The Role of the State Board in the Acquisition of Cultural, Professional and Social Authority
It is said that the ancestor of every action is a thought. It is my intention to share some thoughts with you to precipitate the kind of action that is vested in regulatory agencies.
On August 15, I will celebrate my 50th anniversary as a chiropractor. The years have been turbulent, challenging, emotionally debilitating and rewarding, with every step of the way a contribution to my personal and professional growth.
Upon graduation from the Chiropractic Institute of New York, I chose to return to my home state of Massachusetts to establish a practice, knowing that by doing so I would be practicing in violation of the Medical Practice Act, subject to arrest and imprisonment, a fine, or both. Ask anyone in our profession who lived and practiced under those circumstances if it was easy - it wasn't.
It was difficult on families not knowing if this would be the day a state police detective would come to the office posing as a patient. When my daughter Kathy was in the second grade she came home one day and reported that her teacher said, "What your daddy does (chiropractic) is not nice." That comment by her teacher was the genesis of my immersion in the fabric of the profession and my community to prove that teacher wrong.
In 1966, a statute was enacted to regulate the practice of chiropractic in Massachusetts, finally giving chiropractors the right to bask in the sunlight of legitimacy. Governor John Volpe appointed me to the initial Board of Registration and Examination, where I served for 18 years. After practicing for 16 years in moral defiance of the law, I can assure you that the privilege of licensure should never be taken lightly. How wonderful it is to practice with protection, freedom and accountability. It is through accountability that the first step toward legitimacy is taken. We cannot take the gift of licensure for granted and must be ever mindful that the gift can be changed or taken away by a vote of the legislature or a stroke of the governor's pen. A license is a privilege given by the state - it is not an entitlement.
My comments today are based on experience as a clinician; president of the Massachusetts Chiropractic Society; founding member of the Congress of Chiropractic State Associations (COCSA); chairman of the Massachusetts Board of Chiropractic Examination and Registration; president of the Federation of Chiropractic Licensing Board (FCLB) and the National Board of Chiropractic Examiners (NBCE); president of the Society of Chiropractic Management Consultants; and more recently, director of clinical services for a national chiropractic individual practice association (IPA).
The Social Transformation of American Medicine by Paul Starr, published in 1982, should be mandatory reading for any person seriously interested in the social, political and economic evolution of the chiropractic profession. Starr traces the rise of medicine from a generally weak, obscure, divided profession, insecure in its status and income, to a sovereign power with consolidated cultural, professional and social authority. Paul Starr won a Pulitzer Prize for this writing effort. The book is provocative and insightful; within the pages rests a powerful lesson.
Our rise as a profession can only be through the establishment of a consolidated cultural, professional and social authority. As I see it, our profession, as medicine once was, is weak; it is divided; it is insecure in its status and its economic power and lacks cultural, professional and social authority. We only possess licensing authority.
Starr further states that medicine staked claim to its authority not as individuals, but as a "community that has objectively validated its competence." He says that authority incorporates two sources of control - legitimacy and dependence.
I certainly do not suggest that we take the same path as organized medicine, but take from its evolution those accomplishments that would beneficially apply to our profession. Why not use another profession's experience as a learning tool?
Through consolidated cultural, professional and social authority, the foundation of medicine has remained relatively unshaken even though medical errors kill between 44,000 and 98,000 people in U.S. hospitals each year. These numbers are derived from the Institute of Medicine, and could be much higher.
The medical profession is not weakened when medical mistakes cost the country between $38 billion and $50 billion annually, including $17 billion to $29 billion for preventable events.
It is not weakened when health system errors result in more deaths annually than AIDS, breast cancer or highway accidents.
It is not weakened when 1.5 million people, about five percent of the hospital population, acquire new infections of varying severity during their stay in the hospital.
It is not weakened when it is discovered that there are some 2.2 million unnecessary surgical operations every year (44,000 of them for low back) and a resulting 11,000 deaths.
It was not weakened when the American Medical Association strikes a multi-million dollar deal to endorse blood pressure monitors, heating pads and other health products made by Sunbeam.
It was not weakened when the New England Journal of Medicine violates its financial conflict of interest policy 19 times over the past three years in its selection of doctors to review new drug treatments.
It was not weakened when the public becomes aware in 1995 that the 21 major contributors to the American Academy of Family Physicians were drug companies.
The foundation of medicine is not weakened when a physician is found guilty of fraud, multiple homicides or gross negligence. In those instances, the public labels the guilty doctor as just a "bad apple."
It is through consolidated cultural, professional and social authority that medicine withstands the onslaught.
Why is it that our profession is relegated to an afterthought or incidental within the fabric of the health care delivery and reimbursement system?
Why is it that our market share remains at 8-10 percent in spite of population growth and the educational, clinical and research advances of our profession?
Why is it that the publicity associated with an isolated incident of a CVA due to cervical spine manipulation has an impact on the profession as a whole?
Why is it that the bizarre behavior of a colleague impugns our collective reputation and that of the entire profession?
The answer somehow rests within the profession's failure to seek and acquire the professional, cultural and social authority essential to achieve its rightful status. The attainment of cultural, social and professional authority translates into market share, economic power and political influence.
The chiropractic profession continues to make progress:
- 86 percent of all health plans provides chiropractic benefit.
- Studies demonstrate cost-effectiveness.
- Studies document high patient satisfaction.
- Our educational standards are continuously evolving.
- Foreign schools now outnumber those in the U.S.
- More institutional research validates chiropractic manipulative therapy (CMT)/chiropractic adjustments.
- We are considered by some to be a leader in complementary/alternative medicine (CAM).
- We are considered by some to be mainstream and not part of CAM.
- Many DCs function within integrative collaborative care.
- 45 million households in the U.S. make use of chiropractic services.
- The new breed of graduate is better trained, but also in greater debt.
- Chiropractors now serve on the medical staffs of some 300 accredited hospitals.
- Chiropractors have begun to be gatekeepers.
- Despite this forward progress, there are still many blemishes on the face of the profession, including:
- a circus-like atmosphere that is promoted by demagoguery;
- chiropractors who behave as disciples;
- doctors who practice in violation of the educational and legislative intent associated with the use of clinical diagnosis in practice;
- field practitioners who are clinically challenged;
- poor record keeping by an estimated majority of the profession;
- the $10 chiropractic adjustment;
- free chicken dinners as a means of patient recruitment;
- those who see the patient as an opportunity rather than an opportunity to serve;
- those who defy the statute and rules and regulations under which they practice;
- chiropractors who compromise their clinical and ethical values in order to be players in the personal injury market;
- those who rape and pillage third-party payers, some of whom hide behind the credentials of a diplomate;
- those who fraudulently bill for services by upcoding, unbundling and reinterpreting the meaning of ICD9 and CPT codes;
- measuring success on the basis of patient visit averages;
- measuring success by how little time is spent with the patient;
- administering and billing for supportive procedures that are clinically inappropriate;
- a nine-fold variation in utilization and billing practices;
- those who are guilty of unprofessional conduct;
- those who perpetuate sectarian debate;
- a lack of strong college entrance standards;
- a lack of academic competition;
- high student debt that plunges fear into the hearts of new graduates;
- an embarrassingly high student default rate;
- being considered a nonessential service by the purchasers of health care;
- practice management consultants who prey on doctors who are not prepared for the complexities of practice;
- the vast differences in the knowledge and perceptions of chiropractic services between users and nonusers of chiropractic care.
My comments may be considered harsh. So be it. A truth is a truth is a truth.
These blemishes have created a Berlin Wall that blocks our way to cultural, professional and social authority. Removing the blemishes will permit access to the authority essential to achieve market penetration and market share that translates into economic power and political influence.
Time is of the essence. We live in a time where within a nanosecond our society can rearrange its world view, basic values, social and political structures and not to go unnoticed, health care. The chiropractic profession, without exception, is being affected by these fundamental changes.
The Association of Chiropractic Colleges, the Council on Chiropractic Education, and the Congress of Chiropractic State Associations must be clear about who we are and what we represent. They must be catalysts - proactive instead of reactive - for the challenges associated with change. This can only be accomplished through enlightened leadership.
We should no longer tolerate the bifurcated tongue of two national associations. A profession that seeks consolidated professional, social and cultural authority must speak and act as a unified body. As a coherent whole we can share with the world those values that make our profession unique within the community of health care delivery.
The colleges must commit to the development of a strong student selection process that fosters and encourages academic excellence and competition, because it is good for the profession now and in the future. The educational process in its earliest stages should include the subject matters of value clarification and professionalism that promote and define those uncompromising values that ultimately reveals the character of the doctor.
The colleges cannot allow graduates to walk out the door naÜve about the world in which they will be working. They will be in the profession of chiropractic, but they will also be in the inescapable business of health care.
The theological debate and sectarian atmosphere must end. It is an obstruction to our consolidated authority as a profession. Will its removal require a cataclysmic upheaval within our community?
Now to the FCLB. Within your collective hands is a repository of statutory privileges that every practicing chiropractor in the United States enjoys today. Vested in you, either by legislative mandate or executive mandate is the responsibility to uphold the enabling act, interpret legislative intent and, when allowed, establish rules and regulations for the conduct of the profession.
As board members, you also conduct adjudicatory proceedings and give assurance to the public that a doctor licensed in your jurisdiction has met a standard established by law, and practices within the intent of the legislative mandate and abides by rules and regulations; by no means a small task.
The DC license is essentially a pledge to the public that the holder of the certificate has completed the required training, has a base in technical, specialized knowledge and functions under a code of conduct. Through licensure and oversight comes the reward of professional status and public trust.
It is through public trust that cultural, professional and social authority is derived. It is my opinion that our profession lacks the public trust that translates into market penetration, market share, economic power and political influence.
Each state board must take the responsibility of building greater public confidence in the chiropractic profession. As state boards, you can play a significant and powerful role in building greater public confidence. Exercise caution in allowing the power of the board to become diluted.
You must demand superior competence and continued quality performance from licentiates. For those doctors who are clinically challenged, give them the opportunity to take remedial action; should that fail, impose sanctions designed to modify behavior. Establish standards for record keeping demand adherence to them as a tool of quality assurance. When there is a nine-fold difference in cost and utilization for the management of a patient's complaint, something is not right! What guides the clinical decision making in this instance? If X is due to clinical ineptitude, should it not be of interest to the board? If nine times X is due to clinical ineptitude or greed, should it not be of interest to the board?
It is recognized that a minority of doctors are responsible for the majority of problems that state boards face, but it is that minority that erodes the public's trust. They must be dealt with. If not, their behavior will continue to impinge on our ability to acquire cultural, professional and social authority.
As board members, you must confront and then take the necessary steps to deal with this segment of the profession. You have the vested authority to deal with the issues of unprofessional conduct, clinical ineptitude, overutilization, deceitful and misleading advertising, etc. In order to protect the public, you must set high standards of conduct and performance and hold the collective feet of the profession to the fire. Your voice and opinions have the force of law.
Make history by doing what is right for the public and our profession.
In facing the complex world of our future, your actions will serve society and maintain the integrity and moral basis of our profession.
As a torch lighter, allow me to kindle your collective responsibility to be a powerful force in a movement spawned within this organization to acquire the public trust that will ultimately bring cultural, social and professional authority to the chiropractic profession. The challenge by no means is simple. It will require courage and conviction to serve the interests of the public while preserving the integrity of the profession. The final question is, if not you, who will it be?
Craig Morris,DC,DACRB,FAFICC
Torrance, California
Dr. Craig Morris is a 1981 graduate of, and retired clinical professor from, Cleveland Chiropractic College, Los Angeles. He is board certified in chiropractic rehabilitation and the editor of Low Back Syndromes, Integrated Clinical Management (McGraw Hill), a multidisciplinary textbook. He has taught sports / rehabilitation on all five continents.