How can chiropractic become a respected mainstream profession? The example of podiatry  [Excerpts]

By: Donald R Murphy, Michael J Schneider, David R Seaman, Stephen M Perle and Craig F Nelson.

The chiropractic profession has been in existence for over 110 years. In that time it has overcome a variety of hardships and adversities, including practitioners being jailed for practicing medicine without a license, attempts by the American Medical Association to contain and eliminate the profession, and general ostracism by many within and outside health care.

It has made some remarkable advances in recent years including substantial Federal funding of chiropractic research by the National Institutes of Health and the inclusion of chiropractic physicians in the Veterans Administration healthcare system. However, in spite of this, the profession has not gained a level credibility and cultural authority in mainstream society that is required to establish itself on equal ground with other health care professions.

The profession still finds itself in a situation in which it is rated dead last amongst health care professions with regard to ethics and honesty, and in which only 7.5% of the population utilizes its services, this percentage having dwindled from 10% only a short time ago.

...the podiatric medical profession has been in existence in the United States (US) for about the same amount of time as chiropractic; the first licensing laws for podiatric physicians were enacted in 1895. In the US, podiatry grew up and matured as a new profession within the same health care environment as chiropractic, during a time when new professions...were arising... to provide beneficial care for a variety of human complaints. Yet, podiatrists currently find themselves far more established and respected in mainstream health care and society than chiropractors.... many, perhaps most, major hospitals provide podiatry services, podiatrists regularly serve on the staffs of long-term care facilities, are included on the faculties of schools of medicine, serve as commissioned officers in the Armed Forces, in the US Public Health Service and in many municipal health departments.

One important reason podiatry succeeded in establishing itself in mainstream health care was its traditional dedication to public health. Podiatrists became active members of the American Public Health Association (APHA) as far back as the 1950's, embracing and contributing to the advancement of accepted public health initiatives, in cooperation with others involved in public health. Podiatrists slowly gained an image as proponents of public health, at a time when many chiropractors aggressively...opposed many public health measures such as vaccination and water fluoridation. As a result, podiatrists became influential members of the health care community, and foot health became widely recognized as an important component to overall human health.

The chiropractic profession should openly embrace, and become actively involved in, established public health initiatives....Spinal pain is an enormous public health issue, as the vast majority of Americans will develop a painful back or neck that will require treatment some time in their lives. Back pain-related conditions make up three of the top 10 conditions in the US, and the cost to society from spinal pain is amongst the highest for any condition. Employers are looking for ways to prevent disability from low back pain on the job, and we could fill tremendous void in public health by providing educational programs to the public on how to prevent spinal pain and its related disability. This could provide exposure of chiropractors to a variety of segments of society (since all are affected by spinal pain), including athletes, the elderly, children, workers and military personnel.

In addition, the profession must take an honest public health-oriented approach to clinical practice and wellness care by becoming more involved in teaching patients how to stay healthy without frequent, endless visits to chiropractic offices. Public health is ultimately about self-empowerment and teaching people how to take care of themselves, with an emphasis on prevention and health maintenance.

In 1961 podiatric medicine (experienced) the Selden Commission Report, it led to several improvements in podiatric medical education, some of which are similar to improvements that have been made to chiropractic education, including the adoption of identical requirements to those of all medical schools, advances in faculty development and major library expansion. In addition to these upgrades in the podiatric educational requirements, the Selden Commission report promoted the placement of podiatric education under the aegis of universities, with the inclusion of federally funded research. This led to further movement of the podiatric medical profession toward integration within the healthcare system by mainstreaming its educational institutions as well as demonstrating, and providing support for, its commitment to research. Equally important, it led to the recognition of podiatric physicians as being on equal par with Medical Doctors, Doctors of Osteopathy and Dentists. More recently, the podiatric medical profession has undergone an Educational Enhancement Project....Comparisons to allopathic and osteopathic education were undergone to determine those areas in which podiatric education fell short. Changes were made to bring podiatric education up to par with that of these other professions.

We feel that ...we must take a critical look at our educational institutions, find what is substandard, and correct those deficiencies....Consideration should also be given to upgrading admission requirements to chiropractic schools. In podiatric medicine, such upgrading, which included the requirement of the Medical College Admission Test (MCAT), a requirement of medical school admission, is considered one of the significant events in the profession's history, giving the profession legitimacy in its calls for parity with medicine Podiatric medicine experienced an increase in students following the institution of the MCAT requirement.

The podiatric medical profession began hospital-based postgraduate training in 1956. This training was officially sanctioned as a residency program in 1965. Important in the progress of residency training was when podiatric regulatory bodies started requiring residency training as a condition of licensure. So the development and progression of residency training in podiatry was brought about not only by the academic portion of the profession, but also by the regulatory portion. This led not only to improved clinical competence of podiatrists, but also to greater respect for, and confidence in, podiatric physicians on the part other health care groups as well as by the public at large. Working within hospital-based residency programs allowed podiatrists to be considered peers of the medical community. This type of professional and cultural authority has its roots in the daily interaction between podiatric residents and the other medical physicians in these hospital-based residency programs.

It is essential that the chiropractic profession establish hospital-based residencies.  Rather than focus on interns meeting certain numerical requirements, interns should be encouraged to develop clinical decision making and patient management skills. Further, the emphasis on achieving a certain number of procedures as opposed to the acquisition of skill and knowledge impedes the development of professional moral reasoning by training interns to use patients as a means to meet their own goals, rather than focusing on the needs of the patients themselves.
The chiropractic internship should, as with medicine and podiatry, occur after graduation. The internship and residency should occur partly in a hospital, and partly in outpatient centers of excellence in which the intern/resident takes part in clinical decision making and patient management under the supervision of chiropractic physicians who are among the top in their field. Chiropractic...should move in the direction of requiring the completion of postgraduate residency training as a condition of licensure. As was the case in podiatric medicine, this new requirement would force the profession to upgrade the training of its new practitioners to include a post-graduate residency.

Perhaps the most important factor that helped the podiatric medical profession to flourish was the fact that podiatrists had a clear identity and purpose; the podiatric medical profession was founded on the purpose of filling a need in society – the care of problems of the foot, not a "lesion" and a "philosophy"...they provided society with services that people actually wanted and needed.

The podiatric medical profession focused on a particular set of problems for which allopathic medicine had little interest and a limited ability to deal with effectively.... A key occurrence in the development of the podiatric profession was when the AMA determined that medical physicians should not get involved with "minor" foot problems. This opened the door for podiatrists to flourish in their chosen area of specialty, and retain complete control of their scope of practice without fear of intrusion by organized medicine. The podiatric medical profession did not challenge the medical profession with claims of being an alternative method of treatment for medical problems.

The chiropractic profession must establish a clear identity and present this to society. Based on all the evidence regarding chiropractic practice and education, there is only one societal need (but it is a huge one) that chiropractic medicine has the potential to meet: non-surgical spine care. Our education and training is focused on the spine, and clearly if there is a common bond among all chiropractors, it is spine care....there is no physician-level specialty that has carved a niche as society's one-and-only non-surgical spine specialist whose expertise is focused on the diagnosis and management of spine disorders.

...chiropractic medicine is about back pain, neck pain and headache. First, spine-related pain is one of the largest markets in all of health care. Considering neck/arm pain, back/leg pain and headache, virtually 100% of the population is potentially included (contrast this with the fact that only 7.5% of the population currently see a chiropractor). Second, no medical specialty has successfully carved a niche for itself in this area (although the physical therapy profession is moving rapidly in this direction). Third, spine-related disorders create a great deal of suffering on the part of patients, in addition to exacting great costs on employers, the healthcare system and society at large. Providing much-needed high quality care to individuals suffering from spinal pain, as well as initiating and taking part in public health campaigns designed to educate people about spinal pain, would be a great service to society...

The chiropractic profession fairly recently had a unique opportunity to catapult itself into the role of society's non-surgical spine specialists. In 1994 the Agency for Health Care Policy and Research released its guidelines on the management of acute low back pain in adults. These guidelines recommended spinal manipulation as one of the only treatments for which adequate evidence existed for its efficacy. The report received a great deal of media coverage, with some media outlets actually mistakenly identifying "chiropractic", rather than "manipulation" as the recommended first-line approach. Ironically, the profession chose to avoid being "limited" to the management of a group of disorders (back pain, neck pain and headache) that affect virtually 100% of the population through all stages of life. In the interim it has seen its market share dwindle from 10% of the population to 7.5%. Even amongst patients with back pain, the proportion of patients seeing chiropractors dropped significantly between 1987 and 1997, a period of time in which the proportion seeing both medical doctors and physical therapists increased.

It is interesting that chiropractors have traditionally prided themselves on being "holistic". The emerging model of modern spine care is the "biopsychosocial" model. That is, it is increasingly recognized that in order to provide optimum care for patients with spine-related disorders, one has to consider the whole person. Thus, non-surgical spine care provides chiropractic medicine with a wonderful opportunity to provide truly holistic care for patients, and to be recognized for expertise in this area. Further, because the biopsychosocial approach often requires multidisciplinary involvement, embracing this model will further help to integrate chiropractic medicine into mainstream health care.

The professions, which classically included medicine, law and the ministry, are vocations whose members "profess" to have knowledge that the laity do not comprehend. Given the asymmetry of knowledge between professionals and the laity, society has granted to the professions a certain degree of autonomous control over themselves. However, this social contract demands that each profession, and each professional, place the well being of society and the patient, client or parishioner ahead of the profession and professional. Lay persons put their faith in the professional following the dictum credat emptor (let the buyer have faith) rather than caveat emptor (let the buyer beware). This social contract imparts great freedom on all professions, but with this freedom comes great responsibility.

When an individual consults a member of any of the medical professions, it is reasonably expected that the advice and treatment that he or she receives is based in science, not metaphysics or pseudoscience. In addition, it is reasonably expected that the services he or she receives are being provided for the primary purpose of benefiting the patient, and not for any other reason.... Patients place their faith in the professional, and trust that they will not be subject to fraud, abuse or quackery. By focusing on a specific set of clinical problems (i.e., foot disorders) for which society had a demonstrable need for professional services, using the scientific method to explore ways to better serve society, consistently upgrading their clinical training, and appropriately policing themselves, podiatrists have successfully fulfilled the social contract.

We feel it is important here to briefly contrast and compare podiatry and foot reflexology. While the two professions have always been distinct, there is commonality in that each focuses its treatment efforts on the foot; however, this is where any resemblance between the two professions ends. Podiatric medicine is a science-based profession dedicated to the diagnosis and treatment of foot disorders. Foot reflexology is a metaphysically-based group consisting of non-physicians who believe that many physical disorders arise from the foot. Podiatrists have rejected foot reflexology as an unproven and unscientific practice, and do not consider it part of mainstream podiatric practice. Thus, it would be quite unreasonable to think that podiatry and foot reflexology could ever exist under one professional roof.  Yet, this is the very untenable situation in which we find ourselves in the chiropractic profession. We find science-based practitioners and organizations alongside quasi-metaphysical, pseudoreligious, pseudoscientific practitioners and organizations.

Reform of the chiropractic profession is long overdue.  The podiatric medical profession succeeded in establishing itself as a mainstream profession because of certain specific actions it took, and certain actions it did not take. We see a tremendous opportunity for chiropractic medicine to become what it can and should be: a profession of non-surgical spine specialists who not only offer one useful modality of treatment for spinal pain (manipulation), but offer something much greater and more important – expertise in the diagnosis and management of spinal pain patients. This includes understanding the vast mechanisms of spinal pain as well as diagnosis, treatment and coordination of the treatment of other members of the healthcare team. It also means mastering a variety of non-surgical methods other than just manipulation that are useful in the management of patients with spinal pain. But, most importantly, it means becoming experts in patient management, i.e., helping patients overcome spinal pain, whether that means providing adjustments, exercise, short-term medication use and/or education regarding the issues related to LBP provided in a cognitive-behavioral context.

Currently, there is no profession that adequately fills that role, although as we noted earlier, the physical therapy profession is moving quickly in this direction. The only question is whether the chiropractic profession has what it takes to make the necessary changes.