This past quarter century has been marked by a notable series of accomplishments, challenges and advancements for the profession. Let's reflect on some of the events that will continue to shape us as we begin our next 25 years of chiropractic.
Accreditation and Education
Recognized by the federal government since 1974, the Council on Chiropractic Education (CCE) has steadily influenced the advancement of the profession's educational system through establishing basic educational standards and defined clinical competencies.
The Association of Chiropractic Colleges
Beginning in the late 1970s, the college presidents assembled in informal side-meetings prior to CCE accreditation hearings to discuss educational issues of common interest. The Association of Chiropractic Colleges (ACC) was formally incorporated in 1988, with the mission and commitment to worldwide leadership in chiropractic education, research and service. The ACC has been a strong and sustained voice on Capitol Hill for advancing chiropractic education and research, influencing inclusion of chiropractic services in the health care systems of the Department of Defense (DoD), the Veterans Administration (VA) and the National Health Services Corps.
In 1994, the ACC held its first annual educational conference to promote chiropractic education research and new pedagogical techniques. The ACC Paradigm, developed by the member colleges in 1996, has become the most widely endorsed consensus statement clarifying the profession's role within the health care system.
Research Agenda Conferences
Beginning in 1995, the annual Research Agenda Conference (RAC) focused on research training for college faculty and field practitioners. For RAC's first 10 years, the Health Resources and Services Administration, a U.S. federal government agency, provided funding for these conferences. In 2001, RAC and the ACC entered into partnership to jointly sponsor annual ACC/RAC meetings, gathering the profession's academic administration, faculty and researchers to participate in collaborative workshops, and scientific sessions to present peer-reviewed papers in poster and platform presentations. Today, the annual ACC/RAC meeting represents the premier academic and scientific conference dedicated to chiropractic education and research. The conference proceedings are published in the Journal of Chiropractic Education and may now be accessed on the MEDLINE and PubMed online indexes.
The Wilk Antitrust Suit
In 1976, Chester Wilk and four other chiropractors, along with attorney George McAndrews, launched an antitrust suit against the American Medical Association (AMA) and 14 other medical organizations. The chiropractic plaintiffs charged that the AMA and others had engaged in a conspiracy to monopolize health care and restrain competition by making voluntary professional association between MDs and DCs unethical. The plaintiffs further contended the AMA worked with MD-dominated insurance companies to economically strangle the chiropractic profession. After two court trials and two appeals to the U.S. Court of Appeals for the Seventh Circuit, District Judge Susan Getzendanner found the AMA liable in 1987 for an illegal effort to destroy the profession through boycott. The AMA and other defendants were prohibited from interfering with interprofessional relations between MDs and DCs and their institutions, which has led to increased MD/DC collaboration and relationships.
Chiropractic in the Military
In 2000, President Clinton signed the National Defense Authorization Act, which required chiropractic care be made available to active-duty military personnel. In 2002, President Bush signed the Department of Veterans Affairs Health Care Programs Enhancement Act, which mandated that chiropractic be a permanent benefit within the Department of Veterans Affairs health care system. Each of these landmark laws built upon successful pilot projects in the 1990s demonstrating the value of chiropractic services while developing ways to integrate chiropractors into the health care teams at military bases and VA hospitals.
Today, chiropractic services are provided on 49 military bases and 32 VA hospitals, yet according to a 2005 Government Accountability Office report, only 54 percent of eligible military personnel can reasonably access the chiropractic benefit. On May 14, 2008, the U.S. House of Representatives Armed Services Committee approved a directive aimed at the Secretary of Defense to make chiropractic care a standard benefit for all active-duty military personnel. The legislation is based in part on recommendations from the ACA and the ACC.
Research Recognition
During the 1990s, several research reports published favorable findings on chiropractic. The 1992 RAND study found spinal manipulation benefited certain patients with acute low back pain. The Meade study, published in the British Medical Journal (1990 and 1995) and the Manga Report in Ontario (1993 and 1998), found patient improvement, effectiveness and cost savings related to chiropractic treatment. In 1994, the Agency for Health Care Policy and Research Guidelines for Acute Lower Back Pain, developed by a panel comprised primarily of MDs and chaired by an orthopedic surgeon, concluded spinal manipulation "hastens recovery" from acute lower back pain and recommended it either in combination with or as a replacement for nonsteroidal anti-inflammatory drugs (NSAIDs). Perhaps most significantly, the guidelines identified spinal manipulation as the only professionally administered procedure offering both symptomatic relief and functional improvement.
The National Center for Complementary and Alternative Medicine
The growth in awareness and interest in complementary and alternative health care services has created steadily increasing acceptance and use by the public and third-party payers. According to surveys of patients seeking alternative care (Eisenberg, et al., 1993, 1998), DCs are used more often than other alternative provider groups and with high patient satisfaction. In 1992, the National Institutes of Health established an Office of Alternative Medicine. In 1997, it was upgraded to its current status as the National Center for Complementary and Alternative Medicine (NCCAM). The NCCAM has become the major source of federal funding for chiropractic research. Two DCs have been employed as program directors.
Olympics and Sports Performance
Since 1980, chiropractors have been on the medical staff serving U.S. Olympic athletes. Chiropractors also provide care for members of the National Football League, the National Basketball Association, Major League Baseball and the Professional Golfers' Association, as well as collegiate, scholastic and youth club sports. Many high-profile sports professionals seek chiropractic care to become more competitive.
Future Opportunities
The momentum to expand chiropractic inclusion in military treatment facilities should continue, providing new employment opportunities and access to new and diverse patient populations. The colleges will move forward with academic residency affiliations with VA hospitals, providing DC residents new experience and training in collaboration, co-management and direct patient care within an interdisciplinary practice setting. The opportunity for research in these integrative practice settings might help define chiropractic's role not only for the management of musculoskeletal conditions, but also for nonmusculoskeletal or somatovisceral disorders.
In the context of the rising cost of education, it's projected that ACC-member institutions will forge strategic partnerships among fellow institutions, resulting in sharing instructional technology, information exchange, distance learning and the pooling of intellectual resources. Most importantly, the ACC is best positioned to implement formal strategies (residencies in chiropractic education and research) for nurturing the next generation of chiropractic educators. The sustained ACC/RAC partnership will continue to provide an annual conference platform for developing young researchers, clinician scientists and chiropractic leaders. For the profession to effectively seize the interdisciplinary research opportunities in the DoD and the VA, plans must be developed for instructing these military-based clinicians in basic research protocols. However, finding the necessary resources to fund this objective is essential.
CCE International has taken a leadership role in assisting the development of educational programs outside the U.S. and contributing to the expansion of the profession worldwide. It's anticipated that CCE will seek U.S. Department of Education approval for accreditation of postdoctoral and residency programs to bring the profession in line with other health professions.
The National Library of Medicine has added three chiropractic research journals to its influential MEDLINE and PubMed indexes (Chiropractic and Osteopathy, the Journal of Chiropractic Education and the Journal of the Canadian Chiropractic Association). This provides worldwide access to a broader range of information and current research. Couple this with the online availability of the FCER-sponsored DCConsult, and the practitioner has never had greater access to current evidence-based and practice information. In addition, the profession will find the database being developed by the CCGPP to be an invaluable information resource. Timely access to credible information is the wave of the future.
The Wilk victory in 1987 has substantially improved interprofessional MD/DC relations in the past two decades. However, discrimination has not ended. The economic reality is that MDs and their organizations continue to influence insurance companies, hospitals and media to adversely impact chiropractors and their patients.
For the past decade, the National Chiropractic Legal Action Fund (NCLAF) and the ACA have garnered financial resources to battle within the courts and to change the landscape for negotiating and bargaining with the managed-care and insurance industry. They deserve the profession's continued financial support.
Seeking collective solutions for reimbursement and patient access, the first meeting of the Chiropractic Summit this past February gathered together representatives from 24 chiropractic organizations. Summit activities are facilitated by its steering committee, with representatives of the ACA, ICA, the Congress of Chiropractic State Associations and the ACC. The initial focus is on Medicare and the upcoming national debate on system-wide health reform. The action item judged most urgent was the development and presentation of one message to the profession, the public, the media and (ultimately) to policy decision-makers.
The future of the profession? It likely will be shaped, step by step, in numerous pilot projects and in a wide range of settings. It will be done in individual private chiropractic and medical practices, joint MD/DC practices, and in larger-scale enterprises such as the health care systems serving veterans and the active-duty military. In all of these situations, it's important not to mistake uncertain beginnings for failures.
Inevitably, as new relations are developed and tested, there will be successes and difficulties. Creating positive, sustainable interprofessional relations depends on willingness by all involved to build on their successes and learn from their mistakes.
As inclusion of doctors of chiropractic in these settings becomes the norm and spreads throughout society, key decision-makers and stakeholders will correctly perceive the doctor of chiropractic to be "inside the tent." The perception that it's entirely normal for chiropractors to be included as valued participants in a broad range of health care settings will gradually define us as mainstream, rather than alternative or complementary. The mindset of nonchiropractors is the key. As a profession, we must do everything in our power to demonstrate society will benefit from our contributions to its health and well-being.