While the chiropractic profession engages itself with sorting out its attitudes toward the subluxation and whether it is involved in a mainstream and/or alternative service, there is even a larger issue playing out in the background: a debate on a more massive scale concerning all of "alternative" health care, continuing unabated.
Consider first of all the multiple viewpoints that have been expressed on just what alternative medicine represents. The German nicht-schulmedizin model is essentially self-explanatory, considering alternative medicine as all health care practices not taught at university medical facilities or medical schools. More facetiously, health policy wonks often referred to alternative medicine as those health care practices which were not paid for by insurance and which I didn't disclose to my primary doctor, taking after the findings of David Eisenberg which in many circles represented the emergence of alternative medicine into national consciousness.1
But perhaps most telling was a common opinion voiced by what was the forerunner of the National Center for Complementary and Integrative Health: Alternative medicine represented any health care practice which was not politically dominant at the time.
An Evolving Definition
In order to bring such terms as wellness, vitality and healing into everyday practice, medical bodies seem to have taken pains to avoid stepping on toes by incorporating said terms through more name changes than a fugitive on the lam who has entered the Witness Protection Program. By this. I refer to the earliest reference to the wellness concepts under the umbrella term unconventional medicine.
Nope, too derogatory. That label lasted for all of about a year in the earlier 1990s, when the term morphed into alternative medicine. Then it was decided that this moniker also was too far-out and had to be swept into medicine's tent as integrative medicine.
This evolution was precisely reflected by the NIH branch that dealt with this type of health care. Just follow the changing titles: (i) Office of Alternative Medicine, 1992-1997; (ii) National Center for Complementary and Alternative Medicine, 1997-2015; (iii) National Center for Complementary and Integrative Health, 2015-. By expunging the term medicine, one would think the integrative process has now been completed. But has it, really?
Integration: A Work in Progress
A disturbing finding emerged in an American Cancer Society national study on the use of "questionable" methods, in which users alleged their physicians had recommended the treatments 35 percent of the time and objected to them only 2 percent of the time – while physicians who were queried declared they had recommended the treatments only 2 percent of the time and objected 52 percent of the time.2 This appeared to be a "Don't ask, don't tell" way of dealing with alternative medicine.
A jaundiced, but realistic view as to how integration of alternative health care has proceeded was offered some years ago by David Hess, currently professor of sociology at Vanderbilt University, with whom I had the pleasure of brainstorming when he pointed out two modes of health care integration: strong and weak. The hallmarks of strong integration were the application of alternative (rather than complementary) protocols, complex regimens and observational (rather than experimental methods). Weak integration spoke in terms of complementary, palliative care with the omission of complex dietary and nutritional programs that were characteristic of complementary and alternative medicine (CAM), basically putting CAM on the sidelines as an elective rather than a first course of action.3
From a practical viewpoint, practical guidelines as to how state medical boards should address CAM was put forward by the House of Delegates of the Federation of State Medical Boards on April 27, 2002. The preamble to the model guidelines simply stated4 that the treatment offered should:
- Have a favorable risk-benefit ratio compared to other treatments for the same condition
- Be based upon a reasonable expectation that it will result in a favorable patient outcome, including preventive practices
- Be based upon the expectation that a greater benefit will be achieved than that which can be expected with no treatment
To bring mainstream and alternative medicine into greater congruence – on terra firma rather than "terror forma"– Mark Hyman established that proper pathological assessment and diagnosis in health care is the beginning of the analysis, not the end. Rather than ask, "What is the pathology?" (reminding me of the popular TV show some years ago called "Name That Tune"), one should ask, "What biochemical, basic science, observational and clinical data support an integrative approach to normalize function?"
In this scenario, form follows, function, disease follows disturbed biochemistry, phenomenology follows physiology.
In his treatise, Hyman identified common roots to all pathology: (i) altered mitochondrial energetics; (ii) alterations in form and function of the phospholipid cell membrane; (iii) expression and performance of enzymatic proteins; (iv) proper assembly, maintenance, repair, and regeneration of structural proteins; and (v) variations in expression, function, and integrity of the genes.5 To this we, as chiropractors, may add (vi) neurological imbalance as a reflection of what we may or may not continue to refer to as the subluxation.
The Next Evolution?
What this all adds up to is yet another term alluded to by Hyman that may help to dissolve the boundaries between alternative and mainstream medicine: functional medicine. Not only does this capture what I believe to be the heart of chiropractic, but it also places the emphasis upon wellness and conservative health care above all.
It is encouraging to find this particular term gaining wider acceptance and in fact, giving rise to a new professional society called the International Association of Functional Neurology and Rehabilitation, going on its third year of existence with its own academic journal and annual convention. At its meetings, I found the relationship between medical doctors and alternative practitioners to be particularly seamless, congenial, and productive – hopefully a sign that the integration between alternative and mainstream medicine may have the potential to someday approach an embrace, rather than a handshake.
The fly (or tarantula) in the ointment remains the pharmaceutical industry, which is best left for discussions for another day.
- Eisenberg DM, Kessler RC, Foster C, Norlock FE, Calkins DR, Delbanco TL Unconventional medicine in the United States. Prevalence, costs, and patterns of use. N Engl J Med, 1993;328(4):246-52.
- Lerner IJ, Kennedy BJ. The prevalence of questionable methods of cancer treatments in the United States. Cancer, 1992;42:181-91.
- Hess D. Complementary or alternative? Stronger vs weaker integration policies. Amer J Public Health, 2002;92(10):1579-81.
- Section I: Preamble to model guidelines approved by the House of Delegates of the Federation of State Medical Boards on April 27, 2002 from a draft prepared by the Special Committee for the Study of Unconventional Health Care Practices [Complementary and Alternative Medicine]. New model guidelines for the use of complementary and alternative therapies in medical practice. Alt Ther Health & Med, 2002;8(4):44-47.
- Hyman MA. The real alternative medicine. Reconsidering conventional medicine. Alt Ther Health & Med, 2005;11(5):10-12.
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