In the last few years, there have been several important studies and large population surveys investigating chiropractic's current status, the general population's attitudes toward the profession, and forecasting chiropractic's position in the future health care market.
As recently noted in a major monograph funded and published by the U.S. Department of Health and Human Services,1 Coulter,PhD, and Mootz,DC, state: "The main question is no longer, 'Will chiropractors enter the mainstream of health care?' but 'What role will chiropractors play in the health care system of tomorrow?'" There are many forces at work in the health care market of tomorrow. The better we understand them, the easier it will be to effectively present chiropractic in a positive light. This paper will review some of the important factors contributing to the evolution of health care models and offer ways in which we can best portray and promote chiropractic in the future.
Increasing Utilization and Popularity of Chiropractic
In July 1998, the Institute for Alternative Futures released the findings of its very thorough investigation, The Future of Chiropractic: Optimizing Health Gains.2 The aim of this multimillion dollar project funded by NCMIC Insurance Company was to "serve as a 'future planning map' for the collective profession to use in beginning to build and create a 'shared vision' for tomorrow."3
The document offers many valuable insights into the evolving health care market and chiropractic's role in the future. The commentary notes that the use and number of chiropractors is rapidly growing. The number of chiropractors in the United States will increase from approximately 55,000 in 1998 to 103,000 by 2010.
This enormous growth has been chronicled by other prominent researchers. Cooper,MD, director of the Health Policy Institute at the Medical College of Wisconsin published several papers - one in 1996,4 another in 19985 - reporting on the dramatic expansion of the profession. In fact, Cooper predicts in the 1998 study, if the climate remains positive for chiropractic there could be as many 145,000 chiropractors in the United States by 2015! In addition, in 1998, Hurwitz,DC,PhD,6 in the American Journal of Public Health reported that the number of chiropractors and the percent of the population using chiropractic have approximately doubled during the past 15 to 20 years.
This rapid growth is clearly reflected in the chiropractic colleges which have increased the number of graduates per year from 1,500 in 1980 to an estimated 5,000 by the year 2010, according to the Institute for Alternative Futures. Another important document, Chiropractic in the United States, funded and published by Agency for Health Care Policy and Research (AHCPR), also detailed this remarkable growth. In this document,7 Coulter,PhD, stated that total enrollment in the U.S. chiropractic colleges in the fall of 1995 was 14,040. Between 1990 and 1995, enrollment increased by 44%! During the same period, the total number of graduates per year increased 13% from 2,529 to 2,846. Cooper,MD,8 adds another surprising statistic to these recent figures, declaring that there are now "more chiropractors trained each year than family practitioners."
These papers illustrate not only the rapid growth of chiropractic, but another important trend concerning current reporting about chiropractic. The profession is being taken seriously today in the scientific community and is now definitely considered worthy of diligent investigation. As a result, there have been numerous recent studies concerning chiropractic published in what are considered the world's leading medical journals. This is important because the information can be easily accessed by researchers internationally, since these publications are included in the major databases that exclude most chiropractic publications.
Why So Much Growth in Chiropractic? Evolving Models of Health Care
Several important influences have coincided to produce the expansion. First of all, there is a shift in models of health care. The dominant paradigm is moving away from a focus primarily on the treatment of diseases toward one that emphasizes improving function and quality of life. As another recent and informative report forecasting the changes in health care in the United States by the Institute for the Future notes,9 health care is moving away from a curative model to one that focuses on other important goals of health care including health promotion, health maintenance and functional restoration. This same document identifies consumer demand as a driving force in compelling traditional medicine to expand the breadth of its model to incorporate a broader scope of health care, stating, "Perhaps an obsession with disease has unintentionally relegated health to a position of secondary importance ... The view of health should be expanded to encompass mental, social, and spiritual well-being ... Led by health-conscious seniors and a generation of baby boomers, the medical establishment is confronting a mandate to move beyond the curative model to become engaged in preserving health and preventing illness and disease."
Other recent national surveys confirm the patient demand for wellness care. Astin,PhD, reported in the Journal of the American Medical Association10 that one of the most common reasons that 42% of American adults use alternative care is that "the treatment promotes health rather than just focusing on illness."
Chiropractic offers a model that focuses on the positive dimensions of health. As Coulter,PhD, reports:11 "The goal of chiropractic is correction of dysfunction with relief of pain, restoration of function and enhancement of well-being. The role of the chiropractor is health promotion. Chiropractic offers holistic, personalized, conservative care, using low risk procedures. The concern is for the whole person, not the limb or the case."
The major educational/promotional campaign launched in 1998 by the Alliance for Chiropractic Progress12 emphasizes this focus on well-being, health maintenance and holistic health care, stating: "Because chiropractic education centers on health, not disease, chiropractors carefully evaluate lifestyle issues including nutrition, exercise and stress." Such a focus regards the patient's health-related quality of life and function in terms of activities of daily living as essential dimensions of effective health care which have not been adequately addressed by traditional medicine, with its narrow focus on "biological markers of disease."13
This myopic focus in medicine is one of the principle reasons that Gordon,MD,14 states: "Patients use alternative therapies because they want providers who will take the time to listen and understand them and deal with their personal life as well as their pathology." The emphasis on patient-centered outcomes is reiterated by other recent papers as well. Carey,MD,MPH,15 commented: "Physicians do not address the concerns most prominent in patients' minds. Patients come to us expecting advice for pain relief and for return to normal activities. Simple questions and encouragement, essential parts of every physician's role, might do a great deal to improve the currently poor ratings of physician satisfaction by our patients."
The emphasis on patients' perception of benefit of care as an important perspective has been supported in other recent papers.16 Hufford, PhD, commented: "Consumer changes in medicine are due to the perception that experts often omit from decision making crucial factors available only to the patient. An MD has expertise to predict probable outcomes of treatment and risks, but only patients can say what effect treatment has on their illness, on their quality of life. When the authority of patients to speak about their illness is ignored, medicine is extended beyond physicians' expertise. Such authority is not legitimate."
A lay perspective on the secret of chiropractic's success reinforces this focus on patient satisfaction, as noted by a great athlete and advocate of chiropractic care, Martina Navratilova.17 "A chiropractor was instrumental in putting my body back together. Since then, I've visited the chiropractor many times for a variety of problems and solutions. As Americans become more aware of the need for preventive medicine, alternative therapies will play a bigger role in our lives. After all, people like what works."
The Chiropractor as a Highly Educated Health Professional
In addition to emphasizing health promotion and maintenance, we want to present chiropractic as a profession of highly educated professionals who have received extensive, rigorous and thorough training. Coulter,PhD, et al.,18 in a very recent comparison of the curriculums of three chiropractic and three medical schools, found that the chiropractic curriculum totaled an average of 4,800 hours, while medical schools averaged 4,667 hours. The study noted that while medical students have more extensive clinical training, chiropractic students receive, on average, the same number of hours of microbiology (120 hours) and, very surprisingly, more hours of pathology (205 vs. 162), anatomy (570 vs. 368) and physiology (205 vs. 142).
Yeast,19 in a review of the development of the Alliance for Chiropractic Progress, identified that the public is poorly informed about the length of chiropractic education, about the fact that chiropractors have residency/internship programs, and about the extent of certification and accreditation requirements to practice chiropractic. He concluded that in general, people are ignorant about the extent of chiropractic education but view chiropractors as focused on wellness, health promotion, health maintenance and optimizing performance.
Chapman-Smith20 reports that in a November 1998 poll commissioned by the Canadian Chiropractic Association, one month after the first fatality in Canada as a result of a postmanipulative stroke, "lack of knowledge of the educational qualifications of chiropractors was a much greater impediment to non-users to see a chiropractor than risk of harm." The survey identified that the specific statement most likely to improve opinions of chiropractors was that "chiropractors are highly trained professionals." The article concludes that the main message chiropractors need to give the public relates to their education, qualifications and professional standing.
The "Wellness Demand"
Several recent papers provide new insight into the future of the health care market and note that a motivating force in the changes in health care are driven by consumer demand. Baby Boomers (born between 1946 and 1964) have an ideal that places individuals over institutions and prefer "a health care paradigm emphasizing self-care, prevention and wellness. [This paradigm] will join and to some extent supplant today's treatment-focused model."21 Today, there is a "wellness demand" that exceeds traditional medical care and the insurance industry's coverage of scope of reimbursable services. This "wellness demand," the desire to promote and maintain health, as well as to prevent illness and increase and preserve optimal function, is manifest in the rapid rise and popularity of health and fitness clubs. The trend of ever-growing numbers of adults joining fitness clubs and paying often large fees out of pocket for membership is a clear indication of the public's desire to preserve health and maintain optimal function. Eisenberg's new study in the Journal of the American Medical Association22 identified that in 1997, 42% of all alternative therapies used were exclusively attributed to the treatment of existing illness, whereas 58% were used, at least in part, to "prevent future illness from occurring or to maintain health and vitality." The study also found that there were 243 million more visits to alternative providers than all types of traditional primary care physicians combined in the United States!
The Message for the Future
The promotion of chiropractic should stress that chiropractors are highly trained and skilled health professionals who focus on health maintenance and wellness. We should accent our focus on the multiple factors affecting health over which people have control including exercise, stress management, nutrition and other lifestyle factors. The emphasis should be on intelligent lifestyle counseling and cooperative, dynamic, ongoing care in which chiropractors and their patients work actively together to maintain health, prevent illness and improve optimal performance and fitness. We need to promote a shared vision which champions health promotion, performance enhancement and proactive wellness services.23 As we move into the next millennium, chiropractic should be the standard bearer of holistic health. When the public thinks of the clinicians who provide high quality care and information that focus on improving quality of life and optimal function, they will think of chiropractic.
References
- Cherkin, Mootz. Synopsis, research priorities and policy issues. In: Adams, et al. Chiropractic in the United States: Training, Practice and Research. Rockville, MD: AHCPR, 1997, chapter XII, pp. 117-130.
- The Future of Chiropractic: Optimizing Health Plans. Institute for Alternative Futures, July 1998.
- Executive summary. In: The Future of Chiropractic: Optimizing Health Plans. Institute for Alternative Futures, July 1998, foreword, iv.
- Cooper RA, Stoflet SJ. Trends in the education and practice of alternative medicine clinicians. Health Affairs 1996;15(3):226-238.
- Cooper RA, et al. JAMA 1998;280(9):788-794.
- Hurwitz EL, et al. Am J Public Health 1998;88(5):771-776.
- Coulter ID, et al. In: Adams A, et al. Chiropractic in the United States: Training, Practice and Research. Rockville, MD: AHCPR, 1997. Chapter III: pp. 17-27.
- Cooper RA. JAMA 1997;277(13):1092-1093.
- A Forecast of Health and Health Care in America. Institute for the Future. Funded by the Robert Wood Johnson Foundation. Nov 1998; pp. 143-160.
- Astin JA. Why patients use alternative medicine. JAMA 1998;279(19):1548-1553.
- Coulter. In: Lawrence DJ (ed.) Advances in Chiropractic, volume 3. Mosby, 1996, pp. 431-446.
- The Alliance for Chiropractic Progress: A Partnership of ACA, ICA, ACC, 1998.
- Wilson and Cleary. JAMA 1995;273(1):59-65.
- Gordon. Am Fam Phys Nov 15 1996;2205-2212.
- Carey TS. Spine 1998;23(4):69.
- Hufford. Alternative Therapies 1995;1(1):53-61.
- Martina's Column: Natural Health. Conde Nast Woman's Sports March 1998;60-61.
- Coulter, et al. A comparative study of chiropractic and medical education. Alternative Therapies 1998;4(5):64-75.
- Yeast C. What's happening on the public relations front. JACA 1998;35(8):16,18,19,54.
- Chapman-Smith D. Chiropractic Report 1999;13(2):1,4,5.
- A Forecast of Health and Health Care in America. Institute for Alternative Futures, 1998, pp. 143-160.
- Eisenberg DM. Trends in alternative medicine use in the United States, 1990-1997. JAMA 1998;280:1569-1575.
- Executive summary. The Future of Chiropractic: Optimizing Health Gains. Institute for Alternative Futures, pp. 12-13.
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