only the means and thoroughness of their record keeping. The challenge is to make the record keeping so convenient and useful that chiropractors of all persuasions remain willing, if not eager, to use it.
Like practice itself, the clinical model will contain an enormous number of variables. Unlike experimental models, it will not hypothesize relationships between variables beforehand, for they will be far too numerous and complex. Relationships will be discovered post hoc, by exploring the information structure inherent within the data, which will become clearer as cases accumulate. As relationships appear they will then be used to predict clinical outcomes, with the successes confirming the model, and the failures showing how to improve it. These clinical predictions will differ from hypotheses by being based on experience rather than theory.
Editor's note: The second part of this article will appear in the Oct. 10 issue.
Neil Stern, BS, MD, DC
Dean Black, PhD