There has been much said in the chiropractic media of late regarding the need for professional unity:
- "Best practices" guidelines are being prepared by the CCGPP.
- Several large donations have been made to support the Foundation for Chiropractic Progress.
- The World Federation of Chiropractic has published its consensus document on the identity of chiropractic and the World Health Organization has released its guidelines on chiropractic education.
- Several notables in the profession have published their opinions on the ideal model for chiropractic, using the metaphor of being the "dentist of the spine."
With an overabundance of consensus-based opinions and ideas, one would assume this profession could identify a gathering point where a "meeting of the minds" could occur and thereby rid chiropractic of the internal bickering that remains a nemesis to our collective progress as a profession.
While I don't profess to offer a panacea for this dilemma, I would like to share a personal experience that exemplifies the potential for unity. Granted, the circumstances were beyond the typical experience of general practice and not far beyond the gates of impossibility.
Chiropractic in the Veterans Health Affairs System
Three years ago, mandated by law, the Department of Veteran's Affairs (VA) appointed a federal advisory committee to meet and make recommendations to the secretary regarding the implementation of chiropractic services into the Veterans health care system. After years of reluctance and resistance, the VA was finally forced to take action.
The VA was required to meet federal guidelines for an advisory body which essentially assured that all interested parties have representation at the table. As a result, the following committee was formed and I was asked to serve as chair:
| Reed Phillips, DC, PhD Charles DuVall, DC Leona Fisher, DC Warren Jones, MD Michael McLean, DC Rick McMichael, DC Brian Murphy, PT Michael Murphy, DO Michael O'Rourke, PA Paul Shekelle, MD, PD Cynthia Vaughn, DC |
The initial legislatively mandated committee - the Chiropractic Advisory Committee - expired at the end of December 2004. Then-Secretary of Veterans Affairs, Anthony Principi, elected to constitute a discretionary agency committee, the Advisory Committee on Chiropractic Care Implementation, for a one-year period and appointed the membership of the expiring committee en masse to the new committee. In April 2005, the new Secretary of Veterans Affairs, R. James Nicholson, appointed another chiropractor, Jay C. Cook, to the committee. Sara McVicker, a clinical program manager within VA Patient Care Services, was assigned to be our committee manager. She hailed from a nursing background with many years of service within VA.
When the committee appointments were announced, it was dubbed the "Committee Doomed to Fail" by many. Essentially, no one believed a group as disparate as this could ever come to an agreement on anything, let alone agree on recommendations to be made to the secretary.
Consider a more in-depth analysis of the committee. First, the table was divided between representatives from medicine and chiropractic. Within the medical arena were two MDs, a DO, a PT and a representative of a veterans service organization (who had at one time practiced as a PA). One MD and the PT were VA employees with whom the MD (Shekelle) had participated in numerous research studies involving and having implications regarding spinal manipulation and chiropractic. The other MD (Jones) was serving as the president of the American Association of Family Practitioners and had served on the Department of Defense (DoD) Chiropractic Advisory Committee. The DO also had served on the DoD Chiropractic Advisory Committee. Thus, there was a fairly high level of exposure to chiropractic within the medical component of the committee. While it would be unfair for me to judge what attitudes may have existed in the minds of the members from the medical side of the table, I think it would be fair to suggest there was some skepticism regarding the outcome of our efforts.
From the chiropractic side of the table, the philosophical/political spectrum was present. Dr. McMichael, Dr. Vaughn I were members of the ACA, with McMichael and Vaughn having strong political ties to the ACA. As a chiropractic college president, I had strong ties to the Association of Chiropractic Colleges (ACC) and the Council on Chiropractic Education (CCE). Dr. DuVall represented the National Association of Chiropractic Medicine (NACM). Dr. Fisher was nominated by the World Chiropractic Alliance (WCA), and Dr. McLean had a long-standing relationship and strong political ties to the International Chiropractors Association (ICA).
Before our first meeting, the ACA went public requesting a reconsideration of DuVall's presence on the committee, given the question of whether the organization he represented had adequate membership to really speak as a representative for the profession. Some also questioned why the WCA was allowed a seat at the table for similar reasons. No one was removed from the committee and a unique balance of varied opinions prevailed throughout our deliberations.
I admit my own doubts regarding the ability of this group to come to any agreement about anything and initially considered a refusal of the nomination serve as chair.
The Process Unfolds
Our first meeting was taken up with introductions, some posturing, orientation to the VA way and establishing ground rules for future meetings. The skillful support of Sara McVicker made this meeting productive and her vision of what was needed inside the VA set the stage for future progress. It had become evident that the medical side of the table, with the exception perhaps of Dr. Shekelle, was somewhat ignorant regarding the rigors of chiropractic education, accreditation, licensing and the variability in practice styles. It was decided (and wisely so) to dedicate a good portion of the next meeting to an explanation of these issues. It was also Sara McVicker who recognized that at some point in the future, there would need to be an "Occupational Analysis Study" done on the practice of chiropractic in order to meet the administrative (bureaucratic) requirements to actually hire DCs. Wheels were set in motion to get this accomplished by our first recommendation to the secretary following this meeting.
The second meeting was pivotal in the success of this committee. Presentations were made by all the DC members of the committee regarding issues of education, accreditation, licensing, continuing education, practice and philosophy of chiropractic. My impression was that the medical side of the table was surprised and amazed to learn that chiropractic had such high standards in all areas presented. I believe a certain measure of respect was obtained and skepticism reduced as the cloud of ignorance began to dissipate.
Over the course of the committee's existence (two years as a mandated and one year as a discretionary federal advisory committee), a total of 58 recommendations were made to Secretary Principi, followed by 14 to Secretary Nicholson. These recommendations and the VA response can be found at www.va.gov/primary.
In spite of all the hoopla regarding the disparity of opinions sitting at the table, it is nothing short of a small miracle that there was only one recommendation upon which there was not unanimous agreement. The issue was over "direct access" to chiropractic care for veterans. The resulting vote of two in favor and nine opposed came after a rather lengthy and spirited debate over whether the usual VA practice of requiring a consult for specialty care would unduly hinder access to chiropractic care and /or if trying to change the way VA works and creating a separate process would result in hostility that would have negative effect on the acceptance of DCs and the entire program.
While to some, the two nay votes may have had political overtones (verified by what was said about that vote in the chiropractic media afterward), it never cracked the overall solidarity of the committee, as attested by our ability to reach unanimous agreement on all subsequent recommendations. In the end, the substance of that debate was essentially negated by the fact that at the final meeting of the committee, it was reported that all DCs then working in the VA system had a backlog of patients with waiting time ranging anywhere from two weeks to nearly six months. There appear to be no obstacles to accessing chiropractic care by the gatekeeper system used within the VA.
The End
The VA federal advisory committee has now been replaced by an internal field advisory committee made up of DCs working in the VA system. While chiropractic care is not present in every VA facility, the work of the committee was successful in getting the implementation process underway. Twenty-eight DCs now are working in VA facilities, including two working at two different locations (as of December 2005). Three chiropractic colleges (Bridgeport, Logan, and NYCC) have established academic affiliations with nearby VA facilities, and LACC/SCU is in active discussions with a VA medical center. Such affiliations will help open doors for intern rotations, resident training and collaborative research projects.
It has been heartwarming to see the reluctance and resistance melt away as chiropractors have established a presence within the VA facilities. Not only are the patients highly satisfied with the care received, but the barriers with medicine and physical therapy also have subsided greatly. Although VA was mandated to establish chiropractic care at only one site in each of its 21 geographic service areas, seven additional VA facilities have elected to develop clinics, including two with academic affiliations.
The expectation of this outgoing committee is that chiropractic care will remain a permanent benefit for our veterans and expansion of services will grow as the need for care is better understood.
In closing, I wish to say how pleased I was with the performance and participation of each member of the committee. I believe we parted with a healthy respect for each other and a sense of a job well-done. Even though there were differences in ideas, beliefs and personalities, for the greater good of our deserving veterans, these differences were set aside and as a result unanimity regarding the implementation of chiropractic care in one of the largest managed care organizations in the world prevailed.
Is unity in chiropractic possible? My experience over the past three years has taught me the benefit could be worth the effort.
| Editor's note: Dr. James Edwards discussed the VA committees in his Jan. 15 column. Please read "The VA Committees: Mission Accomplished" online at www.chiroweb.com/archives/24/02/06.html. |
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