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“The only way to avoid the slippery slope is to stay off the slope”.
George F. Will
Columnist and Journalist
If we were to compare the profession of chiropractic to creatures of legend, in its early days chiropractic was like a hydra, whose practitioners possessed a ‘body’ of core beliefs and practice patterns but a rather contentious leadership, one with many ‘heads’. Although there were different personalities vying for control and influence (the Palmers, Carver, Howard and many others), the practice of chiropractic then was probably not as variable as it is today.
Later on, chiropractic evolved into something more like a chimera, a mythical creature with the head of a lion, the body of a goat and the tail of a serpent- diversity at its most extreme. By necessity, amidst its war with organized medicine, it had become one profession, but protracted technique civil wars had divided the body chiropractic into a slapped together beast, although there are some indicators that chiropractors do share some similar beliefs and practice activities.1,2 That said, we (and others authors) have previously addressed chiropractic’s chimerical nature in such areas the complexities of operationalizing the definition of subluxation,3 differences over ‘scope of practice,’4 varying views of ‘innate intelligence’5 and the proper position of the chiropractic profession into the health care delivery system.6 In our present commentary, however, we focus on a question that has become a central concern to many members of the profession: Can chiropractic survive its chimerical nature with respect to technique diversity? Is it willing to try? If so, it is necessary, even in the interest of self-preservation?
Darwin’s seminal work on the process of speciation hypothesized that divergent types of the same creature stem from a common ancestor but developed in response to different environmental stressors. This model can be applied to the chiropractic field as well. In the beginning, there was only one approach to chiropractic. Diagnostically, by palpation, DD Palmer discovered spinal joints that were, by his account, ‘racked out of place’ and thus needed to be ‘racked into place’ as a mean of cure.7 The first case was Harvey Lillard, a deaf janitor. DD’s intent was to restore his hearing, not necessarily to address the custodian’s thoracic spine subluxations. And it came to pass that Harvey’s hearing was restored. There is evidence to suggest DD was very secretive of his discovery and, were it not for a near fatal accident, DD might have only taught ‘chiropractics’ to a select few hand-picked students.7,8 In the early days of chiropractic, chiropractors did it DD’s way.9,10
After a decade had gone by, and BJ Palmer had assumed the mantle of power from his father, the teaching of chiropractic began to change. As his hegemony in the Fountainhead (circa 1910) became more secure, BJ developed different methods of chiropractic, eschewing many of his father’s core beliefs and methods of cure. BJ Palmer introduced, indeed practically legislated, a number of philosophical and clinical innovations be used for optimum patient care (see Table 1). His extreme advocacy of thermography in the mid-1920s and of upper cervical care in the early 1930’s further exacerbated the profession’s discord. Many of these innovations were controversial and engendered opposing viewpoints, prompting many of BJ’s contemporaries to leave the Fountainhead and ultimately establish their own colleges [DD among them11] and develop proto-techniques that would eventually evolve into the more recognizable systems we see today.12 Strife in the House of Palmer thus set up the stage for many other divisions that ensued, along fault lines that intersected each other in a wildly complicated pattern: straights versus mixers, mechanistic and reflex practitioners, and segmental and structural approaches,13 just to name a few.
Chiropractic speciation shows no sign of abating at this time. Moreover, unlike Darwin’s origin of species, where fitter organisms replace those less adapted to the changing environment, new techniques stands along side, rather than replaces, the already impressive array of clinical options available to the field practitioner. Nature, ‘red in tooth and claw’, shows no compassion when an organism is out-competed for limited environmental resources. By comparison, state or provincial licensing boards and chiropractic colleges, handicapped by having limited information on which technique are safest and effective, have proven most reluctant to adopt regulations that would cast any technique to the chiropractic scrap-heap. If in Nature the fittest survive when the environment changes, in chiropractic the fittest techniques are those most capable of creating environments in which they can survive – and flourish. In a recently published textbook Technique Systems in Chiropractic,12 two of us (Cooperstein and Gleberzon) explore in detail this process of chiropractic technique speciation, contrasting the benefits as well as the detriments of this century-old process (see Table 2a and and2b2b).
The current chimerical nature of the chiropractic profession does not come without challenges. Third party payers, for example, may be at a loss to know which, if any, treatments to pay for – especially when many techniques claims to be more efficacious than others and some claim not to address clinical symptoms at all (often a requirement for reimbursement). Government regulators are often unsure who to listen to with respect to representation from the profession, what with both “Broad-scope’ and ‘subluxation-based’ technique representatives both clamoring for public attention.
Although chiropractors have the privilege of being permitted to self-regulate, regulatory bodies are charged with what at times seem to be mutually exclusive tasks. On the one hand, it is their responsibility to protect the public and to ensure that all chiropractors meet minimal clinical competencies and act in a reasonable fashion. On the other hand, regulatory bodies (at least those in Canada) are there for the membership as well, to oppose any attempt by governments or other health care professionals to arbitrarily stifle clinical freedom or reduce chiropractic’s market share. Regulators cannot act in such a Draconian manner that they are perceived to be tyrannical or as the lackeys of government officials or, worse still, medical puppets. Nor can they allow themselves to be seen by government overseers as being unable or unwilling to control fringe practices either. But where does clinical adventurism and experimentation cross the line to abject quackery? At what point does clinical practice become patient experimentation that requires research protocols and protections? In the event that proper safeguards are not developed, the profession potentially leaves itself vulnerable to several negative repercussions (see below).
And then there are the patients. Despite the dim view from third-party payers and some other stakeholders, patients often prefer clinical diversity, as they are accustomed to receiving in other health care fields, such as psychiatry14 and many other aspects of medicine. If one approach does not work for that patient, there is a plethora of others from which to choose.
What, you might proclaim, only two views? Yes, we rejoin, with regards to this issue at least, we think the opinions of chiropractic organizations can be generally divided along two ideological lines. In the parsimonious view, the extreme diversity in the profession is seen as the single greatest barrier to the profession’s survival and acceptance by the outside health care community. The result, if not the intent, is to champion for the use of a relatively limited number of tools in a practitioner’s clinical armamentarium that have withstood the rigor of scientific scrutiny. It sees new technique systems as essentially avaricious, with ethical standards that are a downwardly moving target, whose sole purpose is to separate a patient’s money from their wallets. Indeed, some advocates of new technologies unabashedly promote their product less as a useful clinical tool but more as a better means to generate income, even in a managed care environment. In the parsimonious view, the ever-expanding universe of technique systems in chiropractic is a slippery slope best avoided by staying off the slope.
In the expansive view, technique developers, having codified a group of clinical observations into a standardized approach to patient care, and often having brought forth a purported seminal discovery or innovation in patient care, are seen as the driving force for improvements in chiropractic care. In this view, technique developers are more central than chiropractic colleges in fostering progress and they are seen to be more likely to conduct truly useful research applicable for patient care.
At the most recent ACC-RAC, FCLB and ACA House of Delegates conferences Perle specifically explored what he saw as financial pressure potentially surmounting whatever barriers some practitioner may erect for the protection of their own moral integrity. The need to respond to the demands of fiscal distress, he contends, can lead to the making of decisions that are only motivated by profit. However, the deliberate ignorance of the impropriety of one’s own actions, or even a process of rationalization (‘the insurance company is acting unreasonably with me so I will take advantage of them’) does not give a practitioner carte blanche to act in a manner they know is unethical (see also 15).
So perhaps herein lies the issue. In trying to decide whether the parsimonious or expansive view of chiropractic technique is more reasonable, our generalized limited (but growing) body of knowledge, as seen in all health care professions, is most inhibiting. While much is known about chiropractic efficacy and safety in general, little is known about the specifics of what technique works best for a particular condition. That said, this lack of knowledge cannot be used an excuse for the suspension of proper and appropriate ethical conduct in private practice.
Although it has become something of a cliché that extreme technique diversity hurts the profession, a point we do not question, we think the point is overdone. What is probably more harmful to the profession, and please forgive us for being blunt about it, is deliberate fraud. Some of this takes the form of dubious machines, subluxometers and the like, and some show up in the form of outlandish billings and utilization rates. We have seen very different products and techniques, as different from one another as can be imagined, unite when it comes to nefarious patient management schemes.
As previously mentioned regulatory agencies have one preeminent objective: to assure the public safety by attempting to ensure that all licensees maintain a minimal level of competency. Minimal standards do not mean that all aspects of practice need be homogenous, only that a lower level of homogeneity must exist. The desire to achieve clinical excellence is motivated by one’s moral compass; it is an ethical decision. Thus, the ethically motivated desire to maintain clinical excellence in concert with the heterogeneity of judgment and taste will still produce diversity within the profession that can be good as long as judgment is not clouded by deliberate ignorance or rationalization.
If the profession as a whole does not vigorously meet this most basic of professional requirements – self-regulation – the consequences could be dire. Currently, chiropractors enjoy what could be classified as “Group A” status in health care; that is, they are able to use the designation of ‘doctor’, to diagnose a patient and to provide patient care directly without medical supervision, not unlike dentists, psychologists and nurse practitioners. However if, as a profession, chiropractors do not limit their chimerical nature, whereby some members engage in either unethical behavior or bizarre practice activities that are so extreme that they defy logic or explanation, then chiropractors could, perceptually if not legally, be demoted to a ‘Group B’ status, lumped together with homeopaths, acupuncturists and massage therapists. The author from Ontario (Gleberzon) may be more sensitive to these concerns having seen the triple-whammy of the unsuccessful affiliation process with York University, disappointing recommendations from the Lewis Inquest and the delisting of chiropractic services from the Ontario Health Insurance Plan. That said, the chiropractic profession, in Canada, in the United States and worldwide, must be alert to the possibility that continued unchecked extremist chimerical behavior poses the real possibility that the body politic may develop the impression that chiropractic is not a real profession and that its’ members are not ‘real doctors’. That impression would be just as ostracizing to chiropractors, regardless of where they practice, as official demotion.
From our perspective, we submit that the ship of chiropractic homogeneity has left the harbor and it is impossible to cram the genie of divergent thoughts back into the bottle of unity. Despite the confusion it causes among government regulators, third party payers and patients, despite ongoing and often pointless internal fighting and despite the fact that some chiropractors, when asked to discuss the behaviors of their colleagues of different stripes are just as likely to circle the wagons and shot inwards as they are defend each other, despite all this, it seems to us that the future is diverse.
From a strictly pragmatic perspective, we submit that chiropractic’s diversity is here to stay and is not likely to be a harbinger of its demise. Lacking a compelling body of literature that instructs us of what is the most effective technique to use under this or that clinical scenario, taste and judgment will, by necessity, result in different opinions, creating a profession more chimerical than uniform in appearance. However, with such wide and diverse clinical acumen comes great professional responsibility. When we look at the issue in its entirety, we think that the profession can survive its technique diversity and chimerical nature if it can exert control over those members at the periphery of reasonable conduct. The challenge is to weed out the wheat from the chaff and not let chiropractors at the fringe of ethical behavior hold the remainder of the profession for ideological ransom.
Brian J Gleberzon, Canadian Memorial, Chiropractic College.
Robert Cooperstein, Palmer College of Chiropractic West.
Stephen M Perle, University of Bridgeport, College of Chiropractic.