"If we value the pursuit of knowledge, we must be free to follow wherever that search may lead us. The free mind is not a barking dog, to be tethered on a 10-foot chain."
- Adlai E. Stevenson Jr., speech at the University of Wisconsin, Madison, October 8, 1952
Artificial intelligence was once defined as a blonde who dyes her hair brown. That is an unkind remark. Real artificial intelligence is regaining some respectability in teaching machines how to sense and think, and perhaps how to care for us in our elder years. Eventually, robots could displace some common functions of primary care, but are less likely to displace chiropractic - that is, if chiropractors prepare for or just prepare a healthier future for all.
As a chiropractic student, I studied on weekends and evenings at Stanford University's Lane Medical Library. There, I felt as though I had entered a kind of heaven: access to all journals and a new medical book section. Scholars and scientists often take a bad rap in the business world because they respect ideas as much as money. These days, without scientists, businesses have nothing to sell. Businesses that thrive cultivate and value information. Those that undervalue thinkers, believing the real talent is in cutting deals and selling stuff, only inherit the scraps.
While browsing the Lane Library collection one day, between reading about gross anatomy and embryology, I discovered a small book written by a medical physician, warning of a disastrous future for medicine if something did not change. The author and book title are long gone from my memory, so you will have to take my word for it. His thesis was this: If primary care medicine continues on its predictable "turning the crank" process of working diagnosis, leading to standard-care algorithms, begetting a select few and familiar care pathways, primary care could be automated. This has been a close call a few times. Indeed, whenever a piece of software comes along which seems to rival perfunctory primary care tasks, the software mysteriously vanishes.
In the near future, patients could one day swipe their medical information card at a kind of vending machine in the drugstore and tap the screen through a series of questions that any good doctor should ask, arriving at a working diagnosis with a stated degree of confidence. The machine could then dispense a pill that works 80 percent of the time. You know, like antibiotics for a cold, "so it won't develop into pneumonia." In an "outsourcing" scenario, the computer dials out and a friendly voice from India suggests you take two aspirin and call back in the morning - and please have your 20-digit case number ready. Ready? Have a pencil? Or, "Thank you for calling New Delhi American Hospital, your call is very important to us. Please hold the line for the next available physician." But what if the algorithms get nervous: "Sir, we have you booked on a midnight flight to Delhi for a full physical and neurological examination and possible back surgery on June 18, 2008, at 14:30 hours. A limousine will pick you up at the airport. If you need surgery, you will convalesce on the beach in the Maldives for five months. As you know, it is cheaper to see your American-trained physician in India, and throw in airfare and recovery at a spa for five months, than pay for a week in an American hospital."
Your medical history card with your genetic risk profile, family history and current reported health risks on it may trigger "Dr. Machine" to remind you to exercise five times per week and bump up the fiber, and it is time to get your cholesterol and triglycerides checked, since your last blood work was July 2006. Finally, the screen displays this question:
Wouldn't you not like a print-out of your current "health portfolio," with suggestions for building personal health credits?
Press "No" if Yes, you confirm you would not like a copy.
Press "Yes" if No, you would not prefer to get a non-copy.
Are you sure you would like to make this selection? Not yet, Not yes, or Not no?
And we were doing so well until insurance companies got involved. But you get the idea. The basic stuff of primary care morphs into prevention, and most chronic disease management will be mechanized to individual patient contact, most likely via the Internet.
And so it is that the future of health and health care goes to the "preventers" - the guys who stay the health course. When the big prevention wave hits, chiropractors could have their surfboards ready and be in the water. But it seems unlikely. Most chiropractors and medical docs will be dozing on the beach. Nursing actually is the most perfectly positioned to move into health and risk profiling and preventive counseling for patients, although I am not sure even they are ready.
No doubt, chiropractors are inclined to prevent, but lack the training and commitment to a scientific approach. The training they can get. The commitment - changing chiropractic hearts and minds - is more difficult. The prevention chiropractor will see patients for subluxations, disarticulations, discontinuities and incongruities of lifestyle, nutrition, exercise, job and play safety, and counseling on risks of tobacco, alcohol and illicit drugs, plus improve meaning of care and perhaps even life. More chiropractors are beginning to grasp the comprehensive and compensable picture of prevention. Prevention also is a long-term commitment by payers and patients. With motivators, incentives and rewards - the tools and technology of transformation - it pays off.
When big prevention hits, the chiropractors who insist prevention is "all in the bones" will miss it. Not so bad, really. In 50 years, chiropractors will still have practices in beautiful little towns like Winchester, Indiana, and Greenville, Ohio. And quality of life in those towns always will be enhanced by their practices. It is a perfect fit. My Uncle Ward tells of MDs going to the local chiropractor after dark so as not to be seen by medical colleagues during the 1950s. What hypocrites.
But attributing all or most healing to the spine - prepaid, stay-well programs of overuse, overcharging, and over-treating - turns off many and appeals to only a few. It erodes community goodwill. The hospital board would like to appoint a chiropractor, but Dr. Enthusiastic, DC, is on an implausibility jag after his last seminar, mumbling something about NASA.
Hanging all of the profession's credibility on the spinal subluxation as primary mediator of health is to squarely place one's neck in the noose and wait to see how long the floor holds. Since people think and act deductively, the perfect NIH-sponsored, hypothetico-deductive falsification study is all that is needed for irreparable damage. "The functional MRI shows no lasting change in liver innervation or blood flow after an adjustment," would be a bitter pill to swallow. Yet this is an easily tested premise with today's technologies. You could say the subluxation hypothesis is "locked and loaded," and awaiting testing. This is perhaps the only instance in which it really could be better to think strategically and adaptively than to simply stay the course.
The apocalypse already has begun in the herbal world: Echinacea for immune function, black cohosh for hot flashes, garlic for cholesterol, and St. John's wort for depression have all been discredited within the past 12 months by high-quality studies. Of course, consumers will not stop using these things. And there may be effectiveness of these medicines for individuals, but the world does not think that way. "Echinacea has been disproved" is printed in Time magazine, and that's that. In fact, a naturopath friend says about the black cohosh study: "We do not know why the study did not 'come out' (the way we expected)." She will continue to prescribe and use it, in spite of findings, or maybe prescribe the placebo, since it is as effective but cheaper: "Here, Mrs. Jones, is black cohosh placebo for your hot flashes. Clinical trials have shown BCP to be just as effective as that black cohosh, but it is cheaper and without the side effects."
Personal and professional "hot buttons" are sure signs of a belief in dire need of updating - a belief subluxation in need of adjusting, if you will. The religion-science interface and tension directly reflects our times. This is a wilderness in need of courageous exploration. Beliefs still are worth dying for. And some beliefs appear to be restorative. Can we weigh the "peace that passeth understanding"? Of crucial interest is how much evidence is needed to change hearts and minds. The "evidence-belief" axis suggests how fast and how far institutions and people will change when confronted with new information. The truth is that evidence takes a long time to update beliefs.
So, the chiropractic profession has important choices to make: retreat and defend beliefs, or adapt and extend the subluxation notion to biopsychosocial discontinuities, where a natural healing "signal" awaits discovery within the noise and chaos of environment and disease in each and every patient. Tracing the signal within is the very essence of biological intelligence and is highly individualized. The best healing holds back chaos long enough for an organism to regain composure and balance.
It may amuse us to consider a medicine so mechanical it could easily be replaced - even improved - by computers. But chiropractors who remain committed to the straight and narrow might be just as pickled and put on the shelf if they do not stay current with what works, what has value and what demonstrates health.
Click here for previous articles by J. Michael Menke, MA, DC, PhD.