Christine Goertz, DC, PhD, is vice chancellor of research and health policy at Palmer College of Chiropractic; a member of the board of governors for the Patient Centered Outcomes Research Institute; a member of the American Medical Association PCPI Measures Advisory Committee; chair of the ACA's Performance Measurement Task Force; and senior scientific advisor to the ACA.
In recognition of that passion and dedication, we are proud to honor Dr. Goertz with Dynamic Chiropractic's Person of the Year Award for 2015. In this exclusive interview, Dr. Goertz discusses her motivation to pursue research and health care policy, the current research landscape, the Gallup-Palmer report, and why she feels "there has never been a better time to be a chiropractor."
Why did you decide to become a doctor of chiropractic? I was working on my undergraduate degree and getting ready to begin applying to medical schools when I got pregnant with my first son. It ended up being a difficult pregnancy and delivery, which really opened my eyes regarding the limits to what medicine had to offer in many situations. I began talking to family practice doctors about my concerns, and came away even more discouraged. This was in the mid-1980s, just as managed care was beginning to hit full force, especially in Minnesota, where I was living at the time. It seemed as if medicine was moving even further away from the whole-person, patient-centered, conservative approach to health care delivery that seemed important to me.
I remembered conversations I'd had with a fellow chemistry student who was planning to attend chiropractic college. I began reading more about chiropractic and went to visit a college campus. I quickly realized the chiropractic approach to whole-person care, with an emphasis on conservative treatment modalities, was a far better fit with my own personal philosophy of health care delivery.
What motivated you to pursue research and health care policy, rather than clinical practice? Before I started chiropractic school, I assumed I would go into clinical practice. However, once there, I became increasing curious about the science behind chiropractic. I would sit in class and listen to faculty say, "If X is wrong, adjust Y," and I kept wondering, "How do we really know that is true?" This was almost 30 years ago and there was essentially no data to support the results clinicians were seeing in their offices, or the information students were being taught in chiropractic educational institutions.
I learned I could complete my bachelor's degree along with my DC if I took two elective research courses. My work in health policy also started about this time. I began writing for the student newspaper and got involved with the Minnesota Chiropractic Association's legislative committee. These research and policy activities really fired my interest, but I probably would have still gone into clinical practice if I had not actually been fired from my first job a couple of days before I was supposed to start!
The DC who had promised to hire me realized he could not really afford to bring on an associate at that time. NWHSU offered me a part-time job as a research assistant and the opportunity to see patients in their faculty practice clinic. A few months later, I discovered the University of Minnesota had a program on health services and that the Foundation for Chiropractic Education and Research offered fellowships to pursue advanced training in research. The following fall, I began to work on my PhD in health services research, policy and administration.
Please summarize some of the major research / health care endeavors in which you are currently involved. I strongly believe chiropractic has an important role in the health care delivery system, one which has not yet been fully actualized. There are still many unanswered questions in regards to chiropractic practice and there are still many patients who might benefit from chiropractic care, but don't go for a number of reasons. Research is the key that unlocks the door into mainstream health care delivery and it is policy that turns the handle on that door.
We must first conduct rigorous research to evaluate the quality of the patient care we provide; then we must take our findings and use them to support policy changes consistent with what the data show us. It is for this reason that the Palmer Center for Chiropractic Research (PCCR) is committed to pragmatic, where-the-rubber-meets-the-road science that is able to directly address questions relevant to delivering high-quality patient care. The PCCR has approximately 30 faculty and staff working on 6-12 diverse clinical trials and basic-science research projects at any given time. Building and maintaining this level of research infrastructure is not inexpensive – our annual budget is currently around $5 million.
Since 2008, PCCR has completed five NIH (NCCIH)-funded clinical trials, two HRSA-funded clinical trials, two DoD-funded pilot studies, three basic-science projects and numerous internally funded pilot projects. Currently, one area of focus is studying chiropractic in the military: three Department of Defense projects and one Veterans Health Administration study are ongoing. One of the DoD projects (Assessment of Chiropractic Treatment [ACT]) is looking at the effectiveness of chiropractic manipulative therapy plus standard medical care versus standard medical care alone for pain management and improved function in active-duty service members with low back pain. This study involves 750 participants at three military sites across the country. A similar pilot study published in Spine by our study team a couple of years ago showed very promising results, and we are anxiously awaiting the results of this large trial, which we hope will be available by summer 2016.
A second project, Collaborative Care for Veterans With Spine Pain and Mental Health Conditions (COCOV), funded by NIH, is in the early stages of developing a model for doctors of chiropractic to be part of a multidisciplinary team to treat veterans with chronic pain and mental health disorders. The study team will conduct focus groups of patients and providers, and use that information in the development of guidelines for this particular VHA population.
Both of these projects are consistent with our other area of focus – the study of chiropractic care in multidisciplinary health care delivery. We are also conducting studies that evaluate the addition of a DC to a multidisciplinary team at a specialized rehabilitation hospital, and exploring / describing existing models of multidisciplinary care at multiple health care clinics across the country. Finally, we are working to build a spine care registry, the first such scale effort focused on collecting real-world data from doctors of chiropractic in the chiropractic office.
What are the most important research findings / guidelines thus far that best support chiropractic's value? A number of organizations have endorsed the use of either spinal manipulation or chiropractic care in the treatment of low back pain. These include the American Pain Society / American College of Physicians clinical practice guidelines, which support spinal manipulation for treatment of chronic or subacute LBP; the American Geriatric Society, which has stated chiropractic manipulative therapy is appropriate for managing chronic back pain in older adults; and the Joint Commission, which includes chiropractic therapy within its pain management standards.
The question about which research findings are most important is much more difficult to answer, especially within the confines of this interview. It really depends on one's specific value-driven question. In general, chiropractic research demonstrates the following:
- Chiropractic management for low back pain, neck pain and headache is as good as or better than other forms of conservative medical care.
- There is a very low risk of serious adverse events from chiropractic care.
- Patient satisfaction with chiropractic care is extremely high.
- Chiropractic care costs no more, and perhaps a bit less, than other conservative treatments for back and neck pain.
These conclusions may not seem particularly exciting to many of you who feel you are seeing much more dramatic examples of improved patient outcomes in your offices every day. Remember, we are looking at population averages, not individual patients. And it is possible the "rules" one must follow in treating patients in clinical trials may somehow impact patient outcomes. This is the reason why the registry is so important. However, I would argue these fairly consistently seen study results are in fact very exciting when compared to other common treatments for spine-related conditions.
For more information on the individual studies that are out there, here are a number of resources that can be helpful:
- Dynamic Chiropractic's blog, "Research: Its Not Just for Scientists Anymore" [affiliated with the DC column by the same name, co-authored by Dr. Goertz and Dr. Dana Lawrence]
- Palmer's website, includes 1) a more detailed summary of chiropractic evidence; and 2) my own personal list of 12 research papers I think every DC should read
- The World Federation of Chiropractic has a comprehensive recommended reading list that sorts articles by topic.
Why are quality measures / outcomes so important for chiropractors in particular and health care providers in general? Outcomes and quality measures are the new lexicon of our rapidly evolving health care system. This is a good thing: All health care providers should be focused on providing care that actually works. I believe this is a real opportunity for doctors of chiropractic. As I stated above, our outcomes are at least as good as anything else available to patients suffering from low back and neck pain. Studies show we cost no more and perhaps a little less. The risk is low and satisfaction is high. The quality movement will give us further opportunity to evaluate the comparative effectiveness of care provided both within our profession and with other provider types.
How important are accountable care organization (ACO) and patient-centered medical home (PCMH) models to the future of health care, and why should chiropractors get involved (and how can they)? Both ACOs and PCMHs are health care delivery models that are gaining traction in our rapidly evolving health care delivery system. I think this has the potential to be a really good thing for doctors of chiropractic and the patients we serve, in the long run. However, this may take some time to come to fruition. We can work on facilitating chiropractic inclusion at the national level, but I believe we are more likely to make significant inroads locally, one professional connection at a time.
I recently had an opportunity to meet with the medical director for an ACO who was interested in bringing a DC on board. He had called a local doctor of chiropractic and asked for a meeting – the DC brought me in case he was peppered with questions regarding the evidence base for chiropractic. He was not; instead, the conversation focused on the question I get asked with increasing frequency lately: "How do I find a good one?" He wanted information on credentialing standards, practice guidelines, the five things he should ask when interviewing a DC, what outcome measures were appropriate to evaluate chiropractic practice, etc. I think the better job we do as a profession in answering these questions, the greater our opportunity for involvement.
The recent Gallup-Palmer Report has tremendous takeaway for the chiropractic profession – both good and bad. Summarize your impressions. I think some of the information we learned in the Gallup-Palmer Report was confirmatory, while other findings were a bit of a surprise. The good news is just over 60 percent of people believe DCs are effective at treating neck and back pain; and people who live in areas with higher concentrations of DCs tend to have a more positive opinion of the profession overall.
The sobering news is that less than 10 percent of recent users said they would turn to a doctor of chiropractic first to talk to about their health and nearly a quarter of those surveyed believe chiropractic care is dangerous.
I believe the profession can use this information to develop an effective strategy for removing barriers to expanded access to chiropractic care, starting with our perceived strength in spine-related conditions and working outward from there.
I've heard people say we need more PR / international media attention; or we need more lawyers, ever searching for another victory like the Wilk case; or we need more lobbyists to convince our legislative bodies chiropractic works. And then my own personal favorite: We need more scientists! All of these things might be true, but the Gallup-Palmer Report shows us that, at least in the U.S., these things are not significantly moving the needle.
Patient trust is fundamental to providing high-quality patient care. When we focus on spine care, we are within the patient's "circle of trust." Spine care makes sense to people. It is consistent with our education. It is consistent with our research. It is consistent with the success stories people hear from their friends, families and colleagues, who we now know are the groups most likely to try to discourage a person from going to a DC. I think the Gallup-Palmer Report shows us if we start pushing against the boundaries of that inner circle of trust, we start to lose people.
Over 60 percent of people believe DCs are effective at treating back and neck pain. Far fewer are still with us when we start talking about general wellness. It is possible that focusing on spine care is the right strategy for increasing the number of people who seek chiropractic care by increasing the size of our circle of trust. Once that has been accomplished, we can then follow our evidence base toward more general musculoskeletal conditions, toward wellness; maybe someday even beyond that.
What do you consider the biggest opportunity and biggest challenge for the chiropractic profession within the current health care system? I honestly believe there has never been a better time to be a chiropractor. There are many opportunities – the growing realization that musculoskeletal disorders are the No. 1 cause of global morbidity; an increasing openness toward the use of chiropractic on the part of both patients and other health care providers; a new emphasis on value-based care that levels the playing field, allowing us to demonstrate our strengths in health care delivery; and the new emphasis on patient-centered care, something that has always been the cornerstone of chiropractic practice.
However, we also face some major challenges. Many of those who are in charge of creating and implementing new health care delivery models do not even think about chiropractic (or don't know how to include DCs if they do think of it). The chiropractic profession is not in agreement regarding the role we should play within this rapidly evolving health care delivery system. Should we try to become more integrated within the system or not? Are we primary spine practitioners, wellness doctors or primary care physicians? Can we agree on credentialing standards or practice guidelines?
An additional major challenge is that it is increasingly more difficult to get federal funds to conduct chiropractic research in an increasingly evidence-based world. We have been fortunate in that the federal government, particularly NIH, has previously provided funding that allowed us to develop some basic infrastructure. Now that the platform has been built, however, it is unlikely those outside the chiropractic profession will provide the funding needed to answer the next generation of research questions that are directly relevant to the care we provide.
Editor's Note: Learn about Palmer's ongoing "20 for 20 in 20" campaign to raise money for chiropractic research by clicking here.
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