When I was asked to write this article, many thoughts crossed my mind: Where do I begin? Whom will I offend (and do I care)? Will this article spark positive changes? Do my thoughts mirror the majority of our profession or only a small number? Will others outside our profession read this, and what will they think? When will the chiropractic profession move into the 21st century? When will we as a profession take charge of policing ourselves? With that said, here are my thoughts, observations and many questions regarding the current state of chiropractic and where it needs to go in the next 25 years.
Education Issues
It is time to provide more than just the necessary science courses and other current courses at our educational institutions. As I travel, answering e-mails and returning phone calls, I have learned that a growing population of chiropractors seems to have given up practicing. Some of these individuals have indicated they were trained well in the sciences, but not in how to operate a business. Many who graduate from our schools fail in practice. Not all graduating students have the necessary skills to operate and survive in the business of health care.
I also believe one of our primary objectives should be to produce well-educated chiropractors who possess the skills necessary to make a differential diagnosis and, upon reaching that diagnosis, make a clinical decision on whether the patient will best be treated by the evaluating clinician or by being referred to another specialist.
In addition to producing chiropractors who are able to make critical judgment calls related to treatment and business, there are specific education issues this profession must address, including the following:
- operating a successful small business;
- properly billing and coding insurance companies, managed care companies, Medicare and Medicaid for services rendered;
- developing a fee-for-service practice;
- establishing interprofessional relationships through hospitals, interdisciplinary practices, industry and in the university system;
- judging and validating the plethora of information on literally thousands of products from hundreds of solicitors; and
- eliminating specialty certifications and replacing them with master's-level programs.
By the way, regarding the second-to-last point in the list above, what valid evidence exists that substantiates the vast array of products sold to doctors of chiropractic - many of them sold because the solicitors have learned how to "play the game"? They know the billing codes and promote how much income one can derive from treating X number of patients over a given period of time.
In this day and age, evidence-driven practice requires knowledge of the literature. Insurance companies and our government agencies continue to ask us to produce scientific evidence to validate the type of care we offer - not just manipulation, but also exercise, various modalities and virtually every aspect of patient care. What sources do we utilize, and once we find those sources, how do we know if what we are reading is quality? Here are just a few resources: the Cochrane Collaboration (www.cochrane.org); the CCGPP (www.ccgpp.org); the Rand Corporation (www.rand.org), and Evidence-Based Chiropractic Practice, authored by Michael T. Haneline.
While this resource list is anything but complete, the profession has to understand and come to grips with the fact that virtually everything we do or prescribe for a patient now must be evidence-driven (as opposed to evidence-based, which has strict criteria compared to evidence-driven care). One of the better papers written about how to critically review the literature was authored by Claire Johnson, DC, MSEd.1 This article is a must read for every chiropractor and includes a list of red flags to watch out for not only when reviewing literature, but also when attending a lecture. After all, how does one determine if the author/speaker is imparting information that is valid and not simply their own opinion?
The Foundation for Chiropractic Education and Research (FCER) has been in existence for 60 years. It has been leading the way in supporting funding for research and educational opportunities for this profession. I find it difficult to understand why every chiropractor and chiropractic student does not belong to the FCER. We also need to support the efforts of organizations such as the Association of Chiropractic Colleges, which holds its annual Research Agenda Conference (ACC-RAC). Again, every student, faculty member and practicing DC should attend these meetings. Why don't they? Is it apathy? Is it that they feel they will not learn anything new by joining or attending these organizational meetings? What do we need to do to get them to attend?
I have learned ACC/RAC takes place during national board exams, and our colleges can't afford to send their entire faculty - assuming that all faculty members would attend if given the choice. Would or could ACC/RAC be moved to an alternate date, and if so, would students attend? Why is the burden on the colleges to send their faculty? Why don't more faculty and DCs in private practice attend on their own?
The Schools
Entrance requirements vary from school to school, as do faculty, research approaches/projects and "chiropractic philosophy." Some years ago, many of our colleges and universities here in the U.S. entered into financial agreements with various manufacturers. You can see some of those companies' product logos displayed on clothing and equipment. I am not judging whether this is the right or wrong way to generate sources of income for these institutions, but rather suggesting that our profession look into those offering monetary support to our chiropractic colleges. Do we want to associate ourselves with these products? This is a question the executive leadership of each institution should answer. I do think some of the products the colleges endorse are legitimate and backed by research. Having said this, each college has its own financial needs and must find ways to survive - but at what cost? Certainly sacrificing the institution's reputation is too high a cost.
What are our faculty/student ratios? What type of equipment does each school provide for the students and in their outpatient clinics? Do they offer MRI, CT, digital X-ray, laboratories, physical therapy, textbooks and a wide variety of periodicals? What is the overall diversity of faculty with respect to degrees? How many faculty members have multiple doctorate or other degrees?
Our schools are mandated by CCE to require a minimum GPA of 2.5 for entrance. Only one school (National) mandates the baccalaureate for matriculation.2 Should entrance requirements be the same for each institution, and if so, what should they be? Should all schools require a four-year undergraduate degree prior to entrance into a chiropractic school, or would that requirement eliminate some of our exceptionally bright students who chose to enter chiropractic school early? Should all states also require completion of a bachelor's degree prior to obtaining a license to practice? All good questions that need to be answered sooner than later.
Another issue I hear students and recent graduates discussing is the lack of experience of some of their faculty. One concern is the potential lack of clinical experience gained in an office setting, where decisions must be made regarding care. Some instructors have been hired directly as faculty following their own graduation. While some might possess wonderful teaching skills, does that necessarily qualify them to teach our students? Should our educational institutions start screening their faculty more closely to prevent potential problems?
Why are some techniques taught at some schools and not at others? What criteria are used to decide which of the many techniques will be taught in each school, and by whom? Why does it appear that standardization between schools does not exist? What evidence, if any, exists to substantiate why we teach our students the techniques they are taught? Is there a greater need to teach chiropractic students more about pharmacology, surgical procedures, hospital care and, in general, how mainstream medicine approaches the same conditions we are trained to treat, in addition to those conditions we are not qualified to treat?
And what can we do individually and collectively to increase jobs for our graduating students? Dr. Joe Sweery and others have reached out to industry about employing chiropractors. It appears more and more opportunities exist, but how does the student find out about these opportunities, to whom do they turn, what educational information is critical for them to qualify for placement, and how do we identify those companies willing to employ a DC directly?
Cultural Authority
Cultural authority is the ability to impact public perception and influence the public based on the perceived authority behind the person, institution or profession making the recommendation.3 In "Establishing Chiropractic Cultural Authority," Dr. Joseph Keating Jr., et al., state: "We believe that one of the most significant barriers to the development of 'cultural authority' for DCs is our traditional dedication to a scientifically unsubstantiated (and largely untested) construct: the subluxation."4
When will we seriously address the use of this term, subluxation? To date, we as a profession have no RCTs that show the subluxation does or does not exist. When, if ever, will a study or studies be performed in an attempt to discover whether this lesion exists? Should we attempt a study of this kind?
When early explorers set out to find out if the world was flat, they took risks entering into the unknown, but subsequently discovered the world was actually round. Chiropractors need to critically look at moving into a paradigm shift using terminology that is understood by the scientific community at large. One of our biggest challenges remains those who continue to cling to the so-called "philosophy" of chiropractic with the fervor of religious fanatics. We must realize there is a difference between "belief" and "philosophy."
One of our institutions has abandoned the use of the term subluxation other than to address it as part of our history. When, if ever, will other schools adopt the same policy? If not, why not? In my opinion, we have a major assignment ahead of us if we ever wish to achieve cultural authority. We must rid ourselves of the antiquated terminology some cling to and move toward the use of terms accepted universally within the scientific community. Has the time come to divide the profession into two groups? This question has been asked many times, but is it time now to answer the question and do something about it?
Our Future: Where Are We Going Next?
Where does this profession wish to be in the next 5, 10, 20 years and beyond? We have many entities within chiropractic with largely individual goals: the ACA, ICA, COCSA, FCER, NBCE, our schools, students, and many more. Have these groups come together to address the direction and goals for the profession? If not, would they be willing to consider such a meeting? Once the meeting is concluded, what action steps would be taken to help us reach those goals? What will our goals be as related to hospitals, the armed forces, insurance companies, managed care, interdisciplinary settings, education, cultural authority, entrance requirements, research, funding, Medicare, Medicaid, and so on?
I did not say organizing all these groups for a meeting would be easy, nor am I suggesting this would be an inexpensive endeavor. Furthermore, I realize that reaching a consensus on who we are and where we are going, and answering all the other questions facing us, would be an almost impossible task given the history of this profession. But would hosting a meeting like this at least be a beginning? I often hear that the physical therapists have their goals clearly outlined. Why don't we? Take a moment to look at the goals of the American Physical Therapy Association (APTA).5
We are the future of this profession. Where do we want to go from here? What action steps will we take? Will we be a part of the solution, or will we remain silent and allow others to direct the future? Simply put, our future is up to you.
References
- Johnson C. Keeping a critical eye on chiropractic. JMPT 2008;31:560-61.
- www.nuhs.edu/show.asp?durki=44.
- Fuhr A. "Establishing Chiropractic Cultural Authority." Dynamic Chiropractic, June 18, 2007. www.dynamicchiropractic.com.
- Keating Jr. J, Hyde T, Menke MJ, Seaman D, Vincent RE, Wyatt LH. "In the Quest for Cultural Authority." Dynamic Chiropractic, Dec. 16, 2004.
- www.apta.org.
Dr. Thomas E. Hyde is a graduate of Florida State University and Logan College of Chiropractic.