Similar to the decades-long standoff between the United States and the former Soviet Union, chiropractors have grown accustomed to, but not comfortable with, scrutiny and criticism by the allopathic political machine. The resolution of the Wilk vs. AMA case brought the profession a new array of forces - positive and negative - with which to contend. It is important to understand the new political and economic climate in which we operate, because the relatively simplistic old politic is no more - and will never be again.
"Sore Throat"1 has given the AMA a long bout of laryngitis, but in its place, a variety of new voices can be heard. We've been pleased by some, such as the AHCPR's 1994 endorsement of spinal manipulative therapy (SMT) for acute low-back pain in adults;2 the Manga Report on the costs of chiropractic care;3 and several positive reviews by the RAND Corporation.4-6 In addition, our ears have burned with more recent rounds of scathing criticism from sources such as the National Council Against Health Fraud; the National Association of Chiropractic Medicine; books such as Chiropractic: The Victim's Perspective;7 Spin Doctors;8 and the most recent show by illusionists Penn and Teller.10 These criticisms hearken back to Ralph Lee Smith's AMA-inspired At Your Own Risk9 and prompt a severe emotional reaction that can interfere with clear thinking.
Amid this din of praise and condemnation, we may fail to hear the feedback from a new type of scrutineer: the health-care-policy researcher. Health-care policy has become a profession in its own right, drawing on the knowledge bases of several fields, including actuarial (statistical) analysis; clinical epidemiology; history; economics; political science; and sociology. Although health-care-policy researchers have their own prejudices (as do we all), they usually turn their gaze on chiropractic without the condemnation and animosity we have come to expect from political medicine. With respect to chiropractic, their goal is not to "contain and eliminate," but to understand our position within the health-care marketplace and plan in the interest of society as a whole.
"Chiropractic in the United States: Trends and Issues"11 is perhaps illustrative of the less hostile, but far more methodical examination that have increasingly experienced in recent years. This 32-page report summarizes a variety of contemporary issues confronting chiropractic, including reimbursement; managed care; cost analysis; practice patterns; philosophy; patient-centered care; research; and emerging competition. A third of the article is taken up by the references that support the authors' contentions. We may and will disagree with some or much of the perspective offered, but it is clear its authors, Cooper and McKee, have done their homework. Theirs is a sobering summary of where we are collectively, and what may lie ahead:
"In previous decades, chiropractors did not want their profession to be considered a form of medical practice. Even now, many see themselves as practitioners of a distinct art. Having crossed the chasm into the reimbursed world of health care, they must now prove their quality, effectiveness, and value. The profession is buttressed by satisfied patients and sympathetic politicians and by the general longing for someone who will listen and be supportive. However, as our aging nation struggles to define the health care system that it can afford, it is uncertain whether this will be enough."
Many who read this article will be moved immediately to condemn it because of its early references to such things as the "studies" that purport to show that certain other "studies" show a comparability of the costs of chiropractic versus medicine. These only compared office visit fees and did not show the costs of hospitalization, surgery (necessary or unnecessary) or medications. In other words, they were clearly invalid studies. Then there is the $1 educational booklet "study" by Cherkin (as if it had value). Does this article by Cooper, et al., have limitations? Yes, but putting the obvious aside, the outside world will view our profession as these individuals have done.
Many of our traditional shortcomings still haunt us. There is not enough research. Although we have enjoyed success in outcome studies of patients with some musculoskeletal disorders, the mosaic of outcomes has many missing pieces. Claims for superior benefits of chiropractic care, even for musculoskeletal conditions, are being questioned by independent researchers, and competing claims for benefit from practitioners of massage therapy, exercise regimens and behavior therapy find empirical support in the available database. The cost-effectiveness of chiropractic services also is being challenged increasingly by these competitors, and beyond type-M conditions (such as fatigue; strength and flexibility imbalances; muscle spasms; sprains; and stretched or irritated nerve tissue), our researchers have barely scratched the surface of what must be investigated. Whatever the reasons - economics, human resources, politics, etc. - the facts do not change. Notwithstanding repeated demonstrations of patients' superior satisfaction with "the chiropractic encounter," Cooper and McKee remind us: "Having gained greater entrŽe to third-party reimbursement, chiropractic has been forced to face the challenge that there cannot be two standards, one for chiropractic and another for conventional medicine." Satisfaction is but one piece of that mosaic of outcomes that will increasingly determine health-care policy.
As always, our inability to agree among ourselves about who we are and what we do limits us. Do we wish to be seen as complementary, alternative, or both? Are we primary-care physicians, integrative practitioners, musculoskeletal specialists, or biotheological practitioners? Are we broad-spectrum, alternative-care providers who combine significant manipulative skills with modalities such as massage, electrotherapies, acupuncture and nutritional counseling, or are we nondiagnosing subluxation specialists with no limitations, for whom prevention means lifelong treatment? If the former is the case, do we recognize the potential loss in cost-effectiveness that unrestrained use of "modalities" and access may bring? If the latter is the case, do we appreciate the reduction in legitimacy and professional autonomy that the narrowest of chiropractic orientations implies? Do we seek integration with, or insularity from, the wider health-care system? Our lack of coherent self-definition is not lost on policy-makers. It will be a requirement to advance in the 21st century health-care system, and it needs to be done soon.
Where once we enjoyed the luxury of relatively few competitors in our domain, the field has grown to include many medical and nonmedical practitioners. Manual therapies and related treatments for nonmusculoskeletal conditions are offered by physical therapists (who have been gaining independent practice rights and are moving toward a doctorate degree); rapidly growing armies of massage therapists and acupuncturists; and to a lesser extent, by renewed interest in manipulation among osteopathic and allopathic doctors. Notwithstanding our decades-long claims about the superiority of chiropractic adjusting over other forms of manipulation, neither outcomes data nor market patterns (patient preferences) are available in support of this view. Where once we were practically the only ones singing the praises of manual intervention, now we are becoming a voice in the chorus. Though our successes in the political arena have opened the doors to many third-party reimbursement plans, the often-punitive limits on manipulative and ancillary services we can offer erode our financial viability.
Complicating the problems attributable to our meager database and our inability to self-define is our continuing tendency to "exaggerate" what is known about the chiropractic healing art. While acknowledging "considerable political acumen" within our profession, Cooper and McKee warn that chiropractic "risks damaging its legitimacy in both the public and political arenas" by making unsubstantiated claims. In this age of accountability, evidence-based practice and managed care, the old rhetoric and penchant for testimonials that once built our client base now threatens our credibility. An assertion for the value of chiropractic services that is not buttressed by strong evidence does us more harm than good, for even if we prefer to ignore the holes in the database, others will not! If we wish to be the recognized experts in our own field, we must become the most trustworthy and credible purveyors of hard data about chiropractic, manipulation and whatever else we choose to encompass.
Like it or not, the brave new world of health care in the 21st century is upon us. Now, more than ever before, chiropractors are under the microscope. However, we are now being examined by a new breed of profession-watchers, scholars and policy-makers,whose purposes and biases are not necessarily those of our traditional adversaries. Indeed, the new observers of the chiropractic scene are not inherently friends or foes, but they bring a much more powerful lens to their task: the methodology of health policy research.
There is opportunity here if we are willing to grasp it. Cooper and McKee's analysis, and accumulating works like it, provide a glimpse of ourselves from beyond our own borders, as others see us. It is a relatively objective view that portrays us within the larger scheme of the profession and societal needs. Whether or not we agree with all they perceive, we ignore such analyses at our peril. Read the article and try to retain an objective analysis of what the duo has written. It is perhaps a great starting point and foundational base for a much-needed future strategic-planning process.
I ask a simple question: "If chiropractic were a company and you were to exercise the proper due diligence prior to making your decision, would you invest in it? "We must make the necessary investment to fully analyze Cooper and McKee's article, and the many others that undoubtedly are on the horizon. Chiropractic can no longer shout in the deserted woods and hope someone hears us. It is time for every practitioner to perform a self-analysis to determine in what direction he or she wants the profession to go; participate in that goal by voicing an opinion to the national and state leaders; and join an association. Your membership is the price of admission to the new health-care profession of tomorrow.
- Wilk CA. Sore throat. Dynamic Chiropractic, Jan. 31, 1990. www.chiroweb.com/archives/08/03/02.html.
- Bigos SJ, Bower OR, Braen GR, et al. Clinical Practice Guideline Number 14: Acute Low-Back Problems in Adults. Rockville MD: Agency for Health Care Policy & Research, December 1994.
- Manga P, Angus D, Papadopoulos C, Swan W. The Effectiveness and Cost-Effectiveness of Chiropractic Management of Low-Back Pain. Ottawa: Pran Manga & Associates, 1993.
- Coulter ID, Hurwitz EL, Adams AH, et al. The Appropriateness of Manipulation and Mobilization of the Cervical Spine. Santa Monica CA: RAND Corporation, 1996.
- Shekelle PG, Adams AH, Chassin MR, Hurwitz EL, Phillips RB, Brook RH. The Appropriateness of Spinal Manipulation for Low-Back Pain: Project Overview and Literature Review. 1991a, RAND Corporation, Santa Monica, Calif. (Document #R-4025/1-CCR/FCER).
- Shekelle PG, Adams AH, Chassin MR, Hurwitz EL, Park RE, Phillips RB, Brook RH. The Appropriateness of Spinal Manipulation for Low-Back Pain: Indications and Ratings by a Multidisciplinary Expert Panel. 1991b, RAND Corporation, Santa Monica, Calif. (Document #R-4025/2-CCR/FCER).
- Magner G. Chiropractic: The Victim's Perspective. Amherst NY: Prometheus Books, 1995.
- Benedetti P, MacPhail W. Spin Doctors: The Chiropractic Industry Under Examination. Toronto: Dundurn Group, 2002.
- Smith RL. At Your Own Risk: The Case Against Chiropractic. New York: Pocket Books, 1969.
- Penn and Teller: "Bullsh*t: Alternative Medicine." Showtime Network television program, Jan. 31, 2003.
- Cooper RA, McKee HJ. Chiropractic in the United States: trends and issues. Milbank Quarterly 2003; 81(1):107-38.
Louis Sportelli, DC
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