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:
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:
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:
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
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
Many relevant diagnostic signs are not performed deliberately by the examiner or by the patient at the examiner’s direction. They are observed as the patient reacts to their condition. Fortin’s finger sign, Minor’s sign, and Vanzetti’s sign are three examples of this principle.
On Feb. 1, 2024, two more legislators – John R. Carter (R-Texas) and Robert “Bob” Good (R-Va.) – co-sponsored the Chiropractic Medicare Coverage Modernization Act of 2023, bringing the co-sponsor total to 155, two more than the total achieved over the entire two-year congressional cycle in which identical legislation last appeared (2021-22).
While working at the Lovelace Medical Center in Albuquerque, N.M., one of the primary care physicians stated that imaging every patient prior to receiving chiropractic was not medically necessary. It was at that point I reconsidered the need for the imaging of every patient to avoid malpractice.
