As an American citizen, watching divisions in our society sharpen and grow more barbed and distinct over the past decade has been painful. The visible increase in feelings of isolation and disenfranchisement leaves me with a sense that, in the rending of our social fabric, we are likely to end up not with two separate garments, but a tattered result that fits no one.
Our beloved profession of chiropractic is showing parallel signs of increasing stress, doubtless subject to the same forces.
Harmony vs. Discord and Our Increasing Divide Over Scope
Perhaps no better example of establishing a Venn of common agreement exists than the ACC Chiropractic Paradigm brokered in the 1990s – agreed on by people who could claim sharp ideological differences, but who recognized the potential for harm without being able to stand on the same ground to do so. They accomplished this because they saw the danger and damage of a professional split. Splitting chiropractic does not create a winner and a loser, but two losers and no winners.
Scope-of-practice fights and the basis for supportive arguments on both sides have confused legislators for decades, and I would argue that our lack of accord on fundamental issues of identity, science, clinical and applied philosophies haven't helped the marketplace understand what seeing a doctor of chiropractic even means. Our utilization (adoption) rate by the public is, frankly, dismal and should be a source of professional embarrassment.
Rather than point fingers when we ask "why," every doctor of chiropractic should look in the mirror. Silent or vocal, we are all complicit.
The increasing agitation over the latest arguments to expand chiropractic scope of practice to include prescription rights looks more ominous than any professional issue has for some time, in large part because there is no collective professional countervailing leadership voice. Subscription to the ACC Chiropractic Paradigm has eroded, and it's too easy to view it as an archaic document – an artifact – rather than as a source of dynamic, strategic guidance.
The Dangers Ahead
As someone who has spent the past 15 years not practicing, but watching industry trends and counseling forward-thinking clients on how to ensure alignment of value and opportunity, I can tell you that if the current trend continues unchecked, the inevitable splintering of chiropractic will lead to lower adoption, not greater. I'll simply say that we are kidding ourselves if we think a large proportion of the health care consuming public will be more comfortable coming to a doctor of chiropractic if they know they can get a needle or a prescription along with their adjustment or "mobilization"; there are no data to support that assertion.
As retail-based supply and demand dynamics are inexorably changing health care, anyone who studies retail psychology will tell you that stores that try to be all things to all customers tend to end up with a "going out of business" sign in their window. Today's purchaser of anything is looking for distinction, not homogenization. There is a pairing of values and identity in the outcome of buying something: we don't just want to feel good about how we spend our money, but we want distinction in whom or what we bought it from.
An Opportunity for Success or Failure
If this retail reality is true, there are implications for how we handle the changing health care marketplace opportunity for chiropractic. Do we make our services more distinct or do we blur the areas of professional distinction? Do we imagine that as providers of "holism," we can displace medical providers for the same or similar services delivered in the context of their own symptom-based paradigm? Do we really believe that consumers / patients, given the opportunity to receive services from physical therapists instead of doctors of chiropractic, are going to choose us? And if we think this, what do we base those assertions on?
The "brand" of anyone or any thing isn't what the owner of the brand wishes it to be; a brand is what your customers think they're going to get when they come to you. A brand can be based on a product, service, experience or any combination of those. I would submit to you that one of the reasons we have low adoption in the American public is because we have a confusing brand.
And I would submit further that if we end up splintering the profession, not by what we do, but what we don't do, the winners will be PTs, MDs and increasingly likely, NDs. The act of commission here is to seek legislation that expands scope-of-practice law to include medical procedures. The act of omission here is our failure to act out of a sense of common interest: the persistent lack of alarm and inaction from our professional leaders, across the spectrum of ideologies and practices.
4 Questions We Need Answered
There are some painful realities that we need to grapple with, and it won't be pleasant or easy. Here is a short list of four critical problems that must be addressed:
- We've asked research questions based on reductionistic models, so we should not be surprised if reductionistic results don't help us. What questions should we be asking, and how do we engage broader professional support for the larger, holistic data sets we need to answer them?
- Rightly or wrongly, we have come to be too-easily dismissed as anti-science. Rather than using emotion on one end of the spectrum and reductionistic science on the other, we need to explore again what the most of us can accept in the middle: common science and its context, accommodating a range of beliefs and practices in a "big tent" approach to professional identity.
- We've accepted a race to the bottom in compensation for our services. What long-term strategy do we need to consider and adopt that reframes our value proposition from being cheapest to being the best? In a marketplace increasingly focused on value-based purchasing (outcomes per unit cost), we potentially have a powerful story to tell. What do we need to be able to tell it?
- We need to realign our educational product with what the health care marketplace wants or is likely to ask for. The current business model of professional education is unsustainable, and we're pricing the cost of a chiropractic degree out of the range of anyone who wants a reasonable ROI.
If, after research and sober analysis, there are data that actually support additional education to permit doctors of chiropractic to inject or write prescriptions, let's support the creation of those educational opportunities. But let's not kid ourselves that we actually know what the marketplace wants. We haven't asked.
A Call for What's Needed: Collective Self-Responsibility
Just as either end of our country's political spectrum is vulnerable to criticism, so, too, are we. Those on the evidence-based / evidence-informed end of the spectrum need, in my view, to acknowledge the fact that our science is, frankly, weak, and that they need to acknowledge the power and importance of emotions; of feeling a sense of authorship over self-healing and repair.
And those on the philosophic end of the spectrum need, in my view, to acknowledge the reality that grounding people in an emotion-based approach dependent on repeatedly revving practitioners up in the absence of science is self-limiting, as well as ignoring the importance of being able to claim legitimate support on a core scientific foundation. The former approach leaves people feeling empty; the latter leaves people with too many questions.
Much as our elected leaders may use the word govern to justify their actions, what's playing out looks more like unilateral exercise of power. And so it goes with our profession. Unless those in leadership positions stop valuing the short-term rewards of self-interest, and focus instead on an enlightened sense of collective professional responsibility, no one should be comfortable about our profession's future.
Dr. Stephen Bolles graduated from Northwestern College of Chiropractic in 1986. After practicing for a decade and leading the profession’s state legislative efforts in the mid-1990s, he was appointed VP of Advancement at Northwestern during its transition to Northwestern Health Sciences University, also establishing a range of integrative clinic initiatives in the Twin Cities. In 2003, he went to work at UnitedHealth Group, leading a team that produced and sold its first consumer-facing health and wellness web product. For the past decade, he has consulted independently on a range of strategic health-focused initiatives. He lives in Eden Prairie, Minn.