We are beginning to hear a lot about "consensus" in chiropractic, mostly as it relates to the standards of care process. Many of you may have also heard of the first Consensus Conference on the Validation of Chiropractic Methods which was held in Seattle last March, co-sponsored by the ACA Council on Technique, the Washington State Chiropractic Association, and our own Consortium for Chiropractic Research.
But exactly what is a consensus "process?" Is "expert panel" consensus relative to standards of care the same as a conference consensus on "validation?" As a matter of fact, there are three different types of consensus process which the Consortium and other chiropractic groups are currently developing.
The first of these, obtaining a profession-wide consensus on how to go about "validating" chiropractic methods, is what the conference in Seattle was about. This objective, which may seem rather basic, is of critical importance to chiropractic, for if we do not first establish and agree upon the ground rules of the validation process, there can and will be little or no compliance within the profession to what comes out of that process.
The consensus conference brought together, for the first time, leading chiropractic researchers, the political opinion leaders, and the technique developers in chiropractic. Presentations on the first day of the conference described in detail the standards of care process as it has been occurring in chiropractic and in other health care disciplines, including those clinical, scientific, and consensual methods which have been developed specifically for the purpose of validation of health care procedures. The second day of the conference was devoted to developing a consensus among all participants at the most basic level possible, which, in this case involved a motion to accept "scientific method" in its most general sense.
This was not as easy as it sounds, since what the lay person calls "scientific method" is, itself, a continually evolving process: indeed, there is an entire discipline, the philosophy of science, devoted to trying to define and determine what scientific method is or should be. Nevertheless, the motion to accept the general tenets of scientific method was, with some difficulty, passed by the conference. The next conference of this kind will be held in conjunction with the Consortium's annual C.O.R.E. conference in June 1991.
The second type of chiropractic consensus being developed by the Consortium, is a "concept matrix" for chiropractic techniques. This project, now in its preliminary stages, seeks first to clearly identify a limited number of basic concepts underlying chiropractic techniques and then to determine the degree to which each of the various "brand name" techniques utilize methods based upon particular subsets of these concepts.
There are at least two major advantages to doing this. First, by emphasizing the commonalities rather than the differences between technique systems, a more coherent and unified image of chiropractic will be presented to other health care professionals. And perhaps of even more importance, the ongoing process of scientific validation will be able to avoid putting entire techniques on "trial" or, even worse, pitting one against the other. Rather, individual technique concepts, representing only a fraction of any particular technique, and undoubtedly shared to some extent by others, can be objectively tested and refined as necessary without inordinately affecting any particular technique system.
The third type of consensus process occurring in chiropractic is a part of the standards of care project, sometimes called the "expert panel" consensus process. So-called expert panel consensus, as developed by NIH and RAND Corporation, utilizes hundreds of individual cases which are evaluated by one or more panels of acknowledged experts until a consensus is reached. This process of multiple successive evaluations converging upon agreement is generally known as a "delphi process," and is being utilized by RAND Corporation in the chiropractic standards of care projects it is doing.
Practitioner consensus of one sort or another will probably always be an important part of health care research and analysis. Only a small percentage of all clinical procedures currently used in chiropractic (or in medicine) have been subjected to appropriately controlled clinical trials research. From an economic perspective, as long as any clinical procedure remains low enough in cost and/or low enough in risk to the patient, the very high costs of specific clinical trials research are simply not justified. And in addition, with technology generating hundreds of new procedures every year, it has become increasingly difficult, purely from a logistic point of view, to perform specific clinical trials research on every untested procedure.
In the forseeable future, it is likely, therefore, that consensus among clinicians will remain the most important, (and often the only) indicator of validity available for many low risk, low cost, preventive or conservative procedures despite the general consumer call for controlled experimental verification. And so it will remain a major objective of the Consortium for Chiropractic Research that consensus be determined using the very best methods at our disposal.
Robert D. Jansen, Ph.D.
(Pacific) Consortium for Chiropractic Research
Individual memberships are $65 per year and include a subscription to the Consortium newsletter, which keeps doctors updated on Consortium activities and projects, e.g., standards of care. The membership dues may be charged to your Mastercard or Visa by calling 1-800-327-2289, or you may send a check to: The (Pacific) Consortium for Chiropractic Research, 1095 Dunford Way, Sunnyvale, California 94087.