One of the things that strikes me as I look at the chiropractic profession is that there are some structural flaws–not unexpected, nor uncommon, but that function in ways to restrict progress, maturation, and problem-solving.
So one thought is to offer a set of design principles as one aspect of the conversations necessary to have about our profession. What follows are a starting set of draft design principles for discussion and development by people smarter than I. These are written with the chiropractic profession in mind, but perhaps have broader applicability; I have no idea.
Design Principles for a Viable Profession
1. Define, settle on, and get behind a single identity. This has been a core issue for chiropractic since its earliest years, and the conflict is a painful, almost genetic defect in the profession. But if it’s not addressed and rectified, the profession is on a collision course with a split–in identity, scope of practice, allocation of resources, and membership. Worse, consumers will know even less about how to find ‘a good chiropractor.’
Elements of professional identity must include:
- A paradigm. What’s the theoretical model that explains what the profession does–and by extension, what it does not do? The evolving paradigm based on a vitalistic philosophic foundation offers the most flexibility in terms of how that paradigm is used by the profession (See Life University’s efforts as an example here). Without it, chiropractic is reduced to a mechanistic, technical model–and by extension, therapeutic role (see below). And a mechanistic therapeutic role can be taught to anyone.
- A defined therapeutic role. What’s the basis for agency in a healing art? If you can define what the therapeutic role is (direct intervention, support, passive bystander, etc.) then you can define…
- Optimal relational attributes that do the most to fulfill the therapeutic role. What is the optimal relationship ‘container’ and dynamic between a provider and their patient/member/customer/consumer? This is a natural for chiropractors, and is probably a significant contribution to the good outcomes we produce.
- A clear map of what’s in and what’s out. Chiropractic has suffered from ‘therapeutic creep’ in its domain over the years. From one vantage point it’s professional identity corruption, and from another it’s a perfectly acceptable response to patient needs and technological innovation. But the problem with not having consensus (see below) on these lists is that the profession risks codifying its differences legislatively in scopes of practice. There are already 50 different scope of practice laws in the US–but until the recent passage of a two-tiered profession law in New Mexico, the divisions were internal. Now they’re not, and we are not stronger because of it. What we don’t do as a profession (that deviates from our core identity) should be the basis for options in practice models, not legislatively-enabled professional tiers. Naturopathy has had to deal with this, given the accessibility of mail-order ‘doctor of naturopathy’ degrees as opposed to the rigor of the four-year accredited naturopathic colleges. They have moved toward use of the term ‘naturopathic physicians,’ which on one hand is a clear distinction, while on the other hand still offers confusion to consumers when there are ‘naturopaths’ out there as well.
2. Attain consensus–or die. Chiropractic has taken a run at this more times than can be counted, and it’s always eluded us. The ‘why’ of that fact is relatively easy to determine: people are passionate, but people can also be idiots, going to the mat over dogma. What’s not easy to understand is why there isn’t a greater shared sense of urgency about this. The stakes are getting higher, and it’s hard to see how the profession is going to survive without a significant effort and achievement on this issue.
A case in point is that of osteopathy, which also suffered from the lack of profession-wide subscription to its original (vitalistic) paradigm–and was thus vulnerable to medicine’s ultimatum (the AMA’s successful California Proposition 22 in 1962 that eliminated the practice of osteopathic medicine–later overturned). As osteopathy was co-opted by and into the medical profession, the small proportion of DOs who kept a focus on structural adjustments got smaller and smaller. Last figures I saw recognized that only around 10% of DOs were actively adjusting, though that number may be higher now.
3. Develop leadership. Individual leaders are certainly born, but viable professions figure out how to identify, train, groom, and promote leaders from within. The qualities, skill sets, and outcomes of effective leadership transcend professional boundaries. It needs to be part of chiropractic’s educational and professional culture. And it’s not.
4. Actively solicit outsider input. No one sees themselves as others do, and that goes for professions as well. Chiropractic has stubbornly resisted input from those outside its profession for its entire life. How many chiropractic school boards do not maintain a voting block of DCs who are free to ignore the counsel and experience of non-DC trustees? We would be a stronger profession if we would realize we would not weaken our identity by soliciting and acting on outsiders’ input, but actually become stronger. Seeking input doesn’t mean we have to remake ourselves in others’ image of us, but it should inform what we do on our own.
5. Use CQI on a professional basis. Organizations that use continuous quality improvement processes are passionately interested and culturally oriented to identifying processes, measuring results, and revising how they produce their services or goods based on the data. Chiropractic on the whole acts as if it’s afraid of data because of what we might have to change.
There are three fundamental aspects of dynamic professional improvement that CQI would address:
- Challenge assumptions. What do we think we know, and what’s the basis for knowing it?
- Poke the Paradigm. If our default for what we know is our professional paradigm, then it better ‘hold’ everything we know or discover. If it does not, the paradigm should be challenged–and needs to be, in reality, on an almost continuous basis.
- Research the basis for what we think we know. If data don’t support what we think we know, then poke the paradigm or revise the assumption. If it can’t be supported, then develop the theoretical construct that most effectively allows you to explore it (see subluxation). Or drop it.
6. Define your value in terms relevant to each stakeholder group. All of a profession’s customers are consumers–they just consume different things (services, data, transaction management, etc.). Define what your value is, how you add value to existing solutions or to unmet needs, and work to continuously revise how deep that ‘value add’ is.
So that’s my starting point. A more specific comparison of these design principles with chiropractic in a forthcoming post. Interested in comments and discussion.