It is well recognized that the practice of health care is more art than science whether it is based on allopathic, osteopathic, or chiropractic concepts. Science offers the practice only a certain degree of justification.Because all variables cannot be known in any situation, the limited facts of science often fails us in our reasoning. And what is more variable than our patients with their differing genetic make-up, nutrition, occupational stress, anomalies, history of trauma, personality fabric, and numerous other inconsistencies from the norm? Because patients are a storehouse of unique variables, reasoning based on experiences, their results, and the skills acquired (empiricism) must be added to the formulation of any rational treatment plan.
This presents the basic problem facing any writer in our field. Communication is the ability to communicate an idea from one mind to another. But this is not an easy process because facts and concepts often become intertwined during the communication process.
Facts are specifics. They can be imagined and duplicated. Thus, facts can be communicated from one person to another of reasonable intelligence. Units of measurement, for example, are facts. They mean the same thing to everybody if the context is known: an inch is an inch; a quart is a quart. Circumstances vary, but a clinical fact or law is not variable. The core of science and technology is a data bank of knowledge that has the same significance (projects the same images) to an American, European, or Asian. The science of chiropractic or traditional medicine is founded on basic sciences and clinical laws.
Standardization in examining and diagnostic processes is therefore logical if it is an attempt to establish minimal levels of professional conduct. It should, however, always leave room for expansion and empiric embellishment to meet the needs at hand because the "standard" patient does not exist.
A professional art is a means to achieve a goal. A professional philosophy is an attempt to explain why the goal should be reached. The art and philosophy of chiropractic (or traditional medicine) are based on concepts, and all concepts are intellectual abstract generalities. Many words used in communication are generalities: e.g., table, house, triangle, cow, and automobile. The meaning of such words cannot be imagined; that is, they are almost "meaningless." To imagine a "table," for instance, we must either fantasize or know many facts about the table in question: e.g., size, shape, color, design, purpose, etc. The word "table" in itself communicates little. A blanket can be used for a table at a picnic. There are wood, metal, and plastic kitchen tables of various sizes, colors, shapes, and designs; and there are tables in books to classify basic data of various sizes, shapes, and design. Terms such as adjustment, manipulation, nutrition, physiologic therapeutics, resistance to disease, exercise, and innate are concepts. Thus, any attempt to "standardize" an art or philosophy strives for an impossible goal. The result is dogmatism, fanaticism, and the subjugation of reason and creativity. Analysis of the rationale of radical fringes in any group readily underscores this point.
The attempt to clone physicians is on the rise. It has resulted in recent years from dictates by the insurance industries (health care and malpractice) to "treat by the book approved by us" or else. In addition, such cloning has for decades been reinforced in chiropractic as a principle of those who demand that their personal interpretation of the philosophy of B.J. Palmer of 1928 be followed to the letter in 1990 despite what the founder of chiropractic, D.D. Palmer, established as the basis of chiropractic.
The goal is homeostasis. D.D. Palmer founded chiropractic on the basis of maintaining neurologic homeostasis -- a state he called "tone," as so announced to the world on the title page of his first book. Thus, any method that aids the achievement of this goal is in harmony with the basic premise of chiropractic. Standardization in the case management process therefore is illogical if it is an attempt to establish boundaries for rational thinking and action. And because patients are a storehouse of variables, reasoning based on experiences, their results, and the skills acquired (empiricism) should be added to the formulation of any rational treatment plan. History shows that many of the eclectic procedures of today become the orthodoxy of tomorrow.
To enhance creative thinking in the clinical process, I have recently authored the first of a two-volume work on clinical chiropractic that soon will be published by the Motion Palpation Institute (MPI) -- see announcement elsewhere in this issue. It is a text based on both clinical experience and the basic sciences. The topics of this first text concern common upper body complaints. A companion book has been scheduled to follow that will concern lower body complaints.
The primary purpose of these books is to provide the chiropractor and advanced student a reference to successful therapeutic protocols. This is helpful when (1) a condition is infrequently treated or (2) a condition frequently treated fails to respond as anticipated. Obviously, there is no need to refer to any manual if the doctor is confident that he can treat a particular disorder efficiently, and the patient responds in a mutually satisfactory manner. Even with successful cases, however, the reader may find that future clinical planning and approaches can be enhanced by the suggestions described.
When patients enter a DC's office, they seek relief. Certainly they want to know the cause of their problem (the diagnosis), but their priority is to find relief as rapidly as possible. That is the objective of these books: to offer rational protocols for the relief of pain and disability even before the diagnosis is firmed. More often than not, patients' complaints will be resolved before the final diagnosis is determined.
The protocols suggested are based on positive results with hundreds of patients, but they are not written in stone. They should always be questioned early by the practitioner with, "Why is this point or procedure recommended here?" Knowing the "why" is what differentiates the methodology of the physician from the therapist. It also allows for modification to accommodate the needs of a particular patient or pathologic state -- thus the antithesis of cloning.
Although these books describe many therapeutic approaches, the core therapy is the spinal adjustment. It is alarming how many graduates since 1960 have not been taught how to properly "deliver" a chiropractic adjustment. They have been thoroughly taught the mechanics but not the finesse. The latter is the "art," and it is parallel in importance to the "scientific" mechanical objective. This subject is deeply explored in this text.
Within the foreward of the text, Dr. R.H. Tyler writes, "The most unfortunate prospect is that not everyone will have the opportunity or be inclined to review the wealth of information contained in these volumes. Some will miss the adventure because they do not feel the need and others because of the chains of philosophical bias. This is unfortunate on both counts because there is, quite literally, something for every persuasion of health practitioner who wishes to offer the optimum in care for his patients. The texts are designed for the dissemination of information and then reader cogitation and selection. It is likely there will never be other texts like these. They are unique to our literature, both in content and structure."