Population Health and Chiropractic

My friend and noted integrative health blogger John Weeks challenged me in his response to my post on Leadership Lost with a question: ‘what would you prescribe for chiropractic’s involvement and contribution, as opposed to what would you like to avoid?’

Great question. And I don’t have an answer. At least, not a definitive sense of what it is, because as a profession we haven’t had that conversation. But there are elements out there, so here is my sense of what is probably important. I can only hope that this is a conversation the chiropractic profession begins in earnest with itself, and then with its peer and collaborative professions in health care.

I think a critical container for this is the concept of population health, because it’s the biggest ‘tent’ for the conversation. I believe there are a number of questions that need to be asked to define what chiropractic’s role is–or could be. There are at least four big questions to address along the way.

Question 1: What do we accept as a (shared) responsibility for being part of a health care system? Being part of a system has nothing to do with compensation, integration, philosophy, or anything else: we are part of a system, even if we are not playing the part we desire. Answering this question is important because we need to understand what we intend to fulfill in consumer/patients’ needs (and hopefully expectations) by being a licensed health care provider. Put differently, it’s a way of thinking about citizenship as licensed providers. Citizenship comes with rights and responsibilities. What are ours? As a starting point, I’d offer these opinions.

  • We owe it to a patient to reflect their health status to them. We need to understand what it is about them that is healthy, so that can be enhanced and supported. As Johnny Mercer wrote and behavioral health coaching follows, “You’ve got to accentuate the positive/Eliminate the negative.” True for health.
  • We owe it to a patient to reflect their disease status to them. To an extent we need to make extremely clear to a prospective patient, we need to assess the likelihood of the presence of disease. This does not mean we can or should directly treat anything and everything we find. It also does not mean we necessarily accept full scope of practice options for responding to disease (such as with prescription drugs), but it does mean we should have a clear social contract with people who come to our offices that lets them know what we can and do investigate, when and if we refer, and to whom.
  • We owe it to a patient to partner with them in our efforts. Passive delivery or reception of health care services and information does not increase the ‘health IQ’ of a consumer/patient, and individuals’ stewardship of their own PHI is a very important aspect of improving population health. Developing an explicit, collaborative model of health partnership with consumer/patients is a responsibility we should all be seeking to fulfill.
  • We owe it to the system to collect information. Data about a single health problem can be helpful, but one rarely exists in isolation. Understanding the context for any health ‘deficit’ or disease state means we have to gather data about an individual’s lifestyle, practices, relationships, etc., so that we can develop a more wholistic model of health and disease.
  • We owe it to the population to support, advocate for and insist on a minimum set of environmental conditions for health and growth. Pre- and post-natal maternal and child nutrition, stable and healthy families, clean air/food/water/air, safe living situations, early education….a host of conditions profoundly affect individuals’ and population health. We cannot be responsible members of a system if we do not stand with those who understand these are essential requirements.

Question 2: What paradigm offers a coherent model for preparation, education, practice, research, and development? Each profession has its own distinct paradigm; not every profession has developed the ability to explicate it. As a starting point, I’d offer this perspective.

  • Chiropractic holds that the body is innately capable of self-development, growth, healing, and health. The primary mediator of these innate functions is the nervous system; hence, our primary professional responsibility and contribution is to be able to assess its function and provide services that remove sources of interference.
  • With this, our central philosophy must be based on vitalism, a historical model that has identified an ineffable distinction between body and its energetic source, or source of energy. Stripped of religious, spiritual, mystical or other conceptual structures, there is ‘something there’ that infuses us with life. Without being able to fully explain it, the concept of vitalism permits us to explore and develop our relationship with these innate capacities. (See the LifeOctagon site and resources.) Invigorated by implications of quantum mechanic observations, vitalism offers a way to acknowledge, support, and get out of the way of our own innate abilities.
  • Vitalism gives us a conceptual model that, if we develop and apply it properly offers the prospect of a fully coherent professional system that guides and influences how we prepare people for training, how we train them, what we ask them to do, and what we expect as a product of their efforts in population health. As an example, see the Institute for Alternative Futures‘ work on ‘Vitalism and Value’ for the chiropractic profession.

Question 3: What should our relationship be with other health professions? It’s important we establish, work towards and refine goals to have healthy relationships in the US healthcare ecosystem. Population health suffers when services come from siloed providers, to say nothing of the redundant costs, infrastructure, and failed clinical efforts created as a byproduct of our dysfunctional professional relationships. We don’t control what others seek from us, but we do control what we seek from them and position as our availability and contributions. My opinions, again, on what should characterize these relationships as a departure point for conversation.

  • Health care professions should work individually on their specific contributions, and collectively on population health targets. This means that each profession should be contributing a distinct set of goals based on its paradigm and its sense of its responsibilities, and a clear-cut set of actions, interventions or contributions based on that paradigm.
  • Health care professions should make it their business to understand the value of others’ contributions beside their own. This is already true for just about all non-medical professions, but it is clearly not true for allopathic medicine. Each profession should operate with an understanding of others’ goals and contributions, and collaborate on supportive (non-competitive) efforts. Pluralism benefits everyone.
  • Health care professions should manage their interprofessional relationships based on precepts that guide healthy interpersonal relationships. Not based on power, subjugation, competition, or deceit; based instead on mutual respect, support, advocacy, and caring.

Question 4: How should our contributions be compensated? From considerations about population health, what should guide payment for chiropractic professional services? Starting with the observation and surprising news that the current compensation system is completely broken, irrational, incomprehensible, unrepairable, and being managed by middle-position players taking enormous and unconscionable sums of money out as transaction managers, here are some thoughts.

  • Outcomes should drive compensation. Clearly defined population or community health goals are necessary outcomes. Professionals should strive to achieve them, and those who contribute to those achievements should be compensated for them.
  • Evidence should inform practices, but outcomes should be accepted when clinical research is lacking. In the absence of clinical research, the outcomes (testable applications) become the evidence. Dr. Bill Manahan points out that only 38% of allopathic medicine’s mainstream practices are supported by good science, and he suggests that medical doctors only be paid when they follow good science. That model is appealing if there’s enough good science, but clinical needs in virtually every area outstrip the availability of science. We must make room for testing the theoretical application of understanding and clinical assumptions grounded in science, but not limited by the lack of a mature scientific explanation of observed phenomena. Sometimes we just don’t understand exactly why something works…but it does. And often it can be measured. More, there isn’t enough time or money to go around for necessary research. Allopathic medicine’s customary practices are supported by an allopathically-dominated health system, so there is no check and balance system with any authority, and self-preservation is a powerful imperative. Unless we broaden our systemic acceptance of a wider range of acceptable outcomes, the emperor will get to keep wearing no clothes, because his court is also naked and doesn’t dare comment on his sartorial taste.
  • Teams should be rewarded over individual efforts. The best way to incent collaboration is to link compensation to team performance.

I’ve answered John’s question with more questions, because many people need to consider this. How might all this look? One person’s Utopian vision:

A number of stakeholder professions have established the following overall goals for the population of the United States. It is our collective belief and goal that each individual can and should enjoy, within genetic or other uncontrollable limitations:

  • A lifestyle characterized by an unpolluted environment, food free of chemical and genetic contaminants, relationships free of violence, appropriate levels of physical activity, society-sponsored education customized to individuals’ learning needs and the guidance needed to develop a mature expression of emotional and social intelligence, incorporation of citizenship responsibilities and individual health practices.
  • Pre- and post-natal development characterized by optimal nutrition, safety, joy, wonder, a functional family and economic security.
  • A body able to express innate capacities, development, health and repair based on optimal neurologic system functioning and appropriate support of nutritional, energetic, and other health domain-specific needs.
  • An emphasis on non-drug and non-surgical services where at all possible.
  • Access to necessary services where drugs and surgery are required or important for recovery of health and function.
  • End of life transitions based on comfort, grace, support, and continuity

So. We will see if any of these elements appear in conversations, and where those conversations lead. There is an immense opportunity before us. The current approach just isn’t working.

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