In an ecosystem any form of life is interdependent with a number of others; nothing charts its course alone, and many of the same principles apply to businesses and professions. Chiropractic has been part of the American health care ecosystem for almost 120 years, no matter how it saw its own role–or roles. Whether “straight,” “mixer,” philosophic purist or agnostic, the profession has been part of a system with often contentious but interdependent interests. Despite its own internal challenges, chiropractic has survived in no small part due to one important characteristic: it has always been unique and distinctive from other members of its ecosystem.
Is it still unique? And if it’s not, what price are we paying? Ecosystems also have fairly specific relationships, and if two organisms try and occupy the same position and interdependent relationships, they will almost inevitably struggle to survive. Because survival depends on access to sources of sustenance, safety, and assurances of succession, two competitors for those same resources can rarely both endure unless they blend and lose their competitive distinctions. Plentiful resources may, for a time, allow both to survive, even thrive, but as resources become more limited or less available, territory shrinks, and interests collide. When that happens the organism that can dominate the other will do so.
Chiropractic isn’t exempt from this reality, but many in our profession behave as if it is, assuming that no matter what we do we’ll still be around in another hundred years. That sense of exceptionalism is a great for initiative and self-laudatory back-slapping but it can be a self-blinding, potentially fatal flaw if we assume our survival is guaranteed. I believe there are at least two vulnerabilities that are putting our profession at serious risk. One is that in my view we’ve failed to establish and maintain a unique identity. Another is that without that strong, distinctive identity we’ve been forced to accept others’ terms for being in the healthcare ecosystem.
Why is a unique identity important? Why can’t we be ‘sorta like the other folks?’ Isn’t that a kind of a safe route to take?
The short answer is that we can’t because it won’t work: if we’re ‘sorta like the other folks’ and those ‘folks’ have greater market share or cultural authority, our days are numbered, because they will outcompete us for ecosystem resources. We should not forget that for most of its first century of existence chiropractic was a very stark alternative to medicine. The growth of chiropractic, in fact, depended on it.
Then things changed. There are probably a number of influences involved, but I would submit to you that our identity really began to become distorted and damaged when we accepted being part of the managed care business systems of healthcare. In doing so we exposed ourselves to the unintended consequences of that choice, and they have corrosively played out over the last three decades. The dark side of that choice involved concessions that looked like good trades for many at first, but over time have probably hurt us. Being part of those business systems broadened access and provided data to help us understand aspects of our value, but by permitting that data paradigm to be built on a symptom-based model we lost the ability to enforce a broader view of the benefits of chiropractic care.
Consistent with that view, I want to point to three key concessions that I believe have put our own survival at risk, as we’ve abdicated stewardship of our own identity.
First, we’ve permitted the imposition of a foreign taxonomy as a threshold criterion for the very basis of the appropriateness of care. The concept of ‘medical necessity’ isn’t simply a co-option of an existing term; the term itself comes from a reductionistic viewpoint of health, and is inappropriate for chiropractic. (Test this by inverting the paradigm: try defining surgery in terms of ‘chiropractic necessity.’)
Second, we’ve tolerated and accepted the application of a symptom-based paradigm that misstates and confuses the fundamental benefit of chiropractic care. The body’s innate economy of pain management in the pursuit of maximal function means that we’ve accepted subjective assessments as the prime criterion of value.
Third, we’ve failed to successfully mobilize around the need to establish a research methodology paradigm that accounts for the complexity of the contributions of chiropractic care in our understanding of neurologic functioning. The medical reductionistic/mechanistic model is fine for many aspects of healthcare research; it is simply wrong for chiropractic. It forces an isolation of limited considerations and distorts what we can learn from testing any hypothesis.
The net effect of these three conditions is that for most of the public we are ‘back and neck doctors’ who are permitted (‘approved’) to provide treatments based on a numerical model for a limited set of symptoms while providers are rewarded with paupers’ wages. We’ve become trapped there and have been unable to strengthen the weak science available that doesn’t really support our fullest claims about chiropractic’s benefits for nervous system function. Perhaps worse, because we’ve allowed ourselves to be pushed into this medical model, within those terms we are now also competitors for others who claim the same therapeutic territory–the same position in the healthcare ecosystem. Many will take comfort in our ability to offer those services, and indeed millions can experience relief if widely adopted. But it is also an incomplete conception of chiropractic.
A profession’s ‘brand’ isn’t what the profession thinks it is, it’s what others think it is. When we either claim (by our own marketing) or don’t refute (by our silence and complicit participation) a term or perception that inappropriately represents our ‘brand,’ we change chiropractic. When we accept perception of a role as back and neck doctors, we should not be surprised that others who are in the same ecosystem niche and who enjoy wider acceptance gleefully outcompete with us for sustenance (patients and compensation), safety (systemic acknowledgement of and reliance on our contributions), and assurances of succession (business viability). When we sign managed care contracts and accept compensation for our services for pennies on the dollar, we should understand that we’ve helped create the conditions where discount chiropractic chains spring up that support a race to the economic bottom.
So how did this happen? Paradoxically, when we began to be ‘accepted’ by the system. Being given a seat at the table of healthcare was a seductive opportunity, even if we didn’t really like the terms of engagement. What we assumed was that we’d develop the leverage to make things better, but that never happened. Too many of us mutely accepted the substantial disparity in cultural authority between chiropractic and medicine. Too many of us settled for such obscene differences in compensation that now, for many prospective students the ROI of a chiropractic education is unacceptable, and they are forced to look elsewhere for careers. Too many of us have accepted a mischaracterization of our value proposition that argues we’re better because we’re cheaper and quicker—but not better because we are able to support our claims of longer-term neurologic benefits from chiropractic care.
The financial paradigm we’ve wrung our hands about but accepted is based on minimalist care because we’ve accepted being seen through the wrong end of the telescope. We also have not cared much about our own professional maturity: hell-bent on defiant independence and reluctant to move beyond professional adolescence, we’ve tolerated factions and outliers in chiropractic that have embraced excess if not outright abuse, and we have been too reluctant to call our own members out and disavow them for excesses, misrepresentation and exploitive behavior.
If you disagree with the above and believe our identity is just fine the way it is, it’s hard to accept that’s true if we take a serious look at how poorly the profession is doing in the current healthcare marketplace. There is tremendous consumer confusion as to what chiropractors do beyond back and neck pain relief. But what may be even worse is that it’s possible that consumers aren’t confused, and our shrinking market share is a sign that people have accepted that self-limiting, timid conception of chiropractic.
Viewed in terms of the healthcare ecosystem, it’s difficult to see how chiropractic will survive with an identity that doesn’t offer clear distinctions from other providers. Physical therapists, physical medicine MDs and orthopedists have much more cultural credibility and very clear identities. Their ability to outcompete us for patients, compensation and referral relationships should not give us much comfort about our future. So we should be very wary of anything that makes our identity even more confusing. The faction of chiropractors who are seeking scope expansion to include the ability to prescribe drugs do not understand the real implications of their goals.
Rx for A Profession’s Fracture
Three arguments are usually made about expanding scope to include prescription rights. One has to do with economics, viewing prescription rights as a new revenue stream, and another has to do with clinical benefits for those who want to be a ‘one-stop shop for my patients.’ A third has to do with filling the perceived primary care gap in the US. The first two are partly right, in terms of their arguments: writing scrip can augment revenues, and some patients won’t have to go get painkillers if they want or need them. But the third point is wrong in a very serious way. Drugs and surgery have never been part of chiropractic’s identity, and if we move to include them, we will change our identity to the point where chiropractic won’t be much of an alternative to medicine. The seduction will be great to treat medicine and manipulation as interchangeable therapies. “Mainstream” chiropractic will become a profession of semi-medical doctors who manipulate, but who don’t see their role in terms of optimizing neurologic health in the same way as the profession’s original identity. And political medicine will ensure that prescription rights are on its terms, forcing a co-option of the profession and further weakening its identity. Osteopathy’s assimilation by political medicine was abrupt. Chiropractic’s assimilation will be more gradual, but the end result will be that the profession will split in two. One part will trade its current conditions for the ‘safe haven’ of medicine’s cultural authority, and another part will split off in an effort to maintain the integrity of chiropractic’s original value and identity.
Dualism and Survival
There are five steps that I think are important to take to address this trend.
- Those who want prescription privileges should do so under medical scope laws, not chiropractic. Drugs and surgery are not chiropractic, and if a practitioner wants to broaden their practice to offer them, they should do so under a revised medical scope law, not a revised chiropractic scope law.
- Colleges need to take a visible, honest and transparent position on what they are preparing their students for, and align their curriculae accordingly. If colleges want to support students who want a medical track in addition to chiropractic, that’s their decision, but they should be clear in their marketing and practices that they’re adding medicine, not changing chiropractic.
- With the likelihood that the ACC Paradigm on Chiropractic is going to be rewritten to substantially weaken its definition of a distinct chiropractic identity, a substitute ‘charter of chiropractic identity’ or its equivalent needs to be developed, promoted and subscribed to by those in the profession who agree that the absence of drugs and surgery and/or a focus on subluxation correction are the defining elements of chiropractic identity.
- Chiropractic groups and associations need to explore how, within the limits of antitrust laws, standards and benchmarks for compensation and the provision of care can be defined and established by the profession, for the profession.
- Explore integration with other healthcare professions under circumstances where chiropractic’s distinct, vitalistic paradigm of health and healing forms the basis of its participation and contribution. The appropriateness of chiropractic for an individual is and should be based on chiropractic necessity, not medical necessity.
Chiropractic is an essential part of the healthcare ecosystem; it can never really be outside of it, and it should not be. But unless we take a clear-eyed view of what it takes to occupy and maintain a distinct position in that ecosystem, chiropractic will fracture and a large element of the profession will be subsumed under political medicine. And with that, a great deal of value and contribution to population health will be lost.